Seizure

Hx: A previously healthy 15 yo female presents by EMS for a generalized seizure. The patient is post-ictal and unable to give any history on arrival. The paramedics state they were called to the scene for a seizure and found the patient post-ictal on arrival. Minimal history was obtained from family on scene but there is no history of prior seizures. The patient had a second seizure in route to the ED and received a single dose of diazepam 5mg IV with termination. When the patient’s mother arrives later she confirms the patient has no past medical history.

PMHx: none

SocHx: none

Exam:

  • Vitals: Pulse 100, BP 160/100, RR 20, Temp 98.9F, O2Sat 100% with a NRB mask
  • General: obese female, appears 15 yo, post-ictal, poorly arousable
  • HEENT: normal head, atraumatic, TM’s clear, pharynx clear, normal tongue, gag reflex present
  • Resp: clear to auscultation, adequate respirations, good air movement
  • Cardiovascular: tachycardic, regular, no murmurs, symmetrical pulses x 4 extremities
  • Abdomen: obese, no masses, soft, no pain response with palpation
  • Extremities: no deformity, warm
  • Neuro: withdraws to pain, pupils 4mm bilaterally, eyes midline, no rigidity, no spontaneous movement

Differential:

  • toxic ingestion
  • illicit drug use (cocaine, amphetamines)
  • intracranial mass
  • intracranial hemorrhage
  • arrhythmia (hypkalemia)
  • head injury, trauma
  • CVA
  • withdrawal seizure (alcohol, benzodiazepine)
  • pregnancy

ED Course:

  • IV access, monitor, pulse oximtery, IV fluid bolus, interview of family is conducted.
  • Patient has a generalized tonic clonic seizure shortly after arrival and receives 1 mg lorazepam IV with termination.
  • Patient is taken for CT of the head and has a second seizure where she is given another 1 mg lorazepam dose with termination.
  • When patient is returned to the room, she is post-ictal, but has not awakened between seizures. Discussion with family regarding differential.
  • Patient has a third seizure and final lorazepam 1mg dose IV is given with plans for RSI and propofol infusion.
  • Prior to RSI, mom alerts staff that patient appears to be passing something vaginally.
  • Immediate examination reveals patient is delivering a baby, appears to be 20-22 weeks gestation.
  • Neonatal team is alerted as baby is delivered but shows obvious signs of intra-uterine demise. A brief resuscitation of the baby is attempted with intubation and IV epi without success.
  • Meanwhile, the patient is intubated with RSI and placed on propofol infusion while 4 gram bolus of Magnesium is initiated IV for eclampsia.
  • Labetalol is given IV for BP control (20 mg boluses)
  • Family was unaware of patient’s pregnancy or sexual activity.

Hospital Course:

  • The patient is admitted to the ICU where EEG shows no further seizure activity.
  • After 24 hours of magnesium infusion and continued labetalol for BP management the patient is extubated.
  • She survives to discharge, neurologically intact.

Diagnosis: Eclampsia

Discussion: Eclampsia is a pregnancy related condition consisting of generalized tonic-clonic seizures and coma that occur after a period of pre-eclampsia. Seizures are often preceded by: (see references)

  • hypertension (75%) – with almost half being only mild hypertension.
  • headache (66%)
  • visual disturbances (27%)
  • right upper quadrant or epigastric pain (25%)
  • asymptomatic (25%)

Although ecplampsia is often discussed as occurring during pregnancy, up to 21% of cases occur post-partum, with 20% intrapartum, and 59% antepartum.

Treatment of eclampsia is focused on prevention of recurrent seizures, treatment of hypertension, supportive care, and delivery of baby if pregnant:

  • Magnesium sulfate is given as a bolus of 4-6 grams over 15min followed by an infusion of 2 grams/hour and typically continued for 24-48 hours post delivery. Magnesium is given to prevent further seizures and has been proven to be far more effective than traditional anti-epileptic medications in this scenario. If it does not result in prompt resolution of seizures, second line agents include benzodiazepines and a pathway similar to status epileptics. At this point, imaging and neurology consultation for EEG is suggested to guide management.
  • Labetalol or other IV agents are given to manage blood pressure and reduce systolic below 160 and diastolic below 105
  • Prompt delivery of the baby is required as expectant management has been shown to fail, despite adequate medical therapy.

Women with eclampsia are at increased risk of developing pre-eclampsia with subsequent pregnancies.

References:

Systematic Review of Eclampsia

Up-To-Date Eclampsia

Disclaimer

De-identificaiton is undertaken utilizing the Safe Harbor method described by the US Department of Health and Human Services. All remaining patient information required for teaching purposes has been altered to maintain this standard.

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