Intrapartum care of WWE

Question 1

What are the risks and risk factors for seizures in labour in WWE and how can they be minimised?

Answer 1

• Adequate analgesia and appropriate care in labour should be provided to minimise risk factors for
  seizures such as insomnia, stress and dehydration.
• Long-acting benzodiazepines such as clobazam can be considered if there is a very high risk of seizures
  in the peripartum period.
• AED intake should be continued during labour. If this cannot be tolerated orally, a parenteral alternative should be administered.
• Tonic-clonic seizures occur in about 1–2 % and up to 3.5 % of WWE in labour.
• Within 24 hours of delivery in 1–2%.

Question 2

What is the optimum management of epileptic seizures in labour?

Answer 2

• Seizures should be terminated as soon as possible to avoid maternal and fetal hypoxia and
  fetal acidosis.
• Benzodiazepines are the drugs of choice.
• Continuous fetal monitoring is recommended in women at high risk of a seizure in labour, and following
  an intrapartum seizure
• Any seizure lasting more than 5 minutes is unusual and represents a high risk of progressing to convulsive status epilepticus, which affects around 1% of pregnancies in WWE

Question 3

Tx of seizures in labour

Answer 3

• In those with intravenous access, lorazepam given as an intravenous dose of 0.1 mg/kg (usually a
  4 mg bolus, with a further dose after 10−20 minutes) is preferred.
• Diazepam 5–10 mg administered slowly intravenously is an alternative.
• If there is no intravenous access, diazepam 10−20 mg rectally repeated once 15 minutes later if there
  is a continued risk of status epilepticus, or midazolam 10 mg as a buccal preparation are suitable
• If seizures are not controlled, consider administration of phenytoin or fosphenytoin.The loading dose of phenytoin is 10–15 mg/kg by intravenous infusion,with the usual dosage for an adult of about 1000 mg

Question 4

Pain relief in labour

Answer 4

• All usual stuff is ok
• Diamorphine should be used in preference to pethidine for analgesia in labour. Pethidine is
  metabolised to norpethidine, which is known to be epileptogenic
• If general anaesthesia becomes necessary, avoid anaesthetic agents such as pethidine, ketamine and sevoflurane.The first two are known to lower seizure threshold and the third may have epileptogenic potential.