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Anaesthesia during Caesarean Section in a Pregnant Patient with Epilepsy

Abstract

Convulsive disorders are the second most prevalent and the most serious neurological condition
encountered in pregnant women after migraine. We present a case of a pregnant patient with epilepsy
requiring lower segment caesarean section (LSCS). A 25-year-old female, G3P0+2 at 36+1 weeks with
seizure disorder and hypothyroidism who presented with severe intrauterine growth retardation (IUGR)
with doppler changes. The modality of anaesthesia planned for her was epidural with general
anaesthesia. We used multimodal anaesthetic techniques which not only reduced the dose requirement
of every drug but also provided adequate anaesthesia, analgesia, amnesia and muscle relaxation. The
postoperative analgesia part was also well managed.

Key Message: Multimodal anaesthetic techniques not only reduce the dose requirement of every drug
but also provide adequate anaesthesia, analgesia, amnesia and muscle relaxation.

Introduction:

Seizure disorders are the second most common and the most serious neurological condition
encountered in pregnant women after migraine. The most common cause during pregnancy is
expansion of an arterio-venous malformation or a brain tumour. Non-obstetric causes of seizure in this
group include brain tumours, aneurysms, arterio-venous malformations, metabolic causes
(hypernatremia, alkalosis) and endocrine disorders (hypo or hyperglycaemia, diabetic ketoacidosis,
pituitary apoplexy etc). These causes are of prime importance for anaesthesiologist for successful
perioperative management.[1]

Epilepsy can affect the course of pregnancy, labour, delivery and alter the foetal development, whereas
pregnancy can exacerbate epilepsy.[2,3] Pregnancy with epilepsy is considered high risk mainly due to
the teratogenic potential of antiepileptic drugs and an increased risk of pregnancy and neonatal
complications such as hypertension, preeclampsia, antepartum haemorrhage, caesarean delivery, still
births, neonatal deaths, intrauterine growth retardation and preterm delivery compared with the
general obstetric population.[3] We present a case of a pregnant woman with epilepsy requiring LSCS.
References:

Sarkar MS, Sahoo TKT, Dewoolkar LV. Anesthetic management of a pregnant woman with epilepsy and
bad obstetrical history for emergency caesarean section. The Internet Journal of Anesthesiology. 2007;
13 (2).

Tanganelli P, Regesta G. Epilepsy, pregnancy and major birth anomalies; an Italian prospective,
controlled study. Neurology 1992; 42 (4 suppl 5): 89-93.

Costa AL, Lopes-Cendes I, Guerreiro CA. Seizure frequency during pregnancy and the puerperium. Inter J
Gynaecol Obstet, 2005 Feb; 88: 148-9.

Case Report:

A 25-year-old female, G3P0+2 at 36+1 weeks with seizure disorder and hypothyroidism presented with
severe IUGR with doppler changes. She was a known case of seizure disorder since the past three years
and had been on treatment since diagnosis. She continued to have 2-3 seizures per week. Her last
seizure was 6 days prior to admission. She was diagnosed with hypothyroidism 6 weeks prior. In 2014,
she underwent medical termination of pregnancy for anhydramnios. In 2015, she underwent evacuation
and curettage following an unruptured ectopic pregnancy which was managed conservatively. Both the
procedures were done under general anesthesia without any postoperative complications.

The patient was on the following medications: levetiracetam 500 milligram (mg) thrice daily,
carbamazepine 200 mg thrice daily, lamotrigine 50 mg at bedtime, eltroxine 25 microgram (mcg) once
daily.

On examination, she was conscious and oriented. No pallor, icterus or cyanosis was seen. Vitals were
stable. Respiratory and cardiovascular systems were normal. No central nervous system abnormality
was seen. Airway looked to be easy for mask holding and intubation.

