Epilepsy in pregnancy

Introduction to pregnancy with epilepsy Epilepsy is a chronic disease of transient central nervous system dysfunction caused by a recurrent episode of abnormal neuronal discharge. Depending on the location of the neuron and the extent of discharge, dysfunction may manifest as exercise, sensation, consciousness, behavior, Different disorders such as autonomic nerves or both, each episode or each episode is called seizure. Patients may have one or several seizures as symptoms, and pregnant women with epilepsy may affect the progression of the entire childbirth and the development of the fetus, and pregnancy may also aggravate epilepsy. basic knowledge The proportion of illness: 0.003% Susceptible population: pregnant women Mode of infection: non-infectious Complications: coma, status epilepticus, dehydration

Pregnancy with epilepsy

(1) Causes of the disease

Seizures can be clinical manifestations of brain diseases or systemic diseases, so-called symptomatic epilepsy, or so-called primary epilepsy or epilepsy without these diseases. The main causes of epilepsy are as follows:

Traumatic brain injury (18%):

Craniocerebral trauma is an important cause of localized epilepsy in young and middle-aged people. The chance of epilepsy after trauma is determined by the degree of injury. The incidence of epilepsy is 40% to 50% when the dural penetrating injury or memory loss after injury is more than 24 hours. The incidence is mostly within 2 years after trauma.

Genetic factors (20%):

Genetic factors can affect the susceptibility to epilepsy, primary systemic seizures such as absence, myoclonic seizures, and other family history of epilepsy. By 1994, seven loci were found to be associated with seizures, which is autosomal dominant. The penetrance rate is 70%.

Febrile seizures (18%):

Infants and young children between the ages of 3 months and 5 years often develop febrile seizures in the case of febrile illness. If the seizures last for a long time or are accompanied by abnormalities of the nervous system or brain electricity, there is a great chance of epilepsy later.

Brain tumor or cerebrovascular abnormalities (10%):

In the first episode of epilepsy in pregnant women, brain tumors and cerebral vascular malformations should be excluded, and CT or MRI should be examined.

Withdrawal symptoms of alcohol and other drugs (10%):

Those who have been drinking alcohol for a long time or use narcotics may have seizures when they are abstinent. This is a new problem in the society now, and should be noted when asking about medical history.

Acute systemic metabolic disorder or acute central nervous system damage (8%):

Any pregnant woman may have epilepsy due to acute systemic metabolic disorder or acute central nervous system damage, such as hypocalcemia, hypercalcemia, hyponatremia, hypernatremia, hypoglycemia, hyperglycemia, uremia, Hepatic encephalopathy and the like.

(two) pathogenesis

Any normal person can induce seizures due to electrical or chemical stimuli. The normal brain may have an anatomical-physiological basis for seizures and is susceptible to various stimuli.

The pathophysiological features of seizures are due to a variety of incentives causing rhythmic, repetitive, synchronized neuronal firings in some or all of the brain's brains, resulting in localized brains with a few seconds of simultaneous discharges forming localized episodes; local brain If the synchronous discharge spreads to the whole brain, or lasts for many seconds or even minutes, the localized seizure can develop into a systemic episode, and some of the synchronic discharges from the thalamic cortical circuit with extensive reticular branches can make the abnormal discharge rapidly spread. Throughout the entire brain, causing primary systemic seizures initiated by convulsions, accurately classifying epilepsy in order to properly select anticonvulsant drugs.

Abnormal EEG activity at present for seizures may be related to the following factors:

1. Intracerebral inhibitory factor gamma-aminobutyric acid (GABA) levels are reduced, which weakens the inhibition of brain neuron synapses.

2. Excitatory synaptic mechanisms are enhanced, especially by N-methyl-D-asparate (MN-DA) receptors, which are enhanced by synaptic excitability.

3. Endogenous neuronal burst discharge, anticonvulsant drugs almost all act on the above mechanism.

Pregnancy with epilepsy prevention

For patients with epilepsy, pre-pregnancy, pregnancy, childbirth and postpartum should be strengthened management, which requires close cooperation and management by obstetricians and neurologists.

Pre-pregnancy consultation before pregnancy is necessary for patients with epilepsy, including genetic problems, teratogenicity of AEDs, folic acid supplementation and vitamin K1, childbirth, breastfeeding, and neonatal care. Proper pre-pregnancy counseling reduces the risk of epilepsy itself and the risk of AEDS treatment.

