What is the risk assessment from a neurology perspective for an emergency Lower Segment Caesarean Section (LSCS) in a 24-year-old pregnant woman with Antiphospholipid Syndrome (APLA), Cerebral Venous Sinus Thrombosis (CVST) with seizures, Systemic Lupus Erythematosus (SLE), Gestational Diabetes Mellitus (GDM), Community-Acquired Pneumonia (CAP) with left pleural effusion, and Tuberculous Pleurisy (TB pleura) at 32 weeks gestation, on Anti-Tuberculosis Treatment (ATT), steroids, levetiracetam (Keppra), and enoxaparin (Low Molecular Weight Heparin)?

Neurological Risk Assessment for Emergency LSCS: SEVERE RISK

This patient represents a severe neurological risk for emergency LSCS due to the convergence of multiple high-risk factors: recent CVST with seizures (6 months ago), active APLA syndrome requiring therapeutic anticoagulation, SLE, and the need for perioperative anticoagulation interruption at 32 weeks gestation. 1

Risk Stratification: SEVERE

The severity classification is based on the following critical parameters:

1. Thrombotic Risk - SEVERE

• APLA with prior CVST creates at least a 5-fold increased risk for cerebrovascular events 1
• Active/flaring SLE carries an OR of 19.0 for emergency caesarean section complications 2
• The perioperative period represents a critical thrombotic vulnerability window when enoxaparin must be interrupted for neuraxial anesthesia or surgical hemostasis 1
• Lupus anticoagulant (if present in this APLA patient) confers the greatest risk with RR 12.15 for adverse outcomes 2
• Pregnancy itself increases thrombotic risk through hemostatic and anatomic factors 2

2. Seizure Risk - MODERATE TO SEVERE

• History of seizures 6 months ago places patient at high risk for perioperative seizure recurrence, particularly with surgical stress, anesthesia, and potential medication interruption 1
• The combination of APLA and SLE increases seizure risk independently 1
• Status epilepticus occurred in 42% (8/19) of pregnant patients with CVST in one series 3
• Levetiracetam levels may be subtherapeutic perioperatively due to NPO status and altered pharmacokinetics

3. Hemorrhagic Risk - MODERATE TO SEVERE

• Therapeutic enoxaparin creates competing risks: interruption increases thrombosis risk, continuation increases surgical bleeding 1
• Thrombocytopenia is common in APLA/SLE patients, further complicating hemostasis 4
• Regional anesthesia (neuraxial blockade) is contraindicated or high-risk due to anticoagulation 1
• Parenchymal brain involvement (if present from prior CVST) increases risk of hemorrhagic transformation 3

4. Disease Activity Risk - MODERATE TO SEVERE

• Multiple active conditions (SLE, TB pleura, CAP with pleural effusion) suggest possible disease activity 2
• Active SLE increases risk of pre-eclampsia/eclampsia (OR 12.7) which can mimic or complicate neurological assessment 2
• Steroid use at maintenance doses increases preterm delivery risk (OR 3.5) 2
• GDM adds metabolic stress that can lower seizure threshold

5. Prematurity Risk - SEVERE

• 32 weeks gestation is premature; emergency LSCS at this gestational age carries inherent maternal and fetal risks 2
• SLE with APLA has 25-35% prematurity rate baseline 2
• Emergency (versus planned) delivery prevents optimal timing of anticoagulation bridging

Critical Perioperative Management Algorithm

Pre-Operative (Immediate - within hours)

• Neurological status assessment: Glasgow Coma Scale, focal deficits, seizure activity within last 24 hours 1
• Last enoxaparin dose timing: Must be ≥24 hours before neuraxial anesthesia if considered; ≥12 hours minimum for surgery 5
• Platelet count: Must be >70,000-80,000 for neuraxial; >50,000 for surgery 5
• Levetiracetam level if available: Load with IV levetiracetam if subtherapeutic or unable to take oral 1
• Blood pressure control: Avoid hypertensive surges that could extend prior CVST 1
• MRI brain if any new neurological symptoms: Rule out CVST extension or new thrombosis 3

