22‑year‑old female, gravida 2 para 1 at 37 weeks + 3 days gestation, prior low‑transverse cesarean for epilepsy, previously on lamotrigine and folic acid but stopped lamotrigine after confirming pregnancy, now presenting with labor pains, stable vitals, normal CBC and urinalysis, prior normal brain MRI, no family history of epilepsy – what is the complete diagnosis and management plan (including orders, missing diagnostics, and SOAP note) according to Harrison’s principles and Philippine obstetric‑neurology guidelines?

Complete Diagnosis and Management for 22-Year-Old G2P1 at 37 3/7 Weeks with Epilepsy Presenting in Labor

This patient requires immediate resumption of lamotrigine, co-management with neurology, and planned cesarean delivery given her prior cesarean for epilepsy with close monitoring for seizures and hypertensive complications.

Complete Diagnosis

Primary Diagnoses:

• Active labor at 37 3/7 weeks gestation 1
• Epilepsy, currently uncontrolled (off lamotrigine since pregnancy confirmation) 1
• Status post cesarean section (prior CS for maternal epilepsy indication) 2
• High-risk pregnancy due to epilepsy and prior cesarean 3, 2

Risk Factors to Document:

• Increased risk of seizures during labor and delivery due to medication discontinuation 4, 5
• Increased risk of cesarean delivery (approximately 2-fold higher in women with epilepsy) 2
• Increased risk of non-proteinuric hypertension (higher than general population) 2
• Increased risk of labor induction 2

Critical Management Plan

Immediate Actions (Within 1 Hour)

Seizure Prevention:

• Resume lamotrigine immediately at her previous maintenance dose 4, 5
• Note: Lamotrigine levels drop significantly during pregnancy due to increased clearance, but resumption is critical to prevent peripartum seizures 5
• Establish IV access and prepare magnesium sulfate for seizure prophylaxis if seizure occurs 1, 6

Obstetric Assessment:

• Continuous fetal heart rate monitoring (Category I, II, or III classification) 1
• Cervical examination to assess labor progress 1
• Assess for hypertensive disorders given increased risk in epilepsy patients 1, 2
• Blood pressure monitoring every 15-30 minutes initially, then hourly if stable 1

Mode of Delivery Decision:

• Plan for repeat cesarean section given prior CS and active labor presentation 2
• Vaginal birth after cesarean (VBAC) is contraindicated in active labor without prior counseling and consent
• Anesthesia consultation immediately for regional vs. general anesthesia planning 1

Laboratory and Diagnostic Workup (Missing Diagnostics)

Immediate Labs (STAT):

• Complete metabolic panel (electrolytes, renal function, liver enzymes) 6, 7
• Repeat CBC with platelet count (to rule out HELLP syndrome given epilepsy medication history) 6, 7
• Coagulation profile (PT, PTT, INR) if cesarean planned 6, 8
• Type and screen (minimum) or type and cross-match 2 units PRBCs for cesarean 6
• Lamotrigine level (though results will be delayed, establish baseline for postpartum management) 5

Additional Monitoring:

• Urinalysis with protein quantification (rule out preeclampsia, higher risk in epilepsy) 1, 2
• Liver function tests (AST, ALT, LDH, bilirubin) to screen for HELLP syndrome 6, 7
• Uric acid level 1

Fetal Assessment:

• Ultrasound for fetal biometry, amniotic fluid index, and presentation 1
• Non-stress test if not already on continuous monitoring 1

Neurology Co-Management

Immediate Neurology Consultation for:

• Optimization of antiepileptic drug regimen peripartum 1, 4
• Seizure risk assessment given medication discontinuation 4, 5
• Postpartum medication adjustment plan (lamotrigine levels will rise rapidly postpartum) 5
• Breastfeeding counseling (lamotrigine transfer into breast milk) 5

Anesthesia Planning

Key Considerations:

