Abstracts

Rationale: Refractory Status epilepticus (RSE) is defined as persisting seizure activity thet is unresponsive to first and second line anti-seizure therapy and carries high mortality and morbidity. it requires prompt treatment with anticonvulsants and anesthetic agents. Management of RSE during pregnancy is even more challenging given the limited safety and efficacy data available on prolonged use of anesthetic agents and changed pharmacology of anti-epileptic drugs(AEDs) during pregnancy. Methods: We describe the clinical presentation, electro-imaging finding ,management and clinical course of the 31-year-old pregnant patient who presented to our hospital with RSE. Results: A 31-year-old pregnant at 20-weeks of gestation with refractory epilepsy despite being on Lamotrigine(150mg BID), Topiramate(200mgBID), Levetiracetam(150mg BID)and Vagal Nerve stimulator(VNS,presented with 2 dayss history of frequent focal seizures with intermittent generalization after missing a dose of AEDs metabolic and structural etiologies for worsening of her seizures were excluded by normal laboratory metabolic panel and brain imaging . MRI brain showed mild right frontal cortical hyper-intensity on diffusion weighted images, suggestive of probable seizure related changes(figure 1a).serum drug levels were in lower therapeutic rangefor levetiracetam and below therapeutic range for lamotrigine. despite initial treatment with IV lorazepam &phenytoin(PHT)and increasing VNS output current her seizures continued to progress in duration and frequency, and eventually the patient was not regaining her consciouness between the attacks.bedside EEG showed presence of almost continuous right hemispheric seizure discharges that would frequently spread to involve the left side (figure1b).The patient was intubated and IV Propofol was started with a bolus dose of 50 mg, followed by maintenance infusion of 200mg/hr that stopped the seizure activity within 30 minutes. The infusion was maintained at the same dose for next 48 hrs.the EEG showed generalized anesthetic pattern with intermittent independent bi-temporal epileptogenic abnormalities(figure2). There was no electrographic or clinical seizure recurrence and the was extubated. Fetal ultrasound proior,during and following Propofol infusion were unchanged and showed a 22-week viable fetus, with normal heart rate and movements.Patient remained seizure free and discharged on home AEDs+PHT (300mg/day).Post -discharge ,She continued to have intermittent mild focal seizures in spite of out-patient AED adjustments. Her antenatal follow ups were unremarkable and she gave birth to a full term healthy baby. Conclusions: Early recognition and treatment of RSE is the key for better outcome . Propofol may serve as an effective and relatively safer treatment option for RSE during pregnancy. Further studies and experience in managing RSE insuch population would help outline the standard of care.