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Table of Content - Volume 3 Issue 1 - July 2016


 

Study of clinical profile of convulsions during pregnancy

 

S B Jagtap1, S P Toshniwal2*, Y J Kulkarni3, M V Kabara4

 

1,2Associate Professor, 3JR, 4SR, Department of Medicine, Government Medical College, Latur, Maharashtra, INDIA.

Email: kulkarniyogesh95@gmail.com, drsb_jagtap@yahoo.com

 

Abstract              Background: Convulsions during pregnancy is major cause of maternal and fetal morbidity and mortality. Poor antenatal care, low socio economic status and illiteracy are responsible for higher incidence of eclampsia. This study describes the clinical profile of pregnant females who developed convulsions. Material and Methods: A total of 100 Pregnant females admitted in emergency ward or ICU and developed convulsions during their pregnancy period diagnosed on the basis history and clinical grounds were included. Etiology of convulsions were determined on the basis of history by relatives or paramedics, clinical examination and relevant laboratory investigations. Outcome was assessed at termination pregnancy as morbidity or mortality in the mother or fetus. Results: Out of 100 pregnant females with convulsions, majority 46 belonged to 22-25 years age group. The mean age of patients was23.84±3.55years.60 were primigravida and 75 developed convulsions in third trimester.61 females developed single episode of convulsion while 39 females had multiple episodes of convulsions. 12 had focal and 88 had GTCS type of convulsions. The main presenting complaints were headache, vomiting, fever and altered sensorium. Discussion: Eclampsia can be effectively controlled and treated with timely and good antenatal care. In predicting the mortality and morbidity, age, gravidity and number of convulsions were not significant whereas trimester of development of convulsions, type of convulsions and etiology were found to be significant.

 Keywords: Pregnancy, convulsions, gravidae, trimester, morbidity.

 

INTRODUCTION

Convulsions during pregnancy is major cause of maternal and fetal morbidity and mortality. Apart from idiopathic cause, the various other causes of seizures in pregnancy include anti-phospholipid syndrome, eclampsia, cerebral vein thrombosis, thrombotic thrombocytopenic purpura, cerebral infarction, drug and alcohol withdrawal, and hypoglycemia 1. Epilepsy is a chronic neurologic disorder that may complicate pregnancy, affecting about 0.5% of pregnancies 2. The risk of seizures increases at delivery, with 1% to 2% of women with epilepsy having a seizure during labor or in the first 24 hours postpartum2. Uncontrolled seizures during pregnancy are dangerous to both the mother and fetus. Tonic-clonic seizures can cause physical injury and abruptio placentae in the mother and hypoxia, acidosis, intracranial hemorrhage and death in the fetus3. Pregnancy and puerperium are well established causes of venous thromboembolism (VTE), including intracranial venous thrombosis4,5. Several physiological changes in coagulation system render pregnancy and puerperium prothrombotic states6,7. Major clinical features of obstetric CVT are similar to CVT unrelated to pregnancy. These include headache, focal deficits, seizures and mental status changes. Mental status changes especially somnolence/drowsiness were more common in obstetric CVT8. On the contrary isolated intracranial hypertension was more frequent in CVT unrelated to pregnancy8. It is important to differentiate this condition from other pregnancy associated central nervous system (CNS) disorders i.e. eclampsia and postpartum cerebral angiopathy. Prognosis of CVT is quite variable and the outcome ranges from total recovery to death. The risk of stroke and cerebrovascular complications are increased in pregnancy and puerperium compared to the non-pregnant women9. The reported incidence of primary brain tumors in pregnant women is slightly lower, but the relative frequencies of each brain tumor type appear to be similar for pregnant and non-pregnant women 10.Malaria in pregnancy is significantly associated with higher mortality and morbidity including, cerebral malaria, maternal anemia, intrauterine growth retardation, premature labor, stillbirth and abortion 11,12. In addition; drugs used for treatment of malaria can also contribute significantly to complications associated with this disease. The incidence of eclampsia varies greatly from zone to zone in the same country. Poor antenatal care, low socio economic status and illiteracy are responsible for higher incidence of eclampsia. This study describes the clinical profile of pregnant females who developed convulsions.

 

MATERIAL AND METHODS

This Prospective observational analytical study was conducted over a period of two years in a tertiary care hospital. A total of 100 pregnant females admitted in emergency ward or ICU and developed convulsions during their pregnancy period diagnosed on the basis history and clinical grounds were included in the study after taking informed and written consent from close relative. Pregnant females who developed convulsions due to head injury, drug abuse and poisoning and not willing to give consent were excluded from the study. On arrival to emergency unit, initially stabilization of vital functions was done. All patients were treated with intravenous lorazepam (0.1mg/kg) for cessation of active convulsions. Acute respiratory and cardiovascular problems were addressed. After initial stabilization detail history was obtained, consciousness level was assessed. Clinical signs like heart rate, blood pressure, pupillary reflexes and fundoscopy were examined and noted. Etiology of convulsions were determined on the basis of history by relatives or paramedics, clinical examination and relevant laboratory investigations. Routine investigations like hemogram, renal and liver function test, blood sugar, serum electrolytes were performed. Investigations such as lumbar puncture, MRI scan and metabolic work up depending on the clinical presentation were performed. Following initial investigations in emergency unit, the patients were transferred to intensive care unit where they had further treatment. Standard practice guidelines, as per the protocol of the hospital were used in the management of the patients. Monitoring was carried for recurrence of convulsions and maternal and fetal outcome up to the delivery or termination of pregnancy. Outcome was assessed at termination pregnancy as morbidity or mortality in the mother or fetus.

