Lesson pLan on

epiLepsy in pregnancy

Submitted to- Mrs. Somibala Thokchom

Tutor (OBG)
Rufaida College of Nursing
Submitted by- Ms. Sneha Sehrawat
M.Sc. Nursing (OBG)
III Semester
Rufaida College of Nursing
IDENTIFICATION DATA

NAME: Ms. Sneha Sehrawat

CLASS: MSc Nursing IIYear

SUBJECT: Obstetrics and Gynaecology Nursing

TOPIC: Epilepsy in Pregnancy

UNIT: Medical and Surgical Illness during pregnancy

GROUP: M.Sc. II nd year students (OBG)

SIZE OF THE GROUP: 05

DURATION: 30 mins

PLACE: M. Sc II nd year Classroom

METHOD OF TEACHING: Lecture-cum-discussion

AV AIDS USED: Powerpoint Pregnancy

DATE: 30/08/2017

TIME: 3-4 pm

LANGUAGE: English

PREVIOUS KNOWLEDGE: Students have previous knowledge from clinical experience regarding the

Topic: Epilepsy in Pregnancy.

GENERAL OBJECTIVE

After the class, students will be able to :-

 Acquire knowledge of topic- EPILEPSY IN PREGNANCY.

 Vocalize their learning about the topic .

 Explain various symtoms and riskfactors .

 Able to critically analyze the disease process and use the knowledge in nursing practice.

 Able to understand the management of epilepsy in pregnancy

 Understand the use and assimilate this knowledge in future clinical practices.

Student teacher will be able to :-

1. Develop confidence in facing the group.

2. Develop confidence in teaching.

3. Develop skills in classroom management.

4. Develop in-depth knowledge about the Topic.

5. Develop skills in appropriate utilization of A.V. aids.

7. Develop skills in lecture cum discussion method of teaching.

TIME SPECIFIC CONTENT TEACHING LEARNING EVALUATION
OBJECTIVE ACTIVITIES

INTRODUCTION
1 The oldest medical
min records show that
epilepsy has been
affecting people at
least since the
beginning of
recorded history.
Poverty is a risk and
includes both being
from a poor country
and being poor
relative to others
within one's
country.In the
developed world
epilepsy most
commonly starts
either in the young or
in the old. In the
developing world its
onset is more
common in older
children and young
adults due to the
higher rates of
trauma and infectious
diseases. It is also
one of the leading
cause of postpartum
maternal
complication.
1 ANNOUNCEMEN
min. T OF THE TOPIC
Today, I will discuss
about epilepsy in
pregnancy.
5 To define Epilepsy is recurring The student teacher
min epilepsy spontaneous seizures due to defines epilepsy
during sudden excessive and disordered during pregnancy
pregnancy. with the help of the
electrical discharge from the
powerpoint
neurones of the Cerebral presentation.
cortex.A chronic neurologic
disorder manifesting by repeated
epileptic seizures (attacks or fits)
which result from paroxysmal
uncontrolled discharges of
neurons within the central Define
nervous system . epilepsy in
pregnancy.
Epilepsy is a group of
neurological diseases
characterized by epileptic
seizures. Epileptic seizures are
episodes that can vary from brief
and nearly undetectable to long
periods of vigorous shaking.
These episodes can result in
physical injuries including
occasionally broken bones.

A chronic neurologic disorder

manifesting by repeated
epileptic seizures (attacks or fits)
which result from paroxysmal
uncontrolled discharges of
neurons within the central
nervous system (grey matter
disease)
The clinical manifestations
range from a major motor
convulsion to a brief period of
lack of awareness. The
stereotyped and uncontrollable
nature of the attacks is
characteristic of epilepsy.
3 To enlighten INCIDENCE OF EPILEPSY The student teacher
min about the enlightens about the
incidence of Approximately 50 million incidence of epilepsy
epilepsy in women currently live with in pregnancywith the
pregnancy. epilepsy worldwide. The help of the
estimated proportion of the powerpoint
general population with active presentation.
epilepsy.
7% of epileptic women become
pregnant .
What is the
Epilepsy affects about 0.5-1% of incidence of
pregnant women. epilepsy in
pregnancy?