• Regional anesthesia preferred (epidural or spinal) if platelet count >100,000/mm³ 7, 8
• General anesthesia if platelets <100,000/mm³ or patient refuses regional 7, 8
• Avoid fluid overload during cesarean (increased risk in epilepsy patients on certain medications) 1
• Magnesium sulfate availability at bedside for seizure management 1, 6

Intrapartum Management

If Proceeding with Cesarean (Recommended):

• NPO status immediately 1
• Preoperative antibiotics (cefazolin 2g IV or clindamycin + gentamicin if allergic) 1
• Fluid management: 60-80 mL/hour to avoid overload 1
• Continuous blood pressure monitoring 1
• Seizure precautions: padded side rails, suction at bedside, magnesium sulfate drawn up 1, 6

If Severe Hypertension Develops (≥160/110 mmHg):

• Urgent treatment required 1
• First-line agents: oral nifedipine immediate-release 10-20 mg OR IV labetalol 20 mg bolus OR IV hydralazine 5-10 mg 1
• Target diastolic BP 85 mmHg, systolic <160 mmHg 1

If Seizure Occurs:

• Magnesium sulfate 4-6g IV loading dose over 15-20 minutes, then 1-2g/hour maintenance 1, 6
• Protect airway, turn patient to left lateral position 1
• Expedite delivery after maternal stabilization 6, 7

Postpartum Management

Immediate Postpartum (0-24 Hours):

• Continue lamotrigine but anticipate need for dose reduction as clearance normalizes 5
• Monitor blood pressure every 4-6 hours for at least 3 days 1
• Repeat CBC, liver enzymes, platelets on postoperative day 1 6, 7
• Assess for postpartum preeclampsia/HELLP (30% occur postpartum) 7
• Seizure precautions continue for 48 hours minimum 1, 6

Breastfeeding Counseling:

• Lamotrigine transfers into breast milk in clinically important amounts 5
• However, breastfeeding is not contraindicated; monitor infant for sedation or poor feeding 5
• Folic acid supplementation should continue during breastfeeding 3, 5

Neurology Follow-Up:

• Lamotrigine level check at 2 weeks postpartum (levels rise rapidly after delivery) 5
• Dose adjustment likely needed to prevent toxicity 5
• Long-term epilepsy management plan 1

Obstetric Follow-Up:

• Blood pressure check within 1 week if any hypertension during admission 1
• 3-month postpartum visit to ensure normalization of all parameters 1
• Counseling for future pregnancies: preconceptional folic acid ≥0.4 mg daily, optimize seizure control before conception, avoid valproate 3, 9, 5

SOAP Note Format

Subjective

Chief Complaint: Labor pains

HPI: 22-year-old G2P1(1001) at 37 3/7 weeks by LMP presenting with labor pains. Prior cesarean section [DATE] at [FACILITY] for maternal indication (epilepsy). History of epilepsy, previously maintained on lamotrigine and folic acid. Patient discontinued lamotrigine [DATE] after confirming pregnancy, currently only taking folic acid. No seizures reported since discontinuation. No headache, visual changes, epigastric pain, or right upper quadrant pain. Denies vaginal bleeding or leakage of fluid. Reports regular contractions.

PMH: Epilepsy (no family history), prior cesarean section

Medications: Folic acid (dose?), lamotrigine discontinued since [DATE]

Allergies: NKDA

Social History: (document smoking, alcohol, drug use)

OB History: G2P1(1001), prior cesarean [DATE] for maternal epilepsy

Prenatal Care: (document prenatal visits, any complications, GBS status, blood type, antibody screen)

Objective

Vital Signs: BP ___, HR ___, RR ___, Temp ___, SpO2 ___

• Document if BP ≥140/90 mmHg (increased risk in epilepsy patients) 1, 2

Physical Exam:

• General: Alert, oriented, no acute distress
• Neurologic: Assess for hyperreflexia, clonus (signs of CNS compromise) 7
• Cardiovascular: Regular rate and rhythm
• Respiratory: Clear to auscultation bilaterally
• Abdomen: Gravid, non-tender, assess for right upper quadrant tenderness 6, 7
• Extremities: Assess for edema 1

