Case Study Reports: Fit in Pregnancy

FIT IN PREGNANCY

History

An obviously pregnant woman is brought to the emergency department having suffered a seizure in the park 20 min ago. She had been alone at the time but the seizure was wit- nessed by another woman who said that she had stood up from a bench and then suddenly dropped to the ground. She thought she may have hit her head on the side of the bench with the fall. Her arms and legs had been shaking and then were ‘stiff and trembling’ for about 40 s. The woman’s face had gone dusky and there was some frothing at the mouth. She noticed that the woman’s trousers were wet afterwards.

When the fit stopped the woman had appeared unconscious for a few minutes and then showed some response to being talked to but seemed confused and drowsy.

Examination

She appears to be about 30 years old and in the third trimester of pregnancy. She is now conscious but still drowsy and her Glasgow Coma Scale is 9/15.

Her blood pressure is 140/98 mmHg and heart rate 104/min. Examination shows no obvi- ous cardiac or chest abnormality, and on abdominal palpation there is no apparent ten- derness. The uterus feels approximately 30-week size (midway between umbilicus and xiphisternum), and a fetus can be palpated, cephalic with 4/5 palpable. Reflexes are brisk and plantar reflexes are upgoing.

Questions

·             What is your provisional diagnosis and how would you manage this woman in the first instance?

·              The woman’s husband arrives shortly and explains that she is a known epileptic who has grand mal seizures every few days, despite drug treatment. How should your man- agement alter now?

ANSWER

Any woman with a fit in the second half of pregnancy should be assumed to have eclamp- sia until proven otherwise. The risks of maternal or perinatal mortality are so great that it is better to treat the woman for eclampsia and prevent a further seizure than to spend time investigating and making a certain diagnosis while risking further fits. This case is there- fore an obstetric emergency (despite the fact that the fit resolved spontaneously), and help should be summoned from the anaesthetist, senior midwife, senior obstetrician and paediatrician.

Magnesium sulphate should be given as an intravenous bolus of 4 g, followed by an infu- sion in normal saline of 1 g/h (increased if further fits occur).

Once this has been commenced, a urine sample should be acquired (with insertion of a Foley catheter to monitor urine output) for proteinuria. Fluid input should be restricted initially to 85 mL/h. Blood should be sent for full blood count, urea and electrolytes, urate, liver function tests, coagulation screen and group and save. She should be transferred to a high-dependency area of the labour ward with continuous electrocardiogram and car- diotocograph monitoring.

Once stable and further investigations have been made into her previous history, a deci- sion can be made regarding delivery.

Epilepsy diagnosis

The fact that the woman has epilepsy strongly suggests that this fit is caused by the epilepsy. However, the initial management was still correct as you will not be sure that the fit was due to this until the urinalysis has been confirmed to be normal and the blood pressure, initially high, has normalized, the reflexes returned to normal and the blood tests results are found to be normal.

Reflexes are commonly brisk, with upgoing plantar responses in the post-ictal phase.

This woman regained full consciousness after half an hour and the blood pressure was normal with negative urinalysis and normal blood results. The magnesium was thus dis- continued and she was discharged with her husband, for neurological review within the next few days to discuss compliance and drug regime.