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Year : 2018  |  Volume : 66  |  Issue : 6  |  Page : 1593--1594

Status epilepticus in pregnancy: Most rare and most challenging

Gagandeep Singh 
 Department of Neurology, Dayanand Medical College, Ludhiana, Punjab, India; Department of Clinical and Experimental Epilepsy, Institute of Neurology, Queen Square, London, WC1N 3BG, UK

Correspondence Address:
Dr. Gagandeep Singh
Department of Neurology, Dayanand Medical College, Ludhiana, Punjab




How to cite this article:
Singh G. Status epilepticus in pregnancy: Most rare and most challenging.Neurol India 2018;66:1593-1594


How to cite this URL:
Singh G. Status epilepticus in pregnancy: Most rare and most challenging. Neurol India [serial online] 2018 [cited 2019 May 20 ];66:1593-1594
Available from: http://www.neurologyindia.com/text.asp?2018/66/6/1593/246227


Full Text



Pregnancy is a particularly difficult time for women with epilepsy (WWE). The mortality in WWE is increased during pregnancy, delivery as well as the post-partum period.[1] The excess of deaths during pregnancy in WWE may be either epilepsy-related or pregnancy-related. Among epilepsy-related deaths, status epilepticus is a foremost cause in pregnancy. Early data suggested a rather high mortality associated with status epilepticus during pregnancy.[2] More recent data, particularly obtained from the European Registry of Antiepileptic Drugs and Pregnancy (EURAP) points towards improved maternal and foetal outcomes in status epilepticus during pregnancy, perhaps as a sign of improved management.[3]

Providentially, status epilepticus seems to be rare during pregnancy. This observation, and concerns that harm to the foetus may occur as a result of aggressive treatment during this critical period, make the diagnostic and treatment protocols for status epilepticus in pregnancy somewhat uncertain. Hence, the prospect of a proposal for the management of status epilepticus during pregnancy is both welcome and timely.[4] In this issue, Rajiv et al., describe their experience in the management of status epilepticus during or soon after pregnancy. They collected data on 17 such WWE who developed status epilepticus during pregnancy over a 16-year period. These patients represented nearly six percent of all patients with status epilepticus seen in the tertiary care hospital in Thiruvanthapuram, Kerala. Thirteen cases developed status epilepticus in the one-week period after delivery.[5]

The management of status epilepticus in the puerperal period should be fairly straightforward and quite similar to the management of status epilepticus in non-pregnant individuals, i.e., the initial administration of benzodiazepines, followed by intravenous loading with phenytoin or fos-phenytoin and anesthetic agents (either propofol, midazolam or thiopentone) in that order. The issue of breast-feeding infants does not arise in such sick mothers. Incidentally, the good fetal outcome recorded in nearly 50% of the cases in this series might be attributed to the occurrence of status epilepticus in the puerperal period, as the baby would have been already delivered by this time. Also, incidentally, three cases were attributed to posterior reversible encephalopathy syndrome (PRES) in the absence of eclampsia. No other cause for PRES could be found in these patients. Could these represent the forme fruste or the missed cases of pregnancy-induced hypertension? We cannot be sure. Finally, this report emphasizes that status epilepticus is more frequent in the puerperal period and rare during pregnancy. Why is status epilepticus common during puerperium? There could be several reasons for this: (i) the common occurrence of post-partum cortical venous thrombosis in India, (ii) poor adherence to antiepileptic drugs in the puerperial period, and (iii) PRES developing as a consequence of pregnancy-induced hypertension.

The instances of status epilepticus occurring during pregnancy were cases of eclampsia and were treated with the Parkland Hospital protocol comprising of intravenous magnesium sulphate.[4] Indeed, when eclamptic seizures are refractory to this regimen, intravenous propofol is an option, rather a necessity, as also is emergent termination of pregnancy.[6]

References

1Christensen J, Vestergaard C, Hammer Bech B. Maternal death in women with epilepsy. Neurol 2018;91:e1716-e1720.
2Teramo K, Hiilesmaa V, Pregnancy and fetal complications in epileptic pregnancies, In: Janz D, Dam M, Richens A, Bossi L, Helge H, Schmidt D (Eds) Epilepsy, Pregnancy and the Child. New York 1982, pp: 53-9.
3The EURAP study group, Seizure control and treatment in pregnancy. Observation from the EURAP Epilepsy Pregnancy Registry. Neurology 2006;66:354-360.
4Pritchard JA, Cunningham FG, Pritchard SA. The Parkland Memorial Hospital protocol for the treatment of eclampsia: Evaluation of 245 cases. Am J Obstet Gynaecol 1984;148:951-63.
5Rajiv KR, Menon RN, Sukumaran S, Cherian A, Thomas SV, Nair M, et al. Status epilepticus related to pregnancy: Devising a protocol for use in the intensive care unit. Neurol India 2018; 66:1629-33.
6Dam AK, Mishra JC, Shome PK. Treatment of refractory seizures in eclampsia with protocol – A case report. Indian J Anesth 2004;48:314-15.