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ANESTHESIA MANAGEMENT OF EMERGENCY CAESAREAN SECTION WITH

EPILEPSY AND POST OLIGODENDROGLIOMA RESECTION HYSTORY

Hariyanto, I Putu Kurniyanta

Abstract

The prevalence of epilepsy is 0.4–0.8% in the general population, with the incidence of
epilepsy for childbearing women having been reported as 50 per 100,000.[1] The exact incidence
of epilepsy in pregnancy is unknown. It has been estimated that 3–5 births per 1000 will be to
women with epilepsy.[2] Epilepsy can affect the course of pregnancy, labor, delivery and alter
the fetal development whereas pregnancy can exacerbate epilepsy.[3,4] Pregnancy with epilepsy
is considered high risk mainly due to teratogenic potential of antiepileptic drugs and increased
risk of pregnancy and neonatal complications i.e. hypertension, preeclampsia, antepartum
hemorrhage, cesarean delivery, still births, neonatal deaths, intrauterine growth retardation and
preterm delivery compared with general obstetric population.[5] .We report successful
anaesthetic management of a pregnant patient with history of epilepsy which caused by post
oligodendroglioma resection for emergency caesarean section.

Introduction

Epilepsy is a disorder of the brain characterized by a predisposition to generate abnormal


synchronous neuronal activity. This results in recurrent and unpredictable interruptions of normal
brain function, observed clinically as epileptic seizures.[1] Epilepsy is common; 50 million
people worldwide are affected and the estimated prevalence of active epilepsy [continuing
seizures or the need for antiepileptic drug (AED) treatment] is 4–10 per 1000 people.[2] The
prevalence of epilepsy is 0.4–0.8% in the general population, with the incidence of epilepsy for
childbearing women having been reported as 50 per 100,000.[1] The exact incidence of epilepsy
in pregnancy is unknown. It has been estimated that 3–5 births per 1000 will be to women with
epilepsy.[2] Epilepsy can affect the course of pregnancy, labor, delivery and alter the fetal
development whereas pregnancy can exacerbate epilepsy.[3,4] However, pregnant women with
epilepsy face a number of challenges during the course of their pregnancy. For example, there is
conflicting evidence to suggest a higher risk of intrauterine growth retardation; however, the data
at this time is limited. Approximately one-third of women with epilepsy will experience an
increase in seizure frequency during pregnancy, and approximately one-half will experience no
change.[6] The most important predictive factor is pre-pregnancy severity; women who remained
seizure-free for at least 9 months prior to pregnancy had an 84–92% likelihood of remaining
seizure-free during pregnancy.[7]

Case report

A 35 year old patient G4P3003 presented for emergency caesarean section at 38 weeks in
view of vaginal discharge 10 hours prior to admision. She had history of post oligodendroglioma
resection 6 month ago and shows epilepsy symptom before surgery. She was on Carbamazepine
200 mg B.D for last 6 months and seizure never appeared since she was on oral anti epilepsy
treatment. On examination, she showed normal physical examination and all other investigations,
including liver function test (LFT), haemostatic profile (PPT, aPTT, and INR), renal function test
(RFT), complete blood check, and serum electrolytes.

Vigilant monitoring and management during perioperative period from anesthetic point
of view was needed due to possibility of precipitation of seizure episodes. The case was attended
in the emergency center and after attaching monitors for pulse, blood pressure, SpO2, i.v. fluid
were started and the patient was oxygenated by mask, To avoid precipitation of seizures, the
patient was given 1 mg of midazolam as premedication. The patient was neuraxial anesthesia
with 0,5% bupivakain 12,5 mg during surgery. The procedure was maintained with 2 lpm nasal
canule oxygen and all vitals were monitored vigilantly. The baby was delivered and Inj oxytocin
10U given intravenously. The operation was uneventful and the patient was shifted to the High
Care Unit (HCU) after procedure, and observed for 48 hrs. Both mother and baby were fine at
the time of discharge from the hospital.

Discussion

Pregnancy has variable effect on epilepsy. Seizures may decrease or remain unchanged in
two thirds of patients according to European pregnancy registry of more than 1900 pregnancies.
Risk of epilepsy is the highest during delivery.[8] An evidence-based study published in 2009,
recommended that women with epilepsy (WWE) should be counseled that seizure freedom for at
least 9 months prior to pregnancy is probably associated with a high rate (84%-92%) of
remaining seizure-free during pregnancy (level B).[7,9]
Epilepsy is a symptom characterized by a paroxysmal and transitory disturbance of
cerebral functions, which develop suddenly, cease spontaneously and exhibit a conspicuous
tendency to recurrence. The effects of epilepsy on pregnancy and that of pregnancy on epilepsy
are subtle and complex. The understanding of the interactions between anticonvulsant drug
therapy, pregnancy and the growing fetus are a must for the anesthesiologist for proper
anaesthetic management of a pregnant women posted for cesarean section for successful
outcome.[6]

Many large-scale studies have shown that there appears to be 6.8% chance of birth
defects in the infant born to woman taking antiepileptic drugs (AED). This represents a risk
which is 2-3 times than that of the general population. The risk is more with polytherapy as
compared to monotherapy.[10] Local anesthetics can be anticonvulsant in low doses, but when
given in high doses, can be proconvulsant. The proconvulsant properties of all local anesthetics
are exhibited with toxic blood levels following inadvertent intravascular injection, or from
accumulation following repeated injections. Their anticonvulsant activity is exhibited at subtoxic
plasma levels, for example, 1–2 mg/kg intravenously of lidocaine has been shown to terminate
status epilepticus, as well as reduce the duration of electrically induced seizures in
electroconvulsive therapy.[11] Benzodiazepines are widely used in the emergency therapy of
generalized tonic-clonic seizures because of their potent anticonvulsant properties. Overall, they
are effective in controlling status epilepticus in more than 90% of patients with a generalized
seizure disorder [12]. Midazolam is as effective in suppressing EEG seizure activity as
diazepam, which is often the first line treatment in the emergency treatment of seizure disorders.
Pain control for the pregnant epileptic involves the use of opioid analgesics. Meperidine
neurotoxicity is well known, manifesting clinically as tremors, myoclonus, and seizures. Its CNS
manifestations are thought to be secondary to its biodegradation to its metabolite normeperidine.
[13]. Anaesthesiologists have a major role in this type of cases to prevent precipitation of
seizures preoperatively and postoperatively by avoiding the use of drugs that can precipitate the
seizure like meperidine and the use of midazolam as premedication to reduce the risk of seizure
as well as maintaining haemodynamic of mother throughout labor and delivery of baby
ultimately resulting in wellbeing of both mother and baby.

Conclusion
Anesthesia management for caesarean section on a woman with epilepsy is a challenge
for the anesthesia specialist, with regard to the complexity of the close links between
physiological changes relating to pregnancy and brain physiology. It will have to be performed
carefully with the use of the drugs that can precipitate seizure

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