It is recommended to prevent barrier contraception for half a year before pregnancy, regulate the use of AEDs, and plan pregnancy under the premise of effectively controlling seizures. Drugs that induce epilepsy, such as penicillins and quinolone antibiotics, should be avoided during pregnancy. Correct bad habits and avoid smoking and drinking. Ensure adequate nutrition and sleep.

Prenatal examination of patients with pregnancy epilepsy should undergo strict prenatal examination to detect severe fetal malformations. Serological screening was performed at 14 to 19 weeks of gestation, and systemic ultrasound was performed at 18 to 24 weeks of gestation except for neural tube development defects.

Pregnancy with epilepsy complications Complications, coma, epilepsy, persistent dehydration

If GTCS occurs frequently in a short period of time, and even if the consciousness continues to coma during the interval, it is called epilepticus, often accompanied by high fever, dehydration, leukocytosis and acidosis.

Pregnancy with epileptic symptoms common symptoms convulsions close closed conscious disorder heart rate increased speech interruption consciousness short interruption consciousness loss tremor weakness fatigue

Patients with epilepsy have multiple types of seizures, but each epileptic patient can have only one type of seizure, or there can be more than one type of seizure. A simple partial seizure can develop into a complex partial seizure or a generalized tonic-clonic seizure. Therefore, epileptic seizures and epilepsy are two concepts. Seizure is a clinical manifestation. There are one or several seizure types and the author is epilepsy. The international classification of seizures is The clinical manifestations of multiple episodes are concentrated in a brief description, which is conducive to clinical diagnosis and treatment. The new nomenclature can indicate the location of the disease, which is better than the past classification ("big episode", "small episode", "psychotic seizure" "And "limited episodes"), because most of the clinically puberty authors originate from the localized parts of the cerebral cortex, the series of symptoms manifested by the spread of focal discharge to adjacent areas and even distant parts.

Partial motor seizure

Partial motor seizure refers to the twitching of a local limb, which is more common in one side of the mouth, eyelids, fingers or toes. It may also involve the entire side of the face or the distal end of a limb, sometimes manifested as speech interruption, if the attack starts from one place Slowly moving in the order of the distribution of the cerebral cortex, such as from the thumb along the fingers, wrists, elbows, shoulders, called Jackson epilepsy, lesions in the contralateral motion zone, such as partial motility After the attack, the temporary or insufficiency of the local limb (a few minutes to several days) is called Todd. If the local convulsion lasts for hours or days, it is called persistent partial epilepsy, and the lesion is in the exercise area.

2. Loss of absence

The author of the loss has a regular and symmetrical 3 weeks/s spine slow wave combination on the EEG, a brief interruption of consciousness, 3 to 15 s, no aura and local symptoms, sudden onset and rest, and can be repeated several times a day to hundreds of times. Once, the patient stopped the activity at the time, and the call should not be ok, but the eyes could not be seen, but it could be accompanied by eyelids, 3 times/s tremor of the eyebrows or upper limbs, or simple automatic sexual activity: such as wiping the nose, using the hand Pressing or chewing, swallowing, generally does not fall, holding hands may fall, immediately wake up afterwards, continue the original activities, no memory for the attack, the author of the loss is rare other neurological diseases, but 40% to 50% of patients occasionally A more manageable general tonic-clonic attack.

3. Tonic - clonic seizures

Generalized tonic-clonic seizure (GTCS) is known as a major episode in idiopathic epilepsy. It is characterized by loss of consciousness and generalized convulsions. The seizure can be divided into three phases.

(1) tonic period: all skeletal muscles show persistent contraction, upper eyelids rise, eyeballs are paralyzed, throats are snoring, screams, mouths are strong and then slammed, and may bite the tip of the tongue, neck and torso First flexion and then reversal, upper limbs from the uplift, posterior rotation, into adduction, pronation, lower limbs from self-buckling to strong straightening, strong period of 10 to 20s after the appearance of fine tremor at the extremities.

(2) Circumcision: until the tremor amplitude increases and extends to the whole body, becoming intermittent sputum, that is, entering the sputum stage, each time there is a short muscle tension relaxation, the frequency of the sputum gradually slows down, the relaxation period Gradually prolonged, this period lasts for 0.5 to 1 min. After the last strong incision, the convulsions abruptly terminate. In the above two periods, there are autonomic signs such as increased heart rate, increased blood pressure, increased sweat, salivary and bronchial secretion, and dilated pupils. The breathing was temporarily interrupted, the skin turned from pale to bun, the pupil reflected light and deep, and the shallow reflection disappeared.