Intra-Operative

• General anesthesia is mandatory - regional anesthesia contraindicated due to therapeutic anticoagulation and bleeding risk 1
• Maintain mean arterial pressure 65-90 mmHg: Avoid hypotension (cerebral hypoperfusion) and hypertension (CVST extension, seizure provocation) 1
• Continue levetiracetam IV perioperatively: Do not allow gap in antiepileptic coverage 1
• Minimize surgical time: Reduces thrombotic risk during anticoagulation interruption
• Prepare for massive transfusion protocol: Given multiple bleeding risk factors

Post-Operative (First 72 Hours Critical)

• Intensive neurological monitoring for 72 hours minimum: Hourly neurological checks, low threshold for continuous EEG monitoring to detect subclinical seizures 1
• Resume therapeutic anticoagulation 6-12 hours post-operatively if hemostasis adequate: Balance thrombotic versus hemorrhagic risk 1, 5
• Neuroimaging (MRI/MRV) if ANY new symptoms: Headache, focal deficits, altered mental status, seizures 3
• Continue levetiracetam without interruption: Maintain therapeutic levels 1
• Monitor for pre-eclampsia/eclampsia: Can occur postpartum and mimic neurological complications 2

Specific Risk Mitigation Strategies

Anticoagulation Management:

• Maintain therapeutic anticoagulation with minimal interruption (6-12 hour window only) 1
• Consider bridging with IV unfractionated heparin if enoxaparin must be held >24 hours pre-operatively (allows shorter half-life, easier reversal) 5
• Resume LMWH at therapeutic doses 6-12 hours post-operatively if surgical hemostasis adequate 5, 3
• Continue for minimum 6 weeks postpartum (total 6 months from CVST diagnosis) 5

Seizure Management:

• Optimize levetiracetam dosing pre-operatively: Consider loading dose if levels unknown 1
• Maintain IV formulation perioperatively until oral intake reliable
• Have rescue benzodiazepines immediately available
• Consider prophylactic increase in antiepileptic dose perioperatively given stress

Thrombosis Prevention:

• Sequential compression devices intra-operatively and until fully ambulatory 5
• Early mobilization as soon as hemostasis permits
• Adequate hydration to prevent hemoconcentration

Unfavorable Prognostic Factors Present

This patient has multiple unfavorable factors that elevate risk to SEVERE 1:

• Active/recent CVST (6 months is recent in thrombophilia context)
• Recent seizures (6 months ago)
• Need for anticoagulation interruption (unavoidable for surgery)
• Prematurity (32 weeks)
• Emergency nature (prevents optimal planning/bridging)
• Multiple comorbidities (SLE, TB, CAP, GDM)
• Parenchymal involvement if present from prior CVST 3

Common Pitfalls to Avoid

• Underestimating cumulative thrombotic risk: Each factor (APLA, SLE, CVST history, pregnancy, surgery) multiplies rather than adds risk 1
• Premature discontinuation of anticoagulation: Must continue minimum 6 weeks postpartum 5
• Assuming neurological stability: 72-hour critical window for complications 1
• Delaying neuroimaging with new symptoms: CVST can extend or recur 3
• Inadequate seizure prophylaxis: Maintain therapeutic antiepileptic levels throughout 1
• Attempting neuraxial anesthesia: Contraindicated with therapeutic anticoagulation 1

Mortality and Morbidity Context

• Mortality risk: 4-36% if CVST extends or catastrophic APS develops 1
• Permanent neurological sequelae more likely with parenchymal lesions, thrombophilia, and APLA 3
• Recurrent thrombosis risk remains high despite anticoagulation 6
• However, with appropriate management, maternal mortality can approach zero as demonstrated in specialized series 3

The convergence of APLA, prior CVST with seizures, SLE, need for emergency surgery, and anticoagulation interruption at 32 weeks gestation definitively places this patient in the SEVERE neurological risk category requiring intensive multidisciplinary management with neurology, maternal-fetal medicine, anesthesia, and hematology involvement. 1, 2, 3