A 23-year-old primigravida at 32 weeks gestation is brought to the emergency department by her mother due to a seizure that occurred 30 minutes ago. The mother states her daughter was eating lunch at a restaurant and "suddenly started shaking her arms and legs." During the 45-second episode, the patient's head moved from side to side and her eyes fluttered. The patient has no chronic medical conditions, and her pregnancy has been uncomplicated. Temperature is 37.4 C (99.3 F), blood pressure is 128/84 mm Hg, and pulse is 82/min. The patient is alert and fully oriented. Cardiopulmonary examination is normal. Neurologic examination demonstrates no abnormalities. When the abdomen is palpated, the patient states she is not feeling well and suddenly starts to have rhythmic, asynchronous movements of the upper and lower extremities. The jaw is clenched, and the patient does not respond to questions or follow commands. The episode resolves within 1 minute and the patient is alert and oriented. Repeat blood pressure is 116/74 mm Hg. Fetal heart rate tracing has a baseline of 150/min, moderate variability, and no decelerations. Complete blood count, basic metabolic panel, and urinalysis show no abnormalities. Urine drug screen is negative. Which of the following is the best next step in management of this patient?

Question

A 23-year-old primigravida at 32 weeks gestation is brought to the emergency department by her mother due to a seizure that occurred 30 minutes ago.  The mother states her daughter was eating lunch at a restaurant and "suddenly started shaking her arms and legs."  During the 45-second episode, the patient's head moved from side to side and her eyes fluttered.  The patient has no chronic medical conditions, and her pregnancy has been uncomplicated.  Temperature is 37.4 C (99.3 F), blood pressure is 128/84 mm Hg, and pulse is 82/min.  The patient is alert and fully oriented.  Cardiopulmonary examination is normal.  Neurologic examination demonstrates no abnormalities.  When the abdomen is palpated, the patient states she is not feeling well and suddenly starts to have rhythmic, asynchronous movements of the upper and lower extremities.  The jaw is clenched, and the patient does not respond to questions or follow commands.  The episode resolves within 1 minute and the patient is alert and oriented.  Repeat blood pressure is 116/74 mm Hg.  Fetal heart rate tracing has a baseline of 150/min, moderate variability, and no decelerations.  Complete blood count, basic metabolic panel, and urinalysis show no abnormalities.  Urine drug screen is negative.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d75f_a8d0_bc81_057545b4a957_MD0003_00 This patient has seizure-like spells, which, in the third trimester of pregnancy, raises concern for eclampsia. However, several features suggest psychogenic nonepileptic seizures (PNES) rather than epileptic seizures. PNES (formerly pseudoseizures) present similarly to epileptic seizures but are not associated with increased synchronous neuronal activity. Women are particularly susceptible (80% of cases), and spells typically occur in the presence of witnesses. PNES can be an isolated diagnosis, although patients may have medical or psychiatric comorbidities. Features that more reliably suggest PNES include: Eye closure or fluttering during the spell Side-to-side head shaking Asynchronous limb movement Lack of postictal period (eg, alert and oriented after first episode; second episode resolves within 1 minute) However, even when suspicion for PNES is high, no finding is sufficiently sensitive and specific to confirm the diagnosis, and continuous video electroencephalogram (EEG) to clarify whether a spell is epileptic or nonepileptic is always appropriate. This becomes particularly important in pregnancy given the ramifications of a diagnosis of eclampsia. In the appropriate clinical setting, EEG evidence of baseline physiologic alertness despite a clinical spell can confirm the diagnosis of PNES. Once confirmed, the diagnosis should be conveyed to the patient in a nonjudgmental manner; in a third of cases, appropriate communication improves symptoms. Neurologic follow-up and cognitive-behavioral therapy are recommended. (Choices A, C, D, and E) Eclampsia is managed with magnesium sulfate infusion and delivery (eg, induction of labor or cesarean delivery depending on fetal status). It is often a clinical diagnosis made in pregnant patients with hypertensive disorder of pregnancy (eg, preeclampsia, gestational hypertension) who develop tonic-clonic seizure with no other obvious cause (eg, infarction, drug use). This patient has no hypertension and a normal urinalysis (ie, no proteinuria), making eclampsia less likely. In addition, there is a normal fetal heart tracing and no other indication for delivery. Further diagnostic clarification to confirm PNES is indicated. (Choice B) Antiepileptic drugs (AEDs) have no effect on PNES. In addition, diagnostic clarification should be pursued prior to AED initiation to prevent associated adverse effects, particularly in the setting of pregnancy. Educational objective: Psychogenic nonepileptic seizures present similarly to epilepsy but are not associated with increased synchronous neuronal activity. Suggestive features include asynchronous limb movement, eye fluttering, and lack of a postictal period. Diagnostic clarification with continuous video electroencephalogram to capture and characterize a spell should be pursued prior to treatment initiation.

A 23-Year-Old Primigravida at 32 Weeks Gestation Is Brought to the Emergency