 

RESULTS

This was observational analytical study conducted over a period of 2 years. A total of 100 pregnant females who developed convulsions had been included. Eclampsia as a cause of convulsions in pregnancy was found in 60 out of 100 patients. The mean age of the patients was 23 years (Table 1).

 

Table 1: Age wise distribution of pregnant females of eclampsia

Age group (years)

Number of patients (n=60)

Percentage

(%)

18-21

18

30%

22-25

27

46%

26-29

11

18%

30-35

4

6%

The etiological distribution of these patients were as follows.

 

Table 2: Etiological distribution of pregnant females who developed convulsions

Etiology

Number of patient (N=100)

Eclampsia

60

Seizure disorder

24

Cerebral venous sinus thrombosis

6

Cerebral malaria

3

Hemorrhagic stroke

2

Tuberculous meningitis

2

Tuberculoma

1

Ischemic stroke

1

CNS Glioma

1

Out of 100 patients, 46 (76%) were primigravidae and 14 (24%) were multigravidae. About 48 (80%) patients developed convulsions in third trimester, whereas, 12 (20%) developed convulsions in second trimester. None of the patient developed convulsions during first trimester. The distribution of patients according to the trimester was as follows. The main presenting complaint was headache found in about 36 patients and vomiting in 9 patients. The distribution of presenting features is depicted in Table 3.

 

Table 3: Distribution of presenting feature in eclampsia patients

Presenting clinical

Features

Number of patients(n=60)

Percentage

(%)

Headache

36

60%

Vomiting

9

15%

Blurring of vision

13

22%

Giddiness

9

15%

Out of 60 patients of eclampsia, 46 (76%) patients developedsingle episode of convulsions, whereas 14 (24%) patients developed multiple convulsive episodes. In our study, 27 (45%) patients had systolic BP ≥160 mm Hg and diastolic BP ≥ 110mm Hg, 32 (53.33%) patients had systolic BP 140-159 mmHg and diastolic BP in range of 90-109 mm Hg and 1 (1.66%) patient had BP < 140mm Hg systolic and diastolic < 90 mm Hg. In eclampsia patients, proteinuria was found in 54 patients i.e. 90% and papilledema was present in 12 patients i.e. 20%. Out of 60 patients of eclampsia 37 patients had delivered by cesarean section and 23 had been delivered normally. In our study, 2 mother had died, one had developed massive intracerebral hemorrhage and other had developed HELLP syndrome with DIC with multi-organ failure. In remaining 58 patients of eclampsia, the maternal complications were as shown in Table 4 and 5.

 

Table 4: Distribution of maternal complications in eclampsia patients

Complications

Number of patients

Percentage

AKI

4

6%

Pulmonary edema

2

2.8%

Placental abruption

6

10%

CVA

1

1.4%

Neuro-deficit

3

5.5%

Aspiration pneumonia

3

4.2%

Visual field defects

1

2.3%

                                              

Table 5: Fetal outcome in eclampsia patients

Complications

Number of patients (n=49)

Percentage

IUGR

19

32%

Birth asphyxia

11

18%

Fetal death

12

20%

Meconium aspiration

7

11%

 

DISCUSSION

The occurrence of eclampsia has decreased over time, but characteristics and outcomes seem to be largely unchanged. Eclampsia can be associated with devastating complications and continues to pose a physiopathologic and therapeutic challenge. In present study, eclampsia was major cause of convulsions followed by seizure disorder and cerebral venous thrombosis which was in concordance with the study by Sharshar T et al13. Out of 100 patients, 60 had developed convulsions, due to eclampsia i.e. 60%. Mean age of the patients was 23 years which correlates with the mean age of 25years of the study of Kumar S et al14 and also with 22.35 years by the study of Mauro et al15. Age group distribution in present study correlates with results of Khan Aet al16. According to the study by Khan A et al16, teenagers contribute about 34.42% and about 49.57% patient belongs to age group of 20-24 years. In our study 46 patients, i.e. 76% patients were primigravida and 14 patients i.e., 24% were multigravida which was in concordance with study of Kumar S et al14 showing 71% of primigravida and 29% of multigravida but slightly varies from results of Khan A et al16 showing 83% of primigravida and 17% of multigravida. The mean gestational age at delivery was 35 weeks which was comparable to study by Mauro et al15 of 34 weeks. In present study, 76% patient developed single convulsive episode, whereas 14 patients i.e., 24% developed multiple convulsive episodes which correlates with the study by Kumar S et al14 showing 85% of patient had single convulsive episode and study by Mauro et al15 showing 68% of patient had single convulsive episode. The main presenting complaint in patients of hemorrhagic stroke was headache which was present in both of them i.e. 100% and altered sensorium in one i.e. 50% which simulates with results of Sharshar T et al13 showing 81% of patient having headache and 81% having impaired consciousness. In ischemic stroke patient headache was the only were presenting complaint. In the study by Sharshar T et al13 it was found in 73.33% of patients. In conclusion, eclampsia is most common etiology for development of convulsions in pregnant females. 23-25 years is the most common age group and most convulsions found in third trimester. Maximum number of convulsive pregnant females had headache as the presenting complaint. In predicting the mortality and morbidity, age, gravidity and number of convulsions were not significant whereas trimester of development of convulsions, type of convulsions and etiology were significant. Regular ANC checkup, health education of pregnant females, frequent blood pressure monitoring and urine protein checkup, appropriate AED in minimum dose with proper compliance, prompt diagnosis and appropriate treatment of convulsions will reduce maternal and fetal morbidity as well as mortality.

 

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