kausalaya chakravarthy
TRANSCRIPT
Greetings from
Prerna Anesthesia & Critical Care Services
& Fernandez Hospital
Hyderabad
2 Isolation Rooms with separate AHUs
220 Bed Tertiary care Perinatal Centre ADR – 7500 + Six bed dedicated Maternal CCU Six Bed HDU (LW) 4 Bed Step Down Unit 22 Bed NICU Fetal Medicine Unit Dedicated Obstetric Medicine Unit Critical Care Outreach teams /MOEWS / SMS
220 Bed Tertiary care Perinatal Centre ADR – 7500 + Six bed dedicated Maternal CCU Six Bed HDU (LW) 4 Bed Step Down Unit 22 Bed NICU Fetal Medicine Unit Dedicated Obstetric Medicine Unit Critical Care Outreach teams /MOEWS / SMS
Counseling Room with A-V Facility
Algorithmic approach to Peripartum seizures
Dr. Kousalya ChakravarthyConsultant Prerna Anaesthesia & Critical Care Services
Asst Prof Anaesthesia; Niloufer Hospital
Osmania Medical College; Hyderabad. INDIA
Definition
Seizures can be defined as “abnormal
electrical activity associated with certain
behavioural and neurologic effects
Peripartum Seizures Etiology
Obstetric cause Non Obstetric causes
Hypertensive Disorders of
Pregnancy (HDP)
Eclampsia
Severe Pre eclampsia
with HELLP
Epilepsy
Secondary to neurologic
pathology
Metabolic derangements
as a result of critical
illness
Case 1
Primigravida /38 wks / normotensive / PROM
Patient in labor requested epidural analgesia
Developed GTCS when epidural dose was being
administered!!
BP : 160/100mmHg post seizure
? Intrapartum eclampsia
MgSO4 given, Pre eclampsia (PE) Profile sent
? Cause of convulsions
There is a dictum that new onset of
convulsions in a pregnant patient should be
assumed to be caused by eclampsia unless
proved otherwise!
Management of Eclampsia
1. ABCs / Control of Convulsions
2. Control of Hypertension
3. Management of Fluid Balance
4. Maternal / Fetal evaluation
5. Delivery (if not delivered!)
Magnesium Sulphate RegimeIV Infusion
Loading dose
20% solution, 4 gm
Slow IV, rate not more than 0.5 - 1 gm / min
Maintenance regime
As infusion, 1-2 gm / hr
1
Control of Blood Pressure
IV Labetolol 20mg stat over 10min Intervals ½ hr: 20-20-40-40-80mg Max 220mg(2-3g/kg) 2mg/ml infusion
2
Maintenance SR Nifedipine 10mg BD T. Labetolol 100 – 200 mg bid or tid max 600mg/day
Fluid volume regimes
75 -80ml of fluid /hr balancing input and output
3
4 Maternal EvaluationMINI PE* PROFILE
MINI PE* PROFILEPE* PROFILE
EXTENDED PE* PROFILE
5 Evaluation of Fetus CTG, Ultrasound
*Pre eclampsia profile
Case 1….Cont….
Emergency LSCS in view of fetal compromise
PE Profile was Normal
Intra operatively epidural activated
- While giving epidural patient threw a GTCS
- Accompanied by vomiting
Protocol for Recurrent Seizures
Loading Dose of MgSO4
4 gm,20% Max 1 gm/min . Maintenance of 1gm/ hour
Second episode of SeizuresDraw a sample for Serum Magnesium
2 gm of MgSO4 IV, Increase maintenance to 2gm / hr
Third episode of SeizuresCheck The S Magnesium reports, if wt > 70 kg
2 gm of MgSO4 IV 20% can be repeated again….Clinical guideline for the management of a woman with eclampsia and/or Severe pre eclampsia /august 2012
Protocol for Recurrent Seizures
Recurrence of SeizuresMidazolam
Dose 0.1 mg / kg body weight, slow IV
Still recurrencePhenytoin Sodium
Loading Dose: 15 mg / kg body weight(1000 mg in 100 ml of NS over 45 mins)
Maintenance dose of 5 mg / kg / day(100 mg 8th hourly Slow infusion)
AIRWAY has to be maintained
Status epilepticus
Maintain oxygenation
Protect airway
Terminate seizure activity
Propofol / Thiopentone sodium / Succinyl cholineRSI if need arises!
Oxygen by maskGuedel’s AirwayEndotracheal intubation Midazolam 2- 5 mg IV
Clonazepam 1 mg IV, over 2 to 5 min, not exceeding 0.5 mg / min
Repeat once 15 minutes later if status epilepticus continues
All simultaneously
But Our Dilemma..
Uneventful antenatal period
Successive normal BP recordings
Normal PE Profile
Both episodes of GTCS coincided with epidural dosing of the drug!!
? Local Anesthetic Toxicity
Not suggestive of Eclampsia!!
Case Details… Intra Operatively:
Regained consciousness in 3 minutes.
Epidural block: Dermatomal level of T6 was
present
Surgery done under EA uneventfully –
which rules out LA toxicity!
Case 1.. Postop Events..
On the 1st POD Patient developed
Dysarthria+
Partial ptosis of Left eye, horizontal nystagmus
Left LMN VII Nerve palsy
History Revealed:
Occasional slurring of speech, loss of balance
Urgent Neuro consult / MR angio brain
Follow up….
Tumor resection done after delivery
Post resection – Left occipital pseudomeningocoele
2yrs later admitted for second delivery
Had Functioning VP shunt / no signs of raised ICP
LSCS was done under CSEA/Uneventful
South Australian Perinatal Practice Guidelines Seizures in pregnancy © Department of Health, Government of South Australia.
