Why should a 40‑week gravida 1, para 0 woman in active labor with known focal post‑gliotic epilepsy from prior traumatic brain injury and mild intellectual developmental disorder be referred back to neurology?

Neurology Referral for Laboring Patient with Post-Traumatic Epilepsy

You should not routinely refer this patient back to neurology during active labor unless she develops new neurological symptoms, seizure activity, or complications requiring neurological input for anesthetic management. 1

Primary Rationale Against Routine Referral

The evidence does not support routine neurology consultation for patients with stable, known epilepsy who are in active labor without acute neurological changes. The obstetric and anesthesia teams are equipped to manage labor in patients with known seizure disorders when the condition is stable and previously evaluated. 1

Key Clinical Considerations

Seizure Management During Labor:

• Patients with known focal epilepsy from prior traumatic brain injury who are neurologically stable do not require emergent neurology consultation simply because they are in labor 1
• The primary concern is maintaining therapeutic antiepileptic drug levels and monitoring for seizure activity during labor, which can be managed by the obstetric team 1
• Approximately one-third of women with seizure disorders experience increased seizure frequency during pregnancy, but this would have been identified during prenatal care 1

Anesthetic Planning Considerations:

• Neurology referral becomes relevant if neuraxial anesthesia (epidural/spinal) is planned and there are concerns about pre-existing neurological deficits that could complicate assessment of anesthetic complications 1
• The anesthesia team should be aware of her intellectual developmental disorder and focal epilepsy, as language/communication difficulties increase the risk of delayed diagnosis of neuraxial complications 1
• Pre-existing neurological conditions do not contraindicate neuraxial anesthesia but require careful documentation of baseline neurological status 1

When Neurology Referral IS Indicated

Acute Neurological Changes:

• New-onset seizures or change in seizure pattern during labor 1
• New neurological symptoms not confined to lower body (affecting arms, face, cranial nerves) 1
• Headache with convulsions or altered mental status beyond her baseline intellectual disability 1
• Any acute motor or sensory deficits that cannot be explained by neuraxial anesthesia 1

Post-Delivery Monitoring:

• If she develops postpartum neurological deficits, urgent neurology consultation and imaging may be required 1
• Hospitals should have protocols for rapid re-admission and neurological evaluation of women presenting with acute neurological symptoms postpartum 1

Practical Management Algorithm

Pre-Delivery:

1. Document baseline neurological examination, including her known focal deficits from prior TBI 1
2. Confirm current antiepileptic medication regimen and last dose 1
3. Alert anesthesia team to her epilepsy and intellectual disability if neuraxial anesthesia is considered 1
4. Ensure seizure precautions are in place (padded side rails, suction available) 1

During Labor:

1. Monitor for seizure activity 1
2. Maintain therapeutic antiepileptic drug levels 1
3. If neuraxial anesthesia is administered, document pre-block neurological status carefully given her communication difficulties 1

Post-Delivery:

1. Resume or adjust antiepileptic medications as needed 1
2. Monitor for any new neurological symptoms requiring urgent evaluation 1

Common Pitfalls to Avoid

• Over-consulting: Stable, known neurological conditions managed in the outpatient setting do not automatically require inpatient neurology consultation during labor 1
• Delayed recognition of complications: Her intellectual disability and communication difficulties increase risk of delayed diagnosis of neuraxial complications—maintain high index of suspicion 1
• Inadequate baseline documentation: Failure to document her baseline neurological status before neuraxial anesthesia can complicate assessment of potential complications 1

The key distinction is between stable, previously evaluated conditions (which do not require acute neurology consultation) and new or changing neurological symptoms (which do require urgent evaluation). 1