(3) Late seizures: After the clonic period, there is still a short period of strong sputum, resulting in tightness of the jaws and incontinence. The breathing is first restored, the foam or blood foam is sprayed from the nose and mouth, and the heart rate, blood pressure, and pupils are returned to normal. The muscle tension is relaxed, the consciousness gradually wakes up, and the consciousness recovers from 5 to 10 minutes. After awakening, I feel headache, body aches and fatigue, no memory for convulsions, many patients become distressed after the disturbance of consciousness is relieved, and individual patients are fully awake. There are automatic symptoms or emotional changes, such as anger, panic, etc. Under the control of incomplete drugs, the intensity and duration of seizures may be reduced.

Pregnancy with epilepsy

Detection of related diseases: through the urine protein, blood electrolytes, blood sugar and liver and kidney function tests, cerebrospinal fluid examination, etc., can help diagnose and differentially diagnose related diseases.

Electroencephalogram (EEG): Helps to confirm the diagnosis and resolution type, and is a non-invasive examination. In the GTCS of primary epilepsy, EEG exhibits a low-voltage fast activity during the tonic phase, and gradually becomes slower. High spikes, which are burst waves during muscle contraction, slow waves during muscle relaxation, normal EEG during episodes, or symmetrically synchronized spine-slow complexes, currently considered to be in the interic period Through the induction test during sleep, deep breathing, rhythmic flash or acoustic stimulation, the diagnostic positive rate can reach 80% to 85%; but 10% normal people can also have abnormal rhythm, so the analysis of EEG must be combined with clinical.

Diagnosis and diagnosis of pregnancy combined with epilepsy

diagnosis

Epilepsy is characterized by sudden onset of short-term exercise, sensation, mental, autonomic dysfunction, often accompanied by loss of consciousness during episodes, and a history of seizures before pregnancy. Therefore, it is not difficult to make a diagnosis based on the medical history, symptoms, physical examination and related auxiliary examinations of pregnant women. .

Differential diagnosis

The identified diseases are mainly snoring, syncope, hypocalcemia and eclampsia.

Hysteria

The onset is closely related to mental factors. The consciousness is clear when the attack is normal, the pupil is normal, there is no urinary incontinence, and there are exaggerated, artificial, quirky and other symptoms. The attack lasts for several hours, suggesting that the treatment is effective, and the episode can be recalled after the event. There is no sequelae after the attack. shape.

2. Syncope

Physical weakness, neurovascular dysfunction and fear are often the cause of seizures. There are general malaise, unable to stand and accompanied by loss of consciousness, but no convulsions. At the beginning of the attack, the patient is often in a standing or sitting position. Patients often have vertigo before the attack. The surrounding objects have a sense of shaking, yawning, dark spots in front of the eyes, blurred vision, tinnitus, nausea, sometimes vomiting, pale or grayish white on the face, cold sweat, due to slow attack, the patient can quickly lie down if he can realize, often Can prevent seizures, consciousness can not completely disappear, the depth of consciousness loss and duration are not the same, a few seconds, a few points, or even up to 1/2h, after the attack, the limbs are cold and weak.

3. eclampsia

Have a history of pregnancy-induced hypertension syndrome, convulsions occur in the third trimester of pregnancy, severe hypertension, severe edema of the face and lower extremities and a large amount of proteinuria, mostly without prenatal examination and treatment, easy to identify with seizures.

4. Hypocalcemia

Twitching can occur during any pregnancy, with hand, foot and ankle being the mainstay, with blood calcium below normal or at normal low limits.

5. Cerebrovascular disease

With convulsions associated with increased intracranial pressure or localized neurological symptoms and signs, a head MRI or CT scan can help with differential diagnosis.

6. Amniotic fluid embolism

Most occur in the labor process or premature rupture of membranes, manifested as sudden dyspnea, dry cough or scream, cyanosis, convulsions, convulsions for a short time, followed by shock, more with postpartum hemorrhage and DIC.

7. Adams-Stokes syndrome

At the time of onset, the electrocardiogram showed a second degree of atrioventricular block or severe arrhythmia without localized neurological signs.

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