Literature review
Maria Hirsch, CRNA, DNAPAANA Journal ; October 2011; Vol. 79, No. 5
Our Statistics Over 7 Yrs
Algorithmic approach…….
We derived an algorithm keeping in mind
Eclampsia should be considered in all cases
Eclampsia may not be the cause in all
Systematic approach needed for
Further investigations
Radio diagnosis
Follow up
Systematic analysis
Early diagnosis especially of atypical presentations
Decreased morbidity due to early treatment modalities
Decreased overall hospital stay
More cost effective
Benefits of Algorithmic approach
Atypical presentations can be Focal deficits Refractory seizures Altered sensorium Seizures >7days of delivery
Atypical presentation ……
Rule out Cerebro vascular
compromise SOL - Brain Infectious diseases Drug toxicity Metabolic causes
Further
investigations
ABG with Lactate
S.Ca++, Mg++ levels
Radio diagnosis Neuro consultation/
Neuro ICU
Indications for radio diagnosis
1. Recurrent seizures despite MgSO4 & antihypertensives
2. Altered sensorium post seizures3. Presence of signs of localization4. All Atypical presentations5. Presence of blindness6. Onset <20wks gestation7. Onset of seizures >48hrs postpartum8. Seizures persisting >48hrs
Role of radio imaging
To R/o
CSVT
Cerebral infarcts
Leucoencephalopathy (PRES)
Mass lesions (IC-SOL)
Aneurysm / Bleeding
Case 2
Booked patient Term / BP: 130/90 Proteinuria 1+
Admitted with severe headache…..EXCRUCIATING
Pleading for pain relief
GCS: 15
Pupils NSRL/ VII CN Palsy
? Eclampsia ? IC bleed ? IC-SOL
CT BrainBullet in the Brain!!!!
Case 2....
Emg LSCS & Emg Craniotomy same sitting
CT Vs MRI
Which is a better radiological tool in pregnancy?
A patient complains of postural headache, after an uneventful epidural .
Conservative treatment started With worsening of headache, plain CT scan brain done CT SCAN WAS NORMAL Epidural blood patch was given. After few hours, had a GCTS and later was pronounced
dead!!
Autopsy revealed bilateral subdural hematoma!!!
Fahad Aziz, MD New york Medical JournaNovember 2 2010l
CT BRAINCT BRAIN MRI BRAINMRI BRAIN
CT & MRI of a patient with Intra cerebral bleed & PRES
MRI showing thicker and better delineated PRES & haematoma
CT vs. MRI
CT is faster /readily available can be used in acute
conditions with unstable patients
Deep CSVT is likely to be missed out on a plain CT
Contrast CT brain carries a risk of AKI in hypertensive
disorders of pregnancy
Even the contrast CT brain can miss out deep seated
CSVT
Smaller haemorrhages may be missed on CT scansCT and MR imaging of chronic subdural haematomas: a comparative study SWISS MED WKLY 2 010 ; 14 0 ( 2 3 – 2 4 ) : 3 3 5 – 3 4 0
MRI preferred over CT scan
Decreased risk of radiation ( antenatal) High sensitivity and specificity Cytotoxic edema better diagnosed MR venogram brain is diagnostic of CSVT
DW MR images with T2 weighted FLAIR can be extremely helpful in evaluation of women with new onset peripartum seizures.
Brain MRI in peripartum seizures: usefulness of combined T2 and diffusion weighted MR imaging Journal of the Neurological Sciences Volume 166, Issue 2, Pages 122–125, July 1, 1999
Case 3.. Postpartum seizures
Primi / Post LSCS/ 1st POD Antenatal period - uneventful C/o ? Loss of vision since 1hour (not able to see!) Vitals –stable BP : 140/90mmHg/ Had vomiting GTCS while shifting to ICU!
? Cause of the seizures ? Eclampsia
Postpartum seizures D.D
Case 3.. Postpartum seizures MR Venogram was done to R/O CSVT
Posterior Reversible Encephalopathy Syndrome
Postpartum seizures
Anaesthetic Technique ??
VS
Regional techniques
SAB / EA / CSEA
General anaesthesia
General anaesthesia -Issues of Concern
Level of consciousness Hypertension – Laryngo sympathetic response Sublingual Hematoma – difficult laryngoscopy Difficulty in Airway assessment RSI – Succinyl choline vs. Serum Potassium Intra op hypertension Increased intra operative Blood loss Delayed recovery
Regional techniques in peripartum
Issues of concern with RA: Un co-operative patient Sacral Oedema- difficult landmarks Difficult technique Deranged Platelet & Coagulation profile
Epilepsy per se is not a CI for RA Subarachnoid block is safe in HDP HELLP syndrome, altered coagulation profile, low GCS
score mandate GA
Management post seizure
1. Continue ICU/ HDU Care for 24hrs 2. Close maternal & foetal (if not delivered)
observations
3. MgSO4 - 24hrs after delivery or last convulsion
4. Continue antihypertensive drugs / AEDs
5. Commence postpartum thromboprophylaxis
6. Follow up laboratory findings,
7. Proper Radiology Work-up
To Summarize
The most common cause of ‘New-onset’ seizures in
pregnancy is eclampsia
But.....
Not all first time seizures occurring in the third
trimester are preeclampsia / eclampsia!!
Atypical presentations should have a proper
workup and managed accordingly
Conclusion
Unusual types of cerebrovascular pathology is
relatively common in pregnancy and the dictum
that all peripartum seizures should be regarded as
eclampsia until proved otherwise..
Should be wisely judged!
Thank you