Investigations such as complete blood cell count, renal function tests and liver function tests were
normal. Electrocardiogram did not show any abnormality. Electroencephalogram showed epileptiform
discharges over left temporal and bilateral occipital regions. Magnetic resonance imaging (MRI) of brain
did not show any lesion.
In view of the severe IUGR with doppler changes she was posted for caesarean section. Modality of
anaesthesia planned for her was epidural with general anaesthesia. She was kept nil by mouth for 6
hours prior to surgery. Blood sample was sent for cross matching to the blood bank. All her medications
were given on schedule with sips of water. She was premedicated with ranitidine 50 mg and
metoclopramide 10 mg given intravenously (i.v.). An 18-gauge epidural catheter was inserted in the
lumbar L3-L4 space and fixed at 8 cm. Test dose of 4cc 2% lignocaine with adrenaline was given. An
epidural infusion of 0.25% bupivacaine was started at 5cc per hour. Then preoxygenated with 100%
oxygen. Once the patient was painted and draped, she was induced with 120 mg of propofol. Crash
induction sequence was followed. Intubation was aided by 75 mg succinyl choline and patient was
intubated with No. 7 endotracheal tube.

Until the baby was delivered she was maintained on oxygen and sevoflurane. Once the baby was
delivered and the cord clamped, oxytocin 10 units in 1 pint of Ringers lactate was given intravenous.
Intravenous midazolam 2 mg was administered, and sevoflurane was discontinued. She was maintained
on oxygen plus nitrous oxide with an intermittent dose of atracurium 10 mg (one top up was given).

The baby on delivery had an APGAR score of 8 and progressed to 10 after 5 minutes. The newborn was
attended to by the paediatrician for further care. After the end of the procedure patient was reversed
with neostigmine 2.5 mg and glycopyrollate 0.5 mg. Patient was extubated after thorough oral
suctioning when she was awake. In the immediate postoperative period, she was able to breastfeed her
baby. And then she was shifted to the postoperative recovery. Her vitals were stable throughout the
procedure. Nil by mouth status was omitted 2 hours postoperative.

Postoperative analgesia was maintained with the help of epidural top ups of 0.0625% bupivacaine every
6-hourly supplemented with diclofenac suppositories 100 mg thrice daily. Postoperative stay was
uneventful, and the patient was discharged after 3 days. She was advised regular follow-up with
neurology, obstetric, and paediatric departments.

Discussion:

The major challenges that we faced were:


The patient was epileptogenic and hence there was a risk of intraoperative seizure.

The drug interactions between antiepileptic and anaesthetic agents.

Placental transfer of anaesthetic agents

Ability to breast feed the baby in early postoperative period

Epileptogenic potential of local anaesthetic drugs

Keeping all these risks and challenges into consideration we planned for general anaesthesia
supplemented with epidural analgesia. We decided to give general anaesthesia with the main intention
of avoiding the scenario of any intra operative seizures without a secured airway. Hence, the patient
was electively intubated.

It is often seen that opioids are avoided before delivery of the baby in case of general anaesthesia for
LSCS because of neonatal respiratory depression. This phase is stressful for the patient and often results
in tachycardia and an elevated blood pressure and this further has a potential to trigger a seizure.
Hence, we planned an epidural to supplement the analgesia part without affecting the foetus plus the
mother was on antiepileptic and thyroid medication. The risk with only epidural was that it would need
a higher dose of local anaesthetic drugs which could further trigger a seizure. We could have managed
with spinal anaesthesia also but again the risk of management of a seizure intraoperatively without a
secure airway would be challenging. Further, we could not allow the mother to be in a situation which
makes early breastfeeding difficult.

Hence, we used multimodal anaesthetic techniques which not only reduced the dose requirement of
every drug but also provided adequate anaesthesia, analgesia, amnesia and muscle relaxation. This is
the key message we would like to impart. The postoperative analgesia part was also well managed.
Thus, to conclude combining different modes of anaesthesia helped us in achieving our goal without
undue risk.