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CASE REPORT
Year : 2023 | Volume
: 14
| Issue : 2 | Page : 106-108
Sudden and unexpected seizure during emergency cesarean section in a nonhypertensive hypothyroid primigravida
J Kausik, D Divya, S Parthasarathy
Department of Anaesthesiology, Mahatma Gandhi Medical College and Research Institute, Sri Balaji Vidyapeeth, Puducherry, India
Correspondence Address:
Dr. S Parthasarathy
Department of Anaesthesiology, Mahatma Gandhi Medical College and Research Institute, Sri Balaji Vidyapeeth, Puducherry
India
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/injms.injms_142_22
A 29-year-old primigravida parturient at term with a known case of hypothyroidism for the past 1 year was taken for emergency cesarean section in view of fetal distress. The patient's medical history showed a history of galactorrhea, for which magnetic resonance imaging of the brain and the routine blood investigations were normal. The parturient was posted for emergency cesarean section due to fetal distress. There was no significant comorbid illness or illicit drug intake. All the basic investigations including the thyroid-stimulating hormone were normal. Spinal anesthesia with 2.0 ml of 0.5% hyperbaric bupivacaine to achieve a level of T6 was performed. After the delivery of the fetus, there was a sudden seizure occurred, and the mother lost her consciousness. The hemodynamics remained stable. The patient was given oxygen, 2 mg of intravenous midazolam, and magnesium sulfate by the Pritchard regimen. The newborn's Apgar scores were normal. She had no recollection of the seizure attack after regaining consciousness and normal spontaneous respiration which occurred in a few minutes. Breastfeeding was recommended. To avoid another seizure episode, the Pritchard regimen was followed. The recovery period was uneventful. A cranial computed tomography scan of the brain was also performed, which revealed no abnormalities. Serum electrolytes were within the normal range when tested again. This case is being reported to raise awareness of seizures in nonhypertensive patients.
Keywords: Fits, normotensive, pregnancy, thyroid
Seizures are temporary disruptions in cerebral function due to abnormal, paroxysmal, and hypersynchronous electrical neuronal activity in the cerebral cortex. The etiology of seizures encompasses a wide range of diseases and disorders; a proper history taking is the most important diagnostic tool. Prior history of seizures, stroke, brain tumor or trauma, previous obstetrical history, and precipitating events (alcohol, medications, and illicit drugs) are all notable features.[1],[2] A first seizure may be provoked or unprovoked. It is generally accepted that pregnancy and labor, postpartum, or postnatal period (after birth) can be risk factors for seizures.[3] The literature is sparse about a parturient who suffers seizure during cesarean section, especially in normotensives without any prior history. Hence, we tried to report this successful management of such a case.
Case ReportA 29-year-old primigravida at 39 weeks' gestation, a known case of hypothyroidism for 1 year on regular medication of 50 μg of oral thyroxine with a body mass index of 26 kg/m2, was taken for emergency cesarean section in view of fetal distress. The patient's medical history showed that she had a history of galactorrhea before 2 years. A magnetic resonance imaging (MRI) of the brain taken during the episode was normal. The parturient was scheduled for normal vaginal delivery, but was posted for emergency operative delivery in view of fetal distress; the duration of labor pain was around 6 h without much exhaustion. On arrival in the operating room, the patient had a heart rate of 110 beats/min with a blood pressure of 130/78 mmHg and oxygen saturation of 100%. Intrathecal administration of 2 ml 0.5% hyperbaric bupivacaine was administered to achieve a level of T6. The hemodynamics was stable, and after delivery of the fetus, the patient threw a seizure with a loss of consciousness. The patient had a tonic–clonic type of seizure with uprolling of eyeballs. The duration of seizure lasted for around 30 s. The patient had postictal confusion for 5 min. The motor component of the seizures was limited to unblocked dermatomal segments. There was a transient fall of blood pressure to 106/60 mmHg which was regained immediately without any vasopressor. Intravenous midazolam 2 mg was administered, followed by the implementation of the Pritchard regimen of magnesium sulfate. Supplemental oxygen with airway maintenance was done for 3–4 min, after which she recovered normally. At no point in time, there was apnea or obstructed breathing. The placenta did not show any sign of preeclampsia. The Apgar scores were normal. The patient was warmed, and there was no hypothermia. The metabolic parameters were normal. The Pritchard regimen was continued. The metabolic parameters included renal function test, thyroid profile, and electrolytes which were normal. Magnesium was continued for 48 h. She underwent a computed tomography (CT) scan of the brain, which was normal. She was discharged without any neurological finding on a postoperative day 7 without any antiepileptic with a follow advice in 2 weeks [Table 1].
DiscussionThis is a rare case of a normotensive parturient having a seizure during a cesarean section. The seizure occurred unexpectedly during surgery, immediately following the delivery of the fetus. Because the other clues were unclear, we believe this is the first seizure in adults. The first seizure can be induced or uninstigated. Pregnancy, labor, and the postpartum or postnatal period (after birth) are all thought to be risk factors for seizures, especially if there are complications like eclampsia. Eclampsia is defined as the sudden onset of seizures and/or unexplained coma during pregnancy or postpartum in patients with preeclampsia-like signs and symptoms but no preexisting neurologic disorder.[3] Eclamptic seizures usually occur unexpectedly. The differential diagnosis for seizures is broad; however, until proven otherwise, all seizures in the peripartum period should be considered eclampsia, and treatment should begin immediately. The absence of hypertension and proteinuria, in this case, made us reconsider any possible overlooked diagnosis of eclampsia. Severe hypotension can cause seizures in some patients; however, our patient had stable hemodynamics.[4] There is only one report of atypical seizures in which the authors mention the possibility of seizures in the absence of hypertension.[5] In yet another case report of a rare seizure, the author did not specify the cause.[6]
A seizure may be the first symptom of eclampsia, followed by hypertension. We had no such problems. Due to the stable hemodynamics,[7] no other anesthetic technique was planned. We did not use invasive airway maneuvers because the patient was breathing normally with an unobstructed airway and supplemental oxygen. We began magnesium sulfate treatment and continued for 48 h. We avoided benzodiazepines later on to avoid complications for a breastfed newborn. We resorted the patient to all tests, including a repeat thyroid profile, but she was found to be normal. A cross-check revealed no errors in the drugs administered. We found no link between an old history of galactorrhea and the episode. There have been reports of hyperthyroidism and fits, but not euthyroidism.[8] The patient was not a known case of epilepsy, and CT scan revealed no abnormality. There was no obvious possible metabolic cause of the event. As the MRI scan was normal earlier, we could not link the two events. In our case, the neonate was normal and breastfed without any untoward event.
ConclusionWe report a successful management of sudden unexpected seizure in an already normotensive parturient and create an awareness of seizures in normotensive pregnant women.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published, and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
References
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