Pseudostatus epilepticus in pregnancy

Abstract

Generalized convulsive status epilepticus is a life-threatening disorder characterized by repetitive or prolonged seizures that may result in neuronal death and multi-organ failure. Pseudostatus epilepticus refers to repeated or continuous seizures of psychogenic origin that may resemble those of status epilepticus as there may be tongue biting, incontinence, cyanosis, and even upgoing plantar responses [1]. If pseudostatus is misdiagnosed as true status in a pregnant woman, inappropriate treatment with antiepileptic drugs may lead to respiratory depression requiring intensive care and may rarely result in maternal and fetal death [2,3]. A 23-year-old pregnant woman (gravida 4, para 2, in her 27th week of pregnancy) was admitted to a local district general hospital following recurrent convulsive seizures with no evidence of eclampsia. Persistent seizure activity despite intravenous administration of magnesium, phenytoin, diazepam, and eventually thiopental caused respiratory depression requiring intubation. She was transferred to the Walton Centre for Neurology and Neurosurgery, Liverpool, UK, where cerebral magnetic resonance imaging results were normal, a lumbar puncture showed normal cerebrospinal fluid constituents, and an electroencephalogram showed generalized slowing consistent with thiopentone use. All sedation was stopped without seizure recurrence. The patient required intensive care for 5 days before she was returned to the referring hospital. The patient's old medical notes then became available. Frequent daily “fits” had been misdiagnosed as epileptic seizures in the third trimester of a previous pregnancy although the typical postictal features were absent, and these seizures had proved refractory to pharmacotherapy. After she was delivered of a stillborn infant an epileptologist had concluded that the first “fit” was a postsyncopal reflex anoxic seizure, and that the others were subsequent psychogenic attacks. Two weeks after discharge from the referring hospital, the patient presented again with recurrent refractory seizures and an obstetrician planned delivery by emergency cesarean section. However, the nonepileptic nature of the attacks was explained to the obstetrician, along with a recommendation to delay operative intervention if possible. Pseudostatus epilepticus occurs predominantly in women of childbearing age but there are few reports on this condition in the obstetric literature. The clinical features of pseudoseizures include long duration attacks without fixed pupils, hypoxia, or metabolic acidosis, resistance to eye opening, flexor plantar and eye deviation to alternate sides. Investigation results are typically normal and the attacks are resistant to antiepileptic drug treatment. The frequently acute and dramatic clinical presentation of pseudostatus often causes diagnostic difficulties, and treatment for presumed true status is frequently administered before a background history is available. The fetus is at risk for both hypoxia following attempted seizure suppression and prematurity from needlessly early operative delivery. The optimal management of pseudostatus epilepticus during pregnancy requires close collaboration between obstetricians and neurologists, and diagnostic awareness of the condition is the crucial first step.