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Status Epilepticus and Pregnancy
STATUS EPILEPTICUS AND PREGNANCY Case Report MILTON D. KLEIN, M.D., MILTON IRVING
A.
J.
GOODFRIEND, M.D., AND
SHEY, M.D., NEw YoRK, N.Y.
(From the Department of Obstetrics and Gynecology, Morrisania City Hospital, New York)
'V 1 RILE
the obstetrical literature has a rather complete exposition of epilepsy associated with pregnancy, scant attention is given to- status epilepticus. Since the organization of the Obstetrical Service at the Morrisania City Hospital in 1929, 2 patients were seen with this complication; both died. During this period there were 52,000 deliveries. The prognosis of this disease when associated with pregnancy is, according to most authorities, almost always fatal. 1 - 4 Burnett, 5 however, in 1946 reported the case of a primipara with status epilepticus in the thirty-third week of pregnancy who recovered after induction of labor by rupture of the membranes. The infant lived. One year later, Goodwin and Lawson 6 observed this complication in a primipara during the first trimester of pregnancy. She survived and continued until her expected date of delivery at which time a living child was born. Because of the seriousness of this condition and the infrequency with which it has been described the following case is reported.
W
Mrs. R. J., a 39-year-ol
manufactured by Parke, Davis & 188
Company,
Volume 72 Number I
STATUS EPILEPTICUS AND PREGNANCY
189
11/z grains every four hours, and phenobarbital, 11;2 grains every three hours, by Levine tube. In addition, oxygen, penicillin, and an infusion of glucose and water were admiJt· istered. Between 12:05 A.M. and 10:00 A.M. on Jan. 6, 1954, she had 18 convulsions. Paraldt• hy•le was aven mild convulsions. At 7:30 P.M. she became very rt•Rtless and was having moderately ~trong ut<'rine <'ontrartions at regular 5 minute intenals la~ting :lO Sf!<'onds. One hour aft,,r thH onset of labor she became cyanotic; the temperature was lOP F., the pulse in .. n•aseo to 120, and the reRpirations were 24 per minute; tlw blood pressun• wa~ 110/50. l'ontilllWll' s111't.ion of the seeretions of nose and throat became ner.t'ssary. lle~pite thi~ therapy and although she har :!1.2 hnttr~, 'hP die
Comment There are several features of this case worthy of emphasis. Our patient had been an epileptic for many years and had failed to receive the benf\fits of continuous observation and treatment. It appears that the lack of therapy in our patient had an adverse effect on her disorder. This was manifested by epileptic seizures which within a short period after their onset became very severe, frequent, and uncontrollable. It also seems that the disease had an unfavorable effect on the pregnancy as evidenced by intrauterine death and premature labor. As to the diagnosis, it is imperative that immediate and complete examination be made in every woman with convulsions and/or coma. Convulsivn toxemia of pregnancy had to be considered. The normal blood pressure. th(• absence of albuminuria, and lack of edema were sufficient evidence against the presence of toxemia. J..~ikewise, intracranial lesions such as hemorT'hage~'> and tumors may produce a similar clinical pic•ture. The laek of focal neurological signs, the normal spinal fluid findings. and negative eye grunnch.; rulc•d against such pathological conditions. The therapy was aimed chiefly at the control of the convulsions by lllenns of sedation. Of all the sedatives employed, the continuous intr·avenuus P1mto· thai sodium solution seemed to be most effective. We regret that the Pen to thal was started rather late in the course of the disorder, for it is possible that. had she received this treatment immediately upon admission to the hospital there might have been a better chanee for control of the convulsions. 'l'he question of interruption of the pregnancy was considered when treat. ment failed to produce appreciable improvement after 24 hours. It was om belief, however, that the condition of the patient at all times contraindicated cesarean section or any other operative procedurr. :Even separation and low J·nptnl'e of the membranes was impossible with a long· unripe pr·imiparous cervix.
190
KLElN, GOOD:F'RHJND, AND SHEY
An1
r OlH.luly, & Gyne. l956
Summary A case of status epilepticus during pregnancy is presented; the differential diagnosis and the therapy are discussed. References 1. Sachs, E.: Monatschr. Geburtsh. u. Gyniik. 32: 649, 1910. 2. DeLee, J. B.: Principles and Practice of Obstetrics, ed. 7, Philadelphia, 1938, W. B. Saunders Company. 3. Greenhill, J. P.: Practitioners' Library of Medicine and Surgery, New York, 1934, D. Appleton-Century Company. 4. Jardine, R.: J. Obst. & Gynaec. Brit. Em~. 12: 28, 1907. 5. Burnett, C. W. F.: J. Obst. & Gynaec. Bnt. Emp. 53: 539, 1946. 6. Goodwin, J. F., and Lawson, C. W.: Brit. M. J. 2: 332, 1947.
