A Diagnostic Challenge in the Differential Diagnosis of Recurrent Seizures During Pregnancy: Epilepsy Versus Eclampsia

Introduction: Seizures during pregnancy are associated with adverse outcomes for mothers and infants. Seizures during pregnancy can be associated with multiple factors. To establish effective treatment and management of seizures, it is important to identify all of the factors that may contribute to seizures during pregnancy. Objective: This study aimed to evaluate and identify the cause of seizures in pregnancy to facilitate appropriate treatment. Case Report: We present a case of a 32-week pregnant woman who experienced eclampsia and recurrent seizures during the peripartum period. The patient had a history of inadequately managed epilepsy. Seizure management required multiple medications, including magnesium sulfate, benzodiazepine, and phenytoin. The patient underwent an emergency caesarean utilizing the Rapid Sequence Intubation (RSI) procedure and general anesthesia to rescue the baby. Nicardipine, furosemide, isosorbide dinitrate, captopril, spironolactone, and hydrochlorothiazide were used to manage blood pressure. The patient needs to be continuously observed, and the therapy should be adjusted according to the patient’s condition. Discussion: The patient had a history of epilepsy and had experienced two bouts of generalized seizures with characteristics of eclampsia before being arrived at the emergency room. Determining how to control the seizures in this spesific individual was a challenge. The primary therapy of patients with active seizures should include maintaining the airway, respiration, and circulation. The therapeutic objectives are immediate delivery of a viable fetus and maintenance of maternal health. Perioperative management aims to control blood pressure and seizures, maintain hemodynamics, manage anesthesia for terminating a pregnancy, and support critical care management for any potentially fatal complications from this condition. Conclusion: Seizures in pregnancy are attributable not just to eclampsia but can also cause by another or concurrently together with other causes. Early diagnosis and appropriate treatment are required to achieve the best outcome for this patient.

INTRODUCTION

Neurological diseases might be directly associated with pre-eclampsia, and eclampsia or may be related to pre-existing conditions such as epilepsy, multiple sclerosis, myasthenia gravis, brain tumors, cardiac, metabolic, and neuropsychiatric conditions. These conditions may cause neurological disorders during pregnancy and the puerperium, exacerbated by the physiological changes occur during this period (¹,²). Identifying the causative factors is important for obtaining appropriate treatment and managing seizures. The most frequent cause of seizures in pregnant women during the pregnancy-puerperal cycle is eclampsia. Eclampsia is commonly defined as the new onset of generalized tonic-clonic seizures or coma in pregnancy or postpartum accompanied by signs or symptoms of preeclampsia (³). The incidence of preeclampsia varies from 0.51 - 38.4%, with prevalence rates in developing countries ranging from 1.8 – 18%, while the incidence rate in Indonesia estimated at approximately 3.8-8.5%. In Indonesia, the Maternal Mortality Rate (MMR) in 2019 reached 305 per 100,000 live births, with severe preeclampsia accounting for 26.47% (76.97 per 100,000 live births) (⁴). Regardless, in situations that are resistant and have no improvement with conventional treatment, other possible causes of convulsive crises must be investigated or excluded. Epilepsy is one of the most common causes of seizures during pregnancy. Seizure in pregnancy can cause by various factors other than epilepsy or eclampsia, such as cerebral hemorrage, cerebral infarction, drug and/or alcoholic withdrawal, hypoglycemia, hypertensive encephalopathy, intracranial neoplasm, infections, and electrolyte imbalance (⁵,⁶). This neurological condition has a lifetime incidence of 1.5% in developing countries and 0.6% in industrialized nations (⁷). It is estimated that 0.3–0.7% of pregnant women have epilepsy. Women who had seizures in the year before becoming pregnant need to have their epilepsy closely monitored (¹). This case report aims to evaluate and identify the cause of seizure in pregnancy to facilitate appropriate treatment.