10 To describe Depending on the location of the The student teacher

min the discharge of neurons, seizures describes the
pathophysiol may range from a simple staring pathophysiology of
ogy of epilepsy during
episode (absence seizures) to
epilepsy pregnancy.
during prolonged convulsive
pregnancy. movements with loss of
consciousness.

The initial pattern of seizure

indicates the region of the brain
in which the seizure originates.
In simple partial seizures, only a
finger or hand may shake, or the
mouth may jerk unncontrollably.
The person may talk
unintelligibly; may cause dizzy;
and may experience unusual or
unpleasant sights, sound, odour
or taste, but without loss of
consciousness.

In complex partial seizures, the

person either remains motionless
or moves automatically but
inappropriately for time and
place, or he or shemay
experience excessive emotions
of fear, anger, elation, or
irritability. Whatever the
manifestations, the person does
nt remember the episode when it
is over.

Generalised seizures, previously

referred to as grand mal
seizures, involve both
hemisphere of the brain, causing
both side of the body to react.
Intense rigidity of the entire
body may occur, followed by
alternating muscle relaxation
and cotraction (generalised
tonic-clonic contraction). The
simultaneous contarction of the
diaphragm and chest muscles
may produce a characterstic
epileptic cry. The tongue is often
chewed, and the patient is
incontinent of urine and feces.
After 1 or 2 minutes, the
convulsive movements begin to
subside; the patient relaxes and
liies in deep coma, breathing
noisily. The respirations at this
point are chiefly abdominal. In
this postictal state (after the
seizure), the patient is often
confused and hard to arouse and
 may sleep for hours. Many
patients report headache, sore
muscles, fatigue and depression.

5 To describe The main symptoms of epilepsy The student teacher

mins various are repeated seizures. There are describes various
symptoms of symptoms of
some symptoms which may
epilepsy epilepsy during
during indicate a person has epilepsy. If epilepsy.
epilepsy. one or more of these symptoms
are present a medical exam is
advised, especially if they recur:

 A convulsion with no
temperature (no fever).

 Short spells of blackout,

or confused memory.

 Intermittent fainting
spells, during which
bowel or bladder control
is lost. This is frequently
followed by
extreme tiredness.

 For a short period the

person is unresponsive to
instructions or questions.

 The person becomes stiff,

suddenly, for no obvious
reason

 The person suddenly falls

for no clear reason

 Sudden bouts of blinking

without apparent stimuli
  Sudden bouts of chewing,
without any apparent
reason

 For a short time the

person seems dazed, and
unable to communicate

 Repetitive movements
that seem inappropriate

 The person becomes

fearful for no apparent
reason, he/she may even
panic or become angry

 Peculiar changes in
senses, such as smell,
touch and sound

 The arms, legs, or body

jerk, in babies these will
appear as cluster of rapid
jerking movements.

2 To enlist - In about 70% of people with The student teacher

min various epilepsy, the various causes of
causes of epilepsy during
epilepsy cause is not known. pregnancy with the
during help of the
pregnancy. - In the remaining 30%, the most powerpoint
common causes presentation.

are:

1.Head trauma

2.Infection of brain

3.Brain tumor and stroke

 4.Heridty

5 To THE EFFECT OF The student teacher

emphasize PREGNANCY ON emphasizes on the
mins on the effect effect of pregnancy
EPILEPSY IS UNCERTAIN
of in epilepsywith the
pregnancy in help of the
epilepsy. Frequency of convulsions is powerpoint
unchanged in majority (50%). presentation.
The frequency of convulsions is
unchanged in majority (50%),
increased in 45% and decreased
in about 5% of women. Serum
concentration of anti convulsant
falls in pregnancy. What is the
effect of
All anti convulsants interfere pregnancy on
with folic acid metabolism. Folic epilepsy?
acid deficiency has been
associated with neural tube
defects and other congenital
malformations.

