What is the differential diagnosis and management for a post Lower Segment Caesarean Section (LSCS) seizure?

Post-LSCS Seizure: Differential Diagnosis and Management

Immediate Priority: Eclampsia Until Proven Otherwise

Eclampsia is the most critical diagnosis to consider and treat immediately in any post-cesarean section seizure, as it carries significant maternal mortality (2.4-3.4%) and requires urgent magnesium sulfate administration. 1, 2

Differential Diagnosis

Primary Obstetric Causes

Eclampsia/Severe Preeclampsia

• Most common and life-threatening cause of post-LSCS seizures 1, 3
• Can occur up to 48 hours postpartum (and rarely beyond) 1
• Clinical features include: hypertension (BP >160/90 mmHg), proteinuria >5g/24h, oliguria <400ml/24h, cerebral symptoms, pulmonary edema 1
• May present with epigastric pain, upper abdominal tenderness, visual disturbances, severe headache 1

HELLP Syndrome with Eclampsia

• Hemolysis, elevated liver enzymes, low platelets occurring with eclamptic features 1
• Maternal mortality 3.4% 1
• Presents with epigastric pain, jaundice, nausea/vomiting, and may progress to hepatic rupture, acute renal failure 1
• Degree of thrombocytopenia correlates with liver dysfunction 1

Reversible Cerebral Vasoconstriction Syndrome (RCVS)

• Can be provoked by vasoconstrictive agents like methergine used for postpartum hemorrhage 4
• Presents with seizures and characteristic vasoconstriction on brain imaging 4
• Should be suspected especially if vasoconstrictive medications were administered 4

Non-Obstetric Causes

Metabolic Derangements

• Hypoglycemia, hyponatremia, hypocalcemia, hypomagnesemia 5, 6
• Severe hypoglycemia reported in association with HELLP syndrome 1
• These are correctable acute causes that must be immediately sought 6

Local Anesthetic Toxicity

• Inadvertent intravascular injection during regional anesthesia causes seizures and cardiovascular collapse 1
• Timing between injection and symptom onset is key diagnostic feature 1
• Treatment includes intravenous lipid emulsion (20% Intralipid) 1

High Spinal Anesthesia

• Can cause apnea but unlikely to cause dramatic cardiovascular collapse or hemorrhage 1

Amniotic Fluid Embolism

• Rare but often lethal condition causing acute cardiorespiratory collapse, seizures, and coagulopathy 1
• Bedside echocardiography showing right ventricular dysfunction favors this diagnosis 1
• Bronchospasm occurs in ~15% of cases 1

Cerebrovascular Events

• Stroke, intracerebral hemorrhage, or cerebral venous thrombosis 1, 2
• Cerebrovascular accident is a leading cause of maternal death in eclampsia 2

Pulmonary Embolism

• Recognized pregnancy complication, though unlikely with profuse bleeding 1

Venous Air Embolism

• Can cause acute cardiorespiratory compromise during cesarean section 1

Immediate Management Algorithm

Step 1: Stabilize and Protect Airway (Simultaneous with Step 2)

• Position patient in left lateral decubitus to prevent aspiration and optimize uteroplacental perfusion 1, 3
• Ensure patent airway with equipment immediately available 6
• Administer 100% oxygen 1
• Have intubation equipment ready for potential respiratory arrest 1, 6

Step 2: First-Line Seizure Control - Benzodiazepines

• Lorazepam 4 mg IV slowly (2 mg/min) for active seizures 7, 6
• If seizures continue after 10-15 minutes, give additional 4 mg IV slowly 6
• Alternative: Diazepam if lorazepam unavailable 8

Step 3: Magnesium Sulfate - Essential for Eclampsia

Start immediately if eclampsia suspected (which should be default assumption):

IV Regimen (preferred):

• Loading dose: 4g IV over 5-20 minutes 1
• Maintenance: Continuous infusion as per institutional protocol 1

IM Regimen (Pritchard - if IV access limited):

• Loading dose: 4g IV + 5g IM in each buttock (total 14g) 1
• Maintenance: 5g IM every 4 hours for 24 hours, alternating buttocks 1