A.
J.
GOODFRIEND, M.D., AND
SHEY, M.D., NEw YoRK, N.Y.
(From the Department of Obstetrics and Gynecology, Morrisania City Hospital, New York)
'V 1 RILE
the obstetrical literature has a rather complete exposition of epilepsy associated with pregnancy, scant attention is given to- status epilepticus. Since the organization of the Obstetrical Service at the Morrisania City Hospital in 1929, 2 patients were seen with this complication; both died. During this period there were 52,000 deliveries. The prognosis of this disease when associated with pregnancy is, according to most authorities, almost always fatal. 1 - 4 Burnett, 5 however, in 1946 reported the case of a primipara with status epilepticus in the thirty-third week of pregnancy who recovered after induction of labor by rupture of the membranes. The infant lived. One year later, Goodwin and Lawson 6 observed this complication in a primipara during the first trimester of pregnancy. She survived and continued until her expected date of delivery at which time a living child was born. Because of the seriousness of this condition and the infrequency with which it has been described the following case is reported.
W
Mrs. R. J., a 39-year-ol
manufactured by Parke, Davis & 188
Company,
Volume 72 Number I
STATUS EPILEPTICUS AND PREGNANCY
189
11/z grains every four hours, and phenobarbital, 11;2 grains every three hours, by Levine tube. In addition, oxygen, penicillin, and an infusion of glucose and water were admiJt· istered. Between 12:05 A.M. and 10:00 A.M. on Jan. 6, 1954, she had 18 convulsions. Paraldt• hy•le was a
Comment There are several features of this case worthy of emphasis. Our patient had been an epileptic for many years and had failed to receive the benf\fits of continuous observation and treatment. It appears that the lack of therapy in our patient had an adverse effect on her disorder. This was manifested by epileptic seizures which within a short period after their onset became very severe, frequent, and uncontrollable. It also seems that the disease had an unfavorable effect on the pregnancy as evidenced by intrauterine death and premature labor. As to the diagnosis, it is imperative that immediate and complete examination be made in every woman with convulsions and/or coma. Convulsivn toxemia of pregnancy had to be considered. The normal blood pressure. th(• absence of albuminuria, and lack of edema were sufficient evidence against the presence of toxemia. J..~ikewise, intracranial lesions such as hemorT'hage~'> and tumors may produce a similar clinical pic•ture. The laek of focal neurological signs, the normal spinal fluid findings. and negative eye grunnch.; rulc•d against such pathological conditions. The therapy was aimed chiefly at the control of the convulsions by lllenns of sedation. Of all the sedatives employed, the continuous intr·avenuus P1mto· thai sodium solution seemed to be most effective. We regret that the Pen to thal was started rather late in the course of the disorder, for it is possible that. had she received this treatment immediately upon admission to the hospital there might have been a better chanee for control of the convulsions. 'l'he question of interruption of the pregnancy was considered when treat. ment failed to produce appreciable improvement after 24 hours. It was om belief, however, that the condition of the patient at all times contraindicated cesarean section or any other operative procedurr. :Even separation and low J·nptnl'e of the membranes was impossible with a long· unripe pr·imiparous cervix.
190
KLElN, GOOD:F'RHJND, AND SHEY
An1
r OlH.luly, & Gyne. l956
Summary A case of status epilepticus during pregnancy is presented; the differential diagnosis and the therapy are discussed. References 1. Sachs, E.: Monatschr. Geburtsh. u. Gyniik. 32: 649, 1910. 2. DeLee, J. B.: Principles and Practice of Obstetrics, ed. 7, Philadelphia, 1938, W. B. Saunders Company. 3. Greenhill, J. P.: Practitioners' Library of Medicine and Surgery, New York, 1934, D. Appleton-Century Company. 4. Jardine, R.: J. Obst. & Gynaec. Brit. Em~. 12: 28, 1907. 5. Burnett, C. W. F.: J. Obst. & Gynaec. Bnt. Emp. 53: 539, 1946. 6. Goodwin, J. F., and Lawson, C. W.: Brit. M. J. 2: 332, 1947.