GuidelinesOther guideline
Epilepsy
The guidelines recommend management of common obstetric conditions at primary and referral level, based on local experience and evidence-based practice. They are not intended as strict protocols nor as standard operating procedures, but rather as a guide to safe effective management of common obstetric problems. The guidelines should be most useful to interns, medical officers and registrars.
Most pregnant epileptic patients are already on treatment. Those who have been off treatment & fit-free for over 2 years need not be on medication. Epileptic management is best achieved in a dedicated obstetric epileptic clinic
- Request an 18-22 week detailed ultrasound scan to exclude fetal anomalies
- The drug of choice is carbamazepine, usually at 200-400 mg 12 hourly orally
- Monitor carbamazepine blood levels in poorly controlled epileptics. The therapeutic range is 8-12 mg/mL
- Use monotherapy wherever possible (carbamezapine or lamotrigine)
- Do not change non-carbamazepine treatment (e.g. phenytoin) if it is effective
- Give folic acid 5 mg orally daily throughout the pregnancy
- If convulsions occur in a compliant patient, increase the evening dose of carbamazepine, or add phenobarbitone 30-60 mg or clonazepam 0.5 mg orally as evening doses if necessary.
- Obstetric care is the same as for non-epileptic women
- Do not omit doses of anti-epileptic drugs, even during labour
- At delivery, inform the paediatric doctors that the woman is epileptic
- Breastfeeding is safe with the anticonvulsants mentioned above
- After delivery, readjust treatment to pre-pregnancy doses
Convulsions occurring for the first time in pregnancy
- Admit to hospital
- Consider and rule out eclampsia as a cause
- Consult an internal medicine specialist or neurologist
- Do skull x-ray, and take blood for FBC, U&E, calcium/magnesium/phosphate, antinuclear factor, anticardiolipin antibody, lupus anticoagulant, cysticercosis serology, syphilis serology and HIV before referral
- Electroencephalogram and brain imaging may be ordered by the neurologist
Treatment of status epilepticus
- Turn patient to left lateral, protect airway and give oxygen by mask
- Start an IV infusion – if not possible, give diazepam 10-20 mg rectally
- Check blood glucose level and give 50% dextrose 50 mL IV if glucose is low
- Give lorazepam 0.1 mg/kg (5-10 mg) at 2 mg/kg, or diazepam 0.2 mg/kg (10-20 mg) IV over 2 minutes at 5 mg/minute, or. Beware respiratory depression
- Except in the first trimester, give phenytoin 15-20 mg/kg (±1000 mg) IV infusion in 200 mL normal saline over 30 minutes; repeat 125 mg IV 8 hourly
- If phenytoin is not effective, or as an alternative, give phenobarbital 20 mg/kg IV at 100 mg/minute; repeat 1 mg/kg IV 6 hourly
- Call for neurology support, & consider paralysis and ventilation if seizures cannot be controlled after one hour