Obstetric Exam:

• Fundal height: ___ cm
• Fetal heart rate: ___ bpm, Category ___ tracing 1
• Contractions: Frequency ___, duration ___
• Cervical exam: ___ cm dilated, ___% effaced, station ___, presentation ___
• Membrane status: intact vs. ruptured

Labs:

• CBC: WBC ___, Hgb ___, Hct ___, Platelets ___ (normal per chart, document actual values) 6, 7
• Urinalysis: (unremarkable per chart, document protein, blood, glucose) 1
• PENDING: CMP, LFTs, coagulation profile, type and screen, lamotrigine level

Imaging:

• Prior brain MRI: unremarkable (date?)
• Ultrasound today: (pending - fetal biometry, AFI, presentation)

Assessment

1. Active labor at 37 3/7 weeks gestation
2. Epilepsy, currently off medication (high seizure risk)
3. Status post cesarean section (prior CS for maternal indication)
4. High-risk pregnancy secondary to epilepsy and prior cesarean

Plan

Seizure Management:

1. Resume lamotrigine ___ mg PO immediately (prior maintenance dose) 4, 5
2. Neurology consultation STAT for peripartum seizure management 1
3. Seizure precautions: padded side rails, suction at bedside, magnesium sulfate 6g IV available 1, 6
4. If seizure occurs: magnesium sulfate 4-6g IV load, then 1-2g/hour maintenance 1, 6

Obstetric Management: 2. Plan for repeat cesarean section given prior CS and active labor 2 3. Anesthesia consultation STAT for regional vs. general anesthesia planning 1, 7 4. Continuous fetal monitoring 1 5. NPO in preparation for cesarean 1 6. IV access: 18-gauge or larger, fluid rate 60-80 mL/hour 1

Hypertension Monitoring: 7. Blood pressure every 15-30 minutes initially, then hourly if stable 1 8. If BP ≥160/110 mmHg: treat urgently with nifedipine 10-20 mg PO OR labetalol 20 mg IV OR hydralazine 5-10 mg IV 1

Laboratory Workup: 9. STAT labs: CMP, LFTs (AST, ALT, LDH, bilirubin), coagulation profile, type and screen (or cross-match 2 units) 6, 7 10. Lamotrigine level (for postpartum management) 5 11. Urinalysis with protein quantification 1

Imaging: 12. Ultrasound: fetal biometry, AFI, presentation confirmation 1

Postpartum Planning: 13. Continue lamotrigine postpartum with dose adjustment as needed 5 14. Monitor BP every 4-6 hours for 3 days postpartum 1 15. Repeat CBC, LFTs on POD#1 6, 7 16. Breastfeeding counseling: lamotrigine transfers into breast milk, monitor infant 5 17. Neurology follow-up at 2 weeks for lamotrigine level check and dose adjustment 5 18. OB follow-up at 1 week if any hypertension, routine at 6 weeks 1

Future Pregnancy Counseling: 19. Preconceptional folic acid ≥0.4 mg daily (ideally 4-5 mg in epilepsy patients) 3, 9, 5 20. Optimize seizure control before conception 3, 2 21. Avoid valproate (high teratogenic risk) 9

Critical Pitfalls to Avoid

Do NOT:

• Delay resumption of lamotrigine - seizure risk is highest peripartum when off medication 4, 5
• Attempt vaginal delivery without prior VBAC counseling - patient has prior cesarean and is in active labor 2
• Overlook hypertensive disorders - epilepsy patients have higher risk of gestational hypertension 2
• Ignore signs of HELLP syndrome - right upper quadrant pain, headache, visual changes require immediate evaluation 6, 7
• Fluid overload during cesarean - limit to 60-80 mL/hour 1
• Forget postpartum lamotrigine dose adjustment - levels rise rapidly after delivery, toxicity risk 5

Common Misconception:

• Folic acid supplementation does NOT protect against neural tube defects caused by antiepileptic drugs (unlike spontaneous neural tube defects), but should still be given for other benefits 9, 5