5 To EFFECTS OF EPILEPSY ON The student teacher

min enumerate PREGANACY enumerates the
the effects effects of epilepsy in
of epilepsy  Incidence of fetal pregnancy.
in malformations
pregnancy.  IUGR
 Oligohydramnios
 Preeclampsia
 Still births

Birth defects are increased by

two folds. This could be related
to the severity of the disease
with its genetic predilection and
Enumerate
also due to the anticonvulsants the effects of
used. Pattern of abnormalities is epilepsy on
related to the type of
 anticonvulsant drug. (valproate pregnancy.
5.9%, carbamazepine2.3% and
Lamotrigine2.1%)

3 To THE MALFORMATION The student teacher

min enumerate INCLUDES enumerates the
the malformation occurs
malformatio  Cleft lip and/or palate in baby of the mother
n occurs in with epilepsy during
 Mental retardation
baby of the pregnancy.
mother with  Cardiac abnormalities
epilepsy  Limb defects
during  Hypoplasia of the terminal
pregnancy. phalanges
 Neural tube defects
(because of deficiency of
sodium valproate)
 Neonatal hemorrhage is
related to anticonvulsant
induced reduction of
coagulation factors
(vitamin k dependent)

Risk of developing epilepsy to

the offspring of an epileptic
mother is 10%.

5 To enlist About 1% of the general The student teacher

min risk factors population enlists risk factors of
of epilepsy epilepsy during
during develops epilepsy pregnancy.
pregnancy.
The risk is higher in people with
certain medical conditions:

1.Traumatic Brain Injury

2.Stroke
 3.Alzheimer’s disease

4.Autism

5.Brain Tumors or blood vessel

abnormalities Enlist risk
factors of
epilepsy
during
pregnancy.

5 To enlist 1.Syncope attacks (when pt. is Student teacher

min differential standing; results from global enlists differential
diagnosis of reduction of cerebral blood flow; diagnosis of epilepsy
epilepsy in prodromal pallor, nausea, in pregnancy.
pregnancy. sweating; jerks)

2.Cardiac arrythmias (e.g.

Adams-Stokes attacks).
Prolonged arrest of cardiac rate
will progressively lead to loss of
consciousness – jerks!

3.Migraine (the slow evolution

of focal hemisensory or
hemimotor symptomas in
complicated migraine contrasts
with more rapid “spread“ of
such manifestation in SPS.
Basilar migraine may lead to
loss of consciousness!

4.Hypoglycemia – seizures or
intermittent behavioral
disturbances may occur.

5.Narcolepsy – inappropriate
sudden sleep episodes

6.Panic attacks
7.PSEUDOSEIZURES–
psychosomatic and personality
disorder.
2 To enlist The concern of the clinician is The student teacher
min various that epilepsy may be enlists various
investigation symptomatic of a treatable investigations related
s related to cerebral lesion. to epilepsy during
epilepsy pregnancy.
during Routine investigation:
pregnancy. Haematology, biochemistry
(electrolytes, urea and calcium),
chest X-ray,
electroencephalogram (EEG).

Neuroimaging (CT/MRI)
should be performed in all
persons aged 25 or more
presenting with first seizure and
in those pts. with focal epilepsy
irrespective of age.

Specialised neurophysiological
investigations: Sleep deprived
EEG, video-EEG monitoring.

Advanced investigations (in pts.

with intractable focal epilepsy
where surgery is considered):
Neuropsychology, Semiinvasive
or invasive EEG recordings, MR
Spectroscopy, Positron emission
tomography (PET) and ictal
Single photon emission
computed tomography (SPECT)

Enlist various
investigations
related to
epilepsy
during
pregnancy.
10 To describe The dose of choosen drug should The student teacher
min the be kept as low as possible. describe the
management Valproate and phenytoin are management of
of epilepsy found to be most teratogenic. epilepsy during
during pregnancy with the
pregnancy. The commonly used drugs are: help of the
powerpoint
1.Carbamazepine 0.8-1.2mg presentation.
daily in divided doses,