CASE REPORT

A 28-year-old multigravida was referred to our secondary care facility from a peripheral primary care clinic due to frequent seizures and hypertension. Her medical history indicates that she had suffered inadequately managed epilepsy for 14 years. She was diagnosed with a singleton pregnancy at 32 weeks of gestation, with a history of inadequate antenatal care. The patient’s family reported that the patient experienced tonic-clonic movements lasting two to three minutes. She had no previous history of hypertension, nevertheless, she had a history of generalized seizures since 14-years-old and was not on medication. Upon the patient’s convulsion at home, the midwife from the public health care facility administered an initial treatment of 4 grams of magnesium sulfate for 20 minutes, followed by a maintenance dose of 6 grams, and referred to the hospital. The glasgow coma scale (GCS) at admission was 8 (E2M3V3), blood pressure (BP) measured 176/125 mmHg, heart rate (HR) was 150 bpm, respiratory rate (RR) was 20 times/minute, and temperature was 36.6°C. Laboratory tests at admission showed proteinuria (urine protein 3+) as detailed inFigure 1and urine analysis in table 2. In the ER, the patient received magnesium sulfate 1 gram per hour, oxygenated with a non-rebreathing mask of 10 liters per minute, and underwent emergency cesarean section.

The patient was subsequently moved to the surgery room. Before surgery, the patient's condition was unstable. Basic monitoring was performed, which included pulse oximetry, heart rate, electrocardiography, and blood pressure assessment. The initial vital signs were: blood pressure of 171/101 mmHg, heart rate of 113 beats/min, respiratory rate of 29 times/minute in a semi-fowler position, and SpO2 of 98-99% with 10 liters/minute non-rebreathing mask oxygenation. Following preoxygenation, anesthesia was induced with Rapid Sequence Intubation (RSI), comprising midazolam 2 mg, fentanyl 50 mcg, propofol 100 mg, and rocuronium 40 mg, accompanied with cricoid pressure. The trachea was intubated using a cuffed orotracheal tube (7-mm internal diameter). Anesthesia was maintained with 0.5-1% isoflurane in oxygen at a flow rate of 3 liters/minute. Hydration was maintained with a peripheral intravenous line (Ringer’s lactate). The neonate had an Apgar score of 3 at birth. The Apgar score increased to 4 at 3 minutes and 5 at 5 minutes. The neonate was transferred to the neonatal intensive care unit (NICU) for further management under the pediatric supervision. The remaining intraoperative procedures were successfully performed. After completion of the surgery, she was transferred to the intensive care unit (ICU) for observation.

Table 1.Laboratory examination

Examination	Result
Hemoglobin	13.8 gr/dl
Leucocyte	15,200
Hematocrit	40.3%
Platelet	407,000
ALT	31.07 U/L
AST	11.22 U/L
Sodium	134.14 mmol/L
Potassium	4.02 mmol/L
Chloride	95.53 mmol/L
Calcium	0.92 mmol/L
Creatinine	1.27 mg/dl
Ureum	23.97 mg/dl
Bleeding time	2 minutes
Clothing time	9 minutes

Table 2.Urine analysis

Examination	Result
Spesific gravity	1.020
pH	6.0
Urine color	Cloudy yellow
Urine bilirubin	Negative
Urine protein	+++ (3+)
Urine glucose	Negative
Urine ketone	Negative
Blood	+++ (3+)

Following an emergency caesarean section, the patient was moved to the ICU for close monitoring. The patient was treated with continuous magnesium sulfate infusion, analgesia, and a furosemide pump to manage her blood pressure according to the hospital procedure. She was provided with a mechanical ventilator for her respiratory support. Within the next 30 minutes, her blood pressure suddenly increased to 239/136 mmHg. She received a continuous infusion of furosemide and isosorbide dinitrate (ISDN), an additional 25 mg of captopril, hydrochlorothiazide, and spironolactone to manage her blood pressure with an initial target to reduce her systolic blood pressure (SBP) to 160

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