Case 92: Fits in pregnancy

 CASE 92: FITS 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 witnessed

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 obvious

cardiac or chest abnormality, and on abdominal palpation there is no apparent tenderness.

The uterus feels approximately 30 weeks in 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.

INVESTIGATIONS

No investigation results are yet available for this patient when you see her.

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

management alter now?100 Cases in Obstetrics and Gynaecology

262

ANSWER 92

Any woman with a fit in the second half of pregnancy should be assumed to have eclampsia 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

therefore 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 infusion

in normal saline of 1 g/h (increased if further fits occur).

Once this has been commenced, the blood pressure should be checked, with intravenous

antihypertensives started if appropriate. 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 cardiotocograph monitoring.

Once stable and further investigations have been made into her previous history, a decision

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 postictal 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 discontinued and she was discharged with her husband, for neurological review within the next

few days to discuss compliance and drug regime.

KEY POINTS

• A woman who presents in the third trimester of pregnancy with a grand mal seizure

should be treated as eclamptic until proven otherwise.