2.Phenytoin 150-300mg daily in

two divided doses,

3.Lamotrigine 300- 500mg /day

is given (not an enzyme inducer)

Newer drugs used with safety

are:

1.Topiramate(100-400mg/day)

2.Levetiracetam 1-3 gm/day (not

enzyme inducer)

The management of
epilepsy has been divided
as-
1. Pre conception counseling
2. Antenatal care
3. Labor and Delivery
4. Postpartum care
5. Contraception

NURSING MANAGEMENT

1. Risk for growth retardation

related to epilepsy
2. Risk for pre-term labor
3. Knowledge deficit related to
 the disease condition
4. Anxiety related to
hospitalization
5. Impaired tissue perfusion
related to headache, slurred
speech Risk for injury
related to epileptic episode
6. Fear related to the possibility
of seizure
7. Ineffective individual coping
related to stress imposed by
epilepsy
8. Deficient knowledge related
to epilepsy and its control.

3 To explain Teratogenic effects of The student teacher

min the research antiepileptic drugs: implications explains the research
evidence of for the management of epilepsy evidence of epilepsy
epilepsy in in women of childbearing age, in pregnancy.
pregnancy. Lindhout DL :April 2017

ABSTRACT: Exposure to
antiepileptic drug (AED)
treatment in utero occurs in 1 of
every 250 newborns. The
absolute risk of major
malformations in these infants is
about 7-10%, approximately 3-
5% higher than in the general
population. Specific risk factors
include high maternal daily
dosage or serum concentrations
of AED, low folate levels,
polytherapy, and generalized
seizures during pregnancy.
Adverse pregnancy outcomes,
including congenital heart
malformations, facial clefts,
spina bifida aperta, hypospadias,
growth retardation, and
psychomotor and mental
retardation, are associated with,
although not necessarily caused
by, AED exposure. Specific
cognitive defects, hypertelorism,
and nail hypoplasia can be
causally related to specific AED
exposures.

To prevent teratogenic side

effects, the prospective mother
should be treated with AEDs
only when absolutely necessary.
Monotherapy with the AED that
is most effective in the lowest
possible daily dose (divided into
at least two or three
administrations) should be
prescribed. High-dose folate
supplementation (4-5 mg/day)
reduces the risk of a neural tube
defect in a child whose sibling
had such a defect, but its impact
on the specific teratogenic risks
of AEDs is unknown. A
substantial proportion of fetal
malformations may be
secondarily prevented by
prenatal diagnosis, consisting of
a fetal structural ultrasound
examination at weeks 18 and 20
of gestation and, with VPA or
CBZ administration, an alpha 1-
fetoprotein analysis of amniotic
fluid at week 16. Determination
of a specific defect prevention
strategy depends largely on
parental attitudes toward
prenatal diagnosis and
termination of pregnancy, which
should be discussed before
conception
1 Summary
min
Today, we discussed
about epilepsy in
pregnancy its causes,
risk factor,
differentaial
diagnosis,
pathophysiology,
manangement of
epilepsy in
pregnancy.
1 Conclusions
min
Understanding
various aspects of
epilepsy in
pregnancy , a nurse
midwife can reduce
maternal and
fetalcomplication by
early diagnosis and
prompt management
of the disease.
BIBLIOGRAPHY
- D.C. Dutta Textbook of
Obstetrics and gynecology, page
no 328-329.
- Luef, G (October 2010).
"Hormonal alterations following
seizures.". Epilepsy & behavior :
E&B. 19
- Ahmad S, Beckett MW
(2004). "Value of serum
prolactin in the management of
syncope". Emergency medicine
journal
- Vivekanandhan S, et al.
(2004). "Serum prolactin levels
for differentiation of
nonepileptic versus true
seizures: limited
utility". Epilepsy,
- World Health Organization,
Department of Mental Health
and Substance Abuse,
Programme for Neurological
Diseases and Neuroscience;
Global Campaign against
Epilepsy; International League
against Epilepsy (2005)