Magnesium sulfate is significantly superior to diazepam or phenytoin for preventing recurrent eclamptic seizures 8, 2

Step 4: Monitor for Magnesium Toxicity

• Check deep tendon reflexes (knee jerks) - loss is first sign of toxicity 2
• Monitor respiratory rate (>12/min), urine output (>30ml/hour) 1
• Have calcium gluconate 1g IV available as antidote 1

Step 5: Blood Pressure Control (if severely elevated)

• Target: Keep BP 110-140/85 mmHg systolic, avoid rapid drops 1, 9
• Nifedipine (sublingual or oral) or IV hydralazine 1, 9
• Critical pitfall: Avoid rapid BP reduction causing uteroplacental hypoperfusion and fetal bradycardia 9

Step 6: Second-Line Anticonvulsants (if seizures persist despite benzodiazepines and magnesium)

Choose one of the following - all have similar efficacy (45-47%): 7

• Levetiracetam 30-50 mg/kg IV at 100 mg/min (favorable side effect profile, fewer drug interactions) 7
• Fosphenytoin 18-20 PE/kg IV at 150 PE/min (can cause hypotension 3.2%, cardiac dysrhythmias) 7
• Valproate 20-30 mg/kg IV at 10 mg/kg/min (contraindicated in liver disease, risk of thrombocytopenia) 7

Step 7: Urgent Laboratory Investigations

Essential workup to identify cause:

• Complete blood count with platelet count 1
• Coagulation profile: PT, PTT, fibrinogen, fibrin degradation products 1
• Liver function tests (AST, ALT, LDH for hemolysis) 1
• Renal function: creatinine, urea, uric acid 1
• Electrolytes: sodium, calcium, magnesium, glucose 5, 6
• Peripheral blood smear for hemolysis 1
• Urinalysis for proteinuria 1

Step 8: Imaging and Monitoring

• Brain CT or MRI if: atypical presentation, focal neurological signs, no response to treatment, or to rule out hemorrhage/stroke 1
• Chest X-ray to exclude pulmonary edema 1
• ECG 1
• EEG if non-convulsive status epilepticus suspected (persistent altered consciousness after seizure cessation) 10
• Echocardiography if amniotic fluid embolism or cardiac dysfunction suspected 1

Step 9: Fluid Management

• Critical consideration: Many eclamptic patients are relatively hypovolemic but at high risk for pulmonary edema 1, 9
• Urinary catheter for hourly output monitoring 1
• Conservative fluid administration, especially with hemoconcentration 9
• Central venous or pulmonary artery catheter in critically ill patients 1

Step 10: Ongoing Monitoring (First 24-48 Hours Postpartum)

• Hourly vital signs and neurological checks 9
• Continue magnesium sulfate for 24 hours after last seizure or delivery 1
• Monitor for pulmonary edema development 9
• Watch for massive diuresis as condition resolves 9

Critical Pitfalls to Avoid

1. Assuming all postpartum seizures are eclampsia without considering other diagnoses - while eclampsia should be treated presumptively, maintain differential awareness 1

2. Rapid blood pressure reduction - can cause uteroplacental insufficiency and fetal compromise (if undelivered) or cerebral hypoperfusion 9

3. Aggressive fluid administration in hemoconcentrated patients - high risk of pulmonary edema 9

4. Regional anesthesia with coagulopathy - HELLP syndrome causes thrombocytopenia; avoid neuraxial techniques if platelets <50,000-70,000/mm³ 1

5. Missing non-convulsive status epilepticus - requires EEG monitoring in patients with persistent altered consciousness 10

6. Administering vasoconstrictive agents (methergine) without considering RCVS risk 4

7. Failing to have calcium gluconate immediately available when using magnesium sulfate 1

8. Not recognizing local anesthetic toxicity timing - consider if seizure occurs immediately after regional anesthesia 1

Special Considerations for Anesthesia-Related Causes

If local anesthetic toxicity suspected:

• Stop local anesthetic administration immediately 1
• Administer 20% Intralipid (lipid emulsion therapy) 1
• Standard ACLS with modifications for lipid therapy 1

If high spinal suspected:

• Supportive ventilation 1
• Cardiovascular support as needed 1