Abstracts

Rationale: Women with epilepsy (WWE) have been shown to have higher rates of pregnancy-related complications than women without epilepsy. Furthermore, an increased frequency of birth defects and neurocognitive developmental delay has been observed in babies born to WWE. Resective epilepsy surgery has been shown to reduce seizure frequency in patients with drug refractory lesional epilepsy. To the best of our knowledge, there have been no previously reported cases of WWE undergoing urgent epilepsy surgery during pregnancy. Intraoperative maintenance of adequate cerebral perfusion pressure, avoidance of increases in intracranial pressure, seizures and prolonged procedure were the cornerstone for the successful operation.

Methods: We report a case of a 38-year-old right-handed woman, who at 23 weeks gestation, was admitted to our epilepsy monitoring unit (EMU) in Beaumont hospital for long-term video EEG monitoring for diagnostic and potential epilepsy surgery assessment. She has a longstanding history of lesional refractory focal epilepsy. During pregnancy, she had experienced increased seizure frequency and changes to her seizure semiology. She had recently experienced hypermotoric frontal lobe seizures which resulted in falls. The diagnosis was confirmed using MRI and video EEG monitoring. At 24 weeks gestation, following the discussion of her case in our multidisciplinary meeting, she underwent an urgent right inferior frontal lesionectomy. The procedure was conducted under general anaesthesia, induced with intravenous propofol and maintained with inhaled sevoflurane. Inhalational was preferred than intravenous anaesthesia to avoid prolonged procedure. The patient was positioned in a left lateral position to avoid delay in venous return. Motor mapping was not conducted to avoid the risk of intraoperative seizures.

Results: Our patient has experienced postoperative seizure freedom. She went on to deliver a healthy baby without complication at term. We report the clinical details of this case and review the literature regarding the management of refractory epilepsy in pregnancy and the potential role of surgery in the management of this patient cohort. We address notable perioperative considerations including the timing of surgery, selection of anaesthetic agents, the role of motor mapping and intraoperative patient positioning. The literature review did not reveal any previous case reports of resective epilepsy surgery in an obstetric patient. We identified several risks to both the mother and the foetus which are associated with pregnancy in women with drug-resistant epilepsy, and how these could be mitigated against using epilepsy surgery.

Conclusions: We showed that good maternal and foetal outcomes are possible with lesional epilepsy surgery during pregnancy. It is important to consider timing with respect to the gestational age of the foetus, the maternal condition, and the risks to both the mother and foetus of either undergoing and foregoing surgery. When proceeding to surgery, there are some important perioperative considerations including patient positioning, choice of anaesthetic agents and maintaining adequate cerebral and uteroplacental perfusion.

Funding: Please list any funding that was received in support of this abstract.: N/A.