Epilepsy

1. What is epilepsy?
   1. Seizure – clinical manifestation of an abnormal and excessive discharge of set of a neurons in the brain
   2. Epilepsy – neurological disorder characterized by recurrent epileptic seizures unprovoked by any immediately identifiable cause.
   3. Prevalence – 0.5-1%.

2. What are types of epilepsy?
   1.       Partial/focal seizures
      1. Simple partial – unimpaired consciousness
      2. Complex partial / secoundary generalized
   2.       Generalized seizure
      1. Absence – petit mal
      2. GTC – grand mal
      3. Juvinle Myoclonic seizure

3. What are the secoundary causes ?
   1. Brain tumours
   2. Trauma
   3. APLS
   4. Infection
   5. Electrolyte imbalance
   6. Cardiac – arrhythmia, AS, vasovagal
   7. Pregnancy related
      1. Eclampsia
      2. TTP

• Cerebral venous thrombosis

1. PRES

4. How do you differentiate true seizure from non-epileptic attack disorder ?
   • Closed eye lid resistance to opening
   • Biting of tongue at tip of toungue
   • Side to side head shaking
   • Rapid post ictal orientation

• What is the incidence of major congenital abnormalities with AEDs
  1. Background risk = 2-3%

Major congenital anomalies – NTDs, orofacial clefts, CHD adnd hypospadias

• Valproate – 6.7% – highest incidence
• Lowest incidence – EURAP study
  • Carbamazepine <400mg – 3.4%
  • Lamotrigine <300mg – 2%

Long term effects – sodium valproate

• Decrease IQ – verbal IQ, performance IQ
• Childhood autism (HR – 2.9)

• Preconception care?
  1. Neurological assessment by a specialist
     1. Correct diagnosis
     2. Re-evaluation of drugs
        1. Seizure free for 2 years – discontinue drugs not in juvenile myoclonic epilepsy
        2. Lowest effective dose
        3. Monotherapy
     3. Discuss about the benefits and teratogenic risk
     4. Folic acid 5mg at least 3 months before conception
     5. Advised to get pregnant while patient is seizure free
        1. No seizure for 9 months – 84-92% seizure free during pregnancy
        2. Uncontrolled seizure – risk of SUDEP – X10 time higher
     6. Risk of child having epilepsy
        1. 4-5%

1. Implication of seizure and AEDs

Maternal

• Increase seizure frequency 10-30%
• Increased preeclampsia
• Increased CS
• Increased miscarriage
• Preterm labour
• Placental abruption
• Trauma
• SUDEP
• Psychological problems
  • Increased depression
  • Low self esteem

Fetal

• Congenital abnormalities
• Risk of epilepsy in child

What is SUDEP?

‘sudden, unexpected, witnessed or unwitnessed, non-traumatic and non-drowning death in patients with epilepsy, with or without evidence for a seizure and excluding documented status epilepticus, in which postmortem examination does not reveal a toxicologic or anatomic cause for death.

35 year old mother of 1 child admitted following episode of a seizure how will you access ?

• History from patient and witness
• PET symptoms – headache, visual disturbances, epigastric pain
• Fever , SOB, chest pain
• Palpitation
• Urine for protein
• BP, PR, SpO2, temperature
• Blood investigations
  • FBC, BU, LFT,SE, calcium, phosphate, RBS, clotting profile
• CT/MRI/MRA
• ECG
• EEG

• What happens to epilepsy during pregnancy?
  • 2/3 remain seizure free

• Reasons for detoriaration ?
  • Lack of drug compliance due to fear of teratogenesis
  • Decreased drug level
    • Haemodilution
    • Poor absorption
      • Nausea and vomiting
    • Psychoogical stress

• Antenatal management
  • Early booking
  • Combined clinic
  • Dating scan
  • Anomaly scan +( fetal echo )
  • Serial growth scan
  • (Vitamin K 10-20mg from 36 weeks for who are on enzyme-inducing drugs ) – insuffcient evidence
  • MOD – routine

• Seizure management
  • Call for help
  • Record the events
  • Move the patient from dangerous zone if in bed put the bars
  • Move the dangerous objects away from the patient
  • Left lateral position
  • Oxygen – high flow oxygen
  • Secure airway after convulsion stops
  • Monitor vital signs – BP,PR,ECG, RR, Temperature, saturation , FHR
  • Iv access – FBC, RFT,LFT, clotting profile
  • CTG
    • reduced variability – after diazepam – 1hr
  • Monitor the patient
  • Until proven otherwise manage as eclampsia

• Patient develops GTC 4 episode without regaining consciousness, what is the condition?
  • Status epilepticus

Definition.

30 minutes of continual seizure activity or a cluster of seizures without recovery

• Management
  • Call for help
  • Left lateral position
  • Oxygen
  • Iv access – 2 large bore cannula
  • Blood for investigation
  • Iv drugs
    • Lorazepam 4mg
    • Iv fluids
    • If hypoglycaemic – iv dextrose
    • Iv phenytoin 15mg/kg infusion-15-20mg/kg bolus+ 1-2mg/kg/hr infusion

Intrapartum management

• • Hospital based delivery
  • Don’t leave women unattended
  • Continue antiepileptics
  • Maintain hydration
  • Avoid – maternal exhaustion and hyperventilation
  • High risk – IV or rectal antiepilepstics
  • Continous electronic fetal monitoring
  • Adequate pain relief – avoid pethidine – diamorphine is the choice

Seizure duing labour 

• • Left lateral position
  • Oxygen via face mask
  • Intravenous lorazepam / diazepam iv or rectal

• Postpartum
  • Risk of seizure in 1st 24 hour is 1-2%
  • Additional support
    • Avoid sleep deprivation
  • Encourage to breast feed
    • Lamotrigine and phenobarbitone – breast feed before their medication
  • Advise
    • Changing nappies on the floor
    • Bathing baby in very shallow water or under supervision
  • Neonate
    • 1mg IM vitamin K

• Contraception
• Enzyme inducing drugs
  • Efficacy reduced
    • COCP -lamotrigine level decreased
    • POP
  • Suitable
    • DMPA
    • LNG-IUS- most suitable
    • IUCD

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