Anaesthesia during Caesarean Section in a Pregnant Patient with Epilepsy
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.
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.
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. We present a case of a pregnant woman with epilepsy requiring LSCS.
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.
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.
- 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.