EPILEPSY IN PREGNANCY

Epileptic seizures in pregnancy can be classified as one of three types:

Occur in epileptics who happen to be pregnant.

Hormones that affect the recurrence of epilepsy in women who are
pregnant are estrogen and progesterone. In a pregnant woman whose
estrogen levels in the blood will decrease, thus stimulating the enzyme
glutamic acid decarboxylase activity and therefore the synthesis of
gamma-amino butiric acid (GABA) in the brain decreases. By
decreasing the concentration of GABA in the brain, it will stimulate the
recurrence of epilepsy. Hemodilution in pregnancy will occur, with the
result of reduced glomerular filtration resulting in fluid retention and
edema, resulting in plasma drug levels will decrease. Fluid retention
that occurs causes hyponatremia. This situation will lead to a partial
disruption of the "sodium pump" which resulted in the elevation of

neuronal excitability and promote seizure.

New onset seizure in a pregnant patient.
Pregnant patients with new onset seizures (not ecamptic) should be
worked-up as any new onset seizure patient with a metabolic profile
and head CT with appropriate abdominal shielding. Precipitating
etiologies, such as infections and drug toxicities, should also be
investigated. If no source is identified, anticonvulsants should be
withheld and the patient referred for close follow-up. In pregnant
patients with epilepsy, noncompliance and sleep deprivation are
common causes for seizures. Patients who are actively seizing should
be managed as the non-pregnant patient. The risks to the fetus from
hypoxia and acidosis are greater than the potential teratogenicity of
anticonvulsant medications. Arrange for fetal monitoring during and
after a seizure in patients more than 24 weeks gestation.

Seizures that are unique to the pregnant state: eclampsia.

Eclampsia is the major consideration in pregnant patients of more than
20-week gestation and up to 23 days postpartum 170, 171 who present with
new onset seizures. Magnesium has been demonstrated to be the
therapy of choice in the treatment of acute eclamplic seizures and for

prevention of recurrenteclampic seizures. 172 A systematic review173 of

four good quality trials involving 823 women found magnesium sulfate
to be substantially more effective than phenytoin with regards to
recurrence of convulsions and maternal death. Complications, such as
respiratory depression and pneumonia, were also less for magnesium
than for phenytoin. Magnesium showed a trend towards increased
incidence of renal failure when compared to phenytoin; however, this
was not statistically significant. Magnesium sulfate was alsoassociated
with benefits for the baby, including fewer admissions to the NICU. In
the eclamptic patient, give 4 grams of intravenous magnesium sulfate
followed by a 2 gm/h drip (some centers use intramuscular regimens.)
Control the patients blood pressure if very high (SBP greater than 160
and/or DBP greater than 110) and contact an obstetrician. Agents of
choice for blood pressure control in the emergency setting include
hydralazine (first line) and labetalol. In resistant cases, nitroprusside
may also be used, although fetal cyanide toxicity can occur after even
a few hours of therapy.