LABOR AND DELIVERY

Most patients with epilepsy are able to labor normally

and achive a vaginal delevery. Elective cesarean
section may be considered in patients refractory to
treatmeant during the thrid trimester or in those who
exhibit status eoilepticus with significant stress. During
labor, repeated seizures that cannot be controlled or
status epilepticus may require an operative delivery.
Fetal asphyxia can occur with prolonged or repeated or
repeated seizures. Cesarean delivery may also be
considered when repeated absence or psychomotor
seizures limit maternal awarenessand ability to
cooperate. Tonic- clonic seizures are seen in
approximately 1% to 2% of women during labor.
Lorazepam, a short-acting benzodiazepine, is the drug
of choice for treating seizures acutely. The drug is
administrered in 2 mg boluses every 5 minutes as
necessary. Some use 5 to 10 mg boluses of diazepam
as an alternative.
POSTNATAl
Antiepileptic drug levels must be monitored after
delivery because of the physiologic alterations causing
a decline in levels during gastation leads to a rise
postpartum. If the medication dose was increased
during pregnancy, the regimen should be returned to
that used prior to pregnancy to avoid toxity. During the
first postpartum day an additional 1% to 2% of women
will have tonic-clonic convulsions. Again lorazepam is
the agent of choice for acute control. New-onset
seizures in the postpartum period require complate

evaluation to ro rule out intracerebral hemorrhage,

cortical vein thrombosis, infection, or eclampsia.
Neonates should be given vitamin K 1mg IM after birth
to prevent a coagulopathy. All AEDs can cross into the
breast milk but breastfeeding is not contraindicated for
most agents. The effects os diazepam on nursing
infants are unknown, and it should be used with
caution. Phenobarbital should only be used when no
alternatives exist because neonatal sedation can occur
along with neonatal withdrawal on weaning.

STATUS EPILEPTICUS
Maternal and Fetal Risk
Status epilepticus (SE) is defined as ongoing seizure
activity lasting longer than 30 minutes or recurrent
seizures without full recovery of consciousness between
episodes. The actual incidence during pregnancy is
unknown. The important causes are listed in table 49-4.
Predisposing factors include poor compliance with
AEDs, CNS infections, trauma, and illicit drug use.
Status epilepticus represents a medical emergency.
Most seizures are generalized tonic-clonic. During the
tonic phase, contractions of the respiratory muscles
impair adequate maternal oxygenation, leading to fetal
hypoxia and asphyxia.
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During the covulsive phase, metabolic acidosis ensues.
Rhabdomyolosis occurs and can lead to acute renal
failure. After 30 minutes of continuous brain electrical
activity, even in the absence of the metabolic

derangements, irreversible neuronal injury can occur. Te

hippocampus and amygdala of the temporal lobe are
particularly sensitive to permanent damage. Trauma
from reccurent seizure activity can result in preterm
labor, ruptureof membranes, abruptio placenta, and
fetal death.
Management options
PRENATAL, LABOR AND DELIVARY, AND POSTNATAL.
Diagnostic and therapeutic interventions should be
performed simultaneously. A patent airway must be
secured and supplemental oxygenation given.
Hypotension should be avoided to prevent decreased
cerebral perfusion pressure. Complate bloud count with
differential, electrolyte profile, blood urea nitrogen,
creatinine, urine toxycology screen, and AED levels
should be obtained. Cerebrospinal fluid (CSF) analysis is
performed if meningoencephalitis is suspected.
Intravenous benzodiazepines are used acutely. Again
lorazepam is the drug of choice. It is given in 2-mg
boluses every 5 minutes. Simultaneously, the patient is
loaded with phenytoin 18mg/kg administration at a rate
not axceeding 50mg/min. The administration of
intraveous valproic acid (20mg/kg loading dose) is an
alternative if phenytoin is otherwise contraindicated.
The combination of phenytoin and benzodiazepines is
effective in controlling 75% to 85% cases of status
epilepticus. In those patients with persistent seizures,
higher levels of phenytoin can be achieved with an
additional 5mg/kg. In refractory cases where
barbiturates or a continuous infusion is required to

protect the airway. Continuous electroencephalograpic

monitoring should also be initiated. Once identified, the
underlying cause should be treated.