EMReports | Post-Partum Seizures: Eclampsia or Something Else?

Post-Partum Seizures: Eclampsia or Something Else?

Sean Arbuckle, DO
Resident Physician
Department of Emergency Medicine
Medical College of Georgia

Amy J Bloch, MD
Assistant Professor
Department of Emergency Medicine
Medical College of Georgia

Pearl: Maternal seizures occurring during delivery or postpartum are not always secondary to eclampsia. If the seizures are refractory to magnesium, consider other etiologies and move on to second- or third-line treatments.

Presentation: A 24-year-old woman presented to an outside hospital actively seizing four days following a vaginal birth after cesarean (VBAC). There were no reported complications during the VBAC, and the patient was discharged as scheduled. However, following the epidural, the patient had complained of low back pain and mild diffuse headache. These symptoms persisted, and she returned to the emergency department at the outside hospital two times prior to this presentation with complaints of increasing headache and confusion. Each time a diagnosis of post-lumbar puncture headache was made. A CT of the head was not performed during the first two ED visits. On the third emergency department visit, the patient presented with altered mental status and seizures unresponsive to benzodiazepines. Due to the recent birth history, the refractory seizures were treated unsuccessfully with magnesium. She was then loaded with phenytoin, and the seizures subsided. Thirty minutes post-seizure, the neurological exam was normal without any focal deficits. MRI of the head revealed a collection of ventricular air. (Figure 1) (Figure 2) The only source for ventricular air that could be identified was her recent epidural. This epidural was performed relatively emergently and she had been instructed to bend her neck for the procedure. At that time she felt exquisite pain localized to her lower back and within 10 minutes the headache developed. The patient was transferred to the emergency department awake, alert, and oriented times one. She was oriented to person; confused to place, thinking that she was at home, and confused to time, believing it was two years earlier. Over the course of three hours in the emergency department she became oriented to person, place, and date. Her neurological exam remained normal and pupils were equal in size and reactivity. All vitals were within normal limits except her blood pressure which was 132/82. While the patient was not aware of her baseline blood pressure, outside records confirmed that she had no prior diagnosis of hypertension. All other labs, including blood alcohol, urinalysis, osmolarity, and urine drug screen, were negative.

Discussion: The differential for seizures, including during the post-partum period, is diverse, and definitive treatment requires a systematic approach. In patients with recent epidurals, pneumocephaly secondary to the procedure should be considered in the differential. Complications of epidural procedures are severe and include progressively worsening headache,^1,2,3 pneumocephalus,^4,5,6 back pain,¹ altered mental status, seizures, infections and difficulty urinating or having a bowel movement secondary to cauda equina.⁷ Whereas there are several case reports of air being introduced into the dural space from routine surgical procedures such as ENT surgery and neurosurgical procedures,⁸ there are very few cases of pneumocephalus secondary to epidurals.

Understanding the procedural steps of an epidural may help the emergency medicine physician conceptualize the complications. The area on the back is prepped and a numbing agent is injected prior to the epidural. The epidural needle is inserted into the epidural space surrounding the spinal cord. A test is performed to ensure that the epidural is correctly placed. In the past, air has been used to confirm correct placement of the epidural, but new confirmation techniques use injection of saline.¹ The amount of air does not appear to increase complication rates significantly but does affect the length of time to resolution.⁹ Once the placement is confirmed, the medications are given as a continuous drip and a small catheter is left in place to deliver the medications continuously throughout labor. Many of the complications can be managed as an outpatient but some of the rare complications will require hospitalization and possible surgery, such as cauda equina syndrome from compression.

First-line treatment for any seizure is benzodiazepines. During pregnancy and up to two months postpartum, magnesium is recommended for seizures secondary to suspected eclampsia. Second line treatment for seizures is phenytoin or fosphenytoin, and third-line treatment is barbiturates. Treatment of pneumocephalus is symptomatic with airway protection, and the majority of symptoms will resolve completely.¹⁰ The patient in this case made a complete recovery in three days following admission to the neurology service. During her admission, she underwent an extensive work-up, including head CT, MRI/MRA, EEG, and various laboratory tests.

References:

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Krisanda TJ, Laucks SO. Pneumocephalus following an epidural blood patch procedure: An unusual cause of severe headache. Ann Emerg Med 1994;23:129-131.
Aida S, Taga K, Yamakura T, et al. Headache after attempted epidural block: The role of intrathecal air. Anesthesiology 1998;88:76–81.
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Sherer DM, Onyeije CI, Yun E. Pneumocephalus following inadvertent intrathecal puncture during epidural anesthesia: A case report and review of the literature. J Matern Fetal Med 1999;8:138-140.
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Spinal and epidural anesthesia. Medline Plus medical encyclopedia. http://www.nlm.nih.gov/medlineplus/ency/article/007413.htm
Reasoner DK, Todd MM, Scamman FL, Warner DS. The incidence of pneumocephalus after supratentorial craniotomy. Anesthesiology 1994;80:1008-1012.
Laviola S, Kirvela M, Spoto MR, et al. Pneumocephalus with intense headache and unilateral pupillary dilatation after accidental dural puncture during epidural anesthesia for cesarean section. Anesth Analg 1999;88:582–583.
Taveras JM, Wood EH. Intracranial pneumography: Morbidity and complications. In: Taveras JM, Wood EH, eds. Diagnostic Neuroradiology. Baltimore: Williams & Wilkins; 1964:1248–1266.

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