Basic information about the case profile: maternal, female, 20 years old. Complaints: 36 weeks of menopause + 5, 16 hours of pesticide use. Current medical history: 150mL of glyphosate pesticide was taken at 6 pm yesterday, local gastric lavage, blood potassium 6.27mmol/L, and relevant symptomatic supportive treatment (details unknown). Anamnesis: history of epilepsy, long-term use of oxcarbazepine (2#/bid), levetiracetam (1#/bid), but irregular medication, multiple seizures during pregnancy, and general disease control.
Prenatal examination: uterine height 32cm, abdominal circumference 98cm, fetal heart rate 150 times/min, vaginal examination not done.
Color ultrasound: head position, double top diameter 8.7cm, head circumference: 32cm, abdominal circumference 31.9cm, femur length 6.7cm, amniotic fluid maximum depth 3.1cm, amniotic fluid index 6.9cm, fetal heart rate 130 times/min, heart rhythm; Anterior wall of the placenta, grade I, 3.2 cm thick, umbilical cord placental entrance is located at the right lower edge of the placenta, umbilical cord: no obvious indentation on the neck.
Preoperative examinations:
Anesthesia administration
Anesthesia process
The patient enters the room, clear consciousness, can cooperate, good fetal heart, blood pressure: 140/85mmHg, heart rate: 95 times/min, pulse oxygen: 98%, and a seizure in the ward 2 hours before the medical history is known;
12:40 Sevoflurane: 8L/min; Propofol 50 mg IV, rocuronium bromide 50 mg IV;
12:45 Insertion of 6.5# catheter in the trachea;
12:56 A live baby girl was cut out Apgar score 7 points, 8 points, irregular breathing, heart rate of about 130 beats / minute, cyanosis of the skin all over the body, weak muscle tone, stimulation of the soles of the feet and other initial resuscitation after the complexion gradually reddened, transferred to the NICU;
13:00 Stop sevoflurane, midazolam 2mg IV, sufentanil 30ug IV;
Anesthesia maintenance: remifentanil 0.3 ug/kg*min propofol 4 mg/kg*h;
intraoperative intravenous oxytocin 20 units;
14:05 Intraoperative bleeding of 500mL, the operation was successful, and the operation was returned to the ICU;
Postoperative procedure
12-07 Admitted to the ICU, anti-inflammatory, anti-infectious, hydration, nutritional support, and maintenance of internal environment stability.
12-09 The patient was transferred out of the ICU and transferred to the maternity ward.
12-13 18:59 The patient had a sudden seizure with convulsions throughout the body, which lasted about 1 minute and remissioned. At 22:35, the seizure was repeated, with loss of consciousness and limb convulsions, lasting about 1 minute, and terminated after a stable 10 mg intravenous postponement. 12-14 00:40 Recurrence for longer than before.
12-14 Patients are discharged
Discussion and analysis
Glyphosate poisoning
Glyphosate is currently the most widely used herbicide in the world, a new non-organophosphorus herbicide with low toxicity, not an inhibitor of acetylcholinesterase and no special antidote at present, so the use of atropine and phosphodine is not advocated.
Common manifestations include gastrointestinal symptoms (nausea, vomiting, abdominal pain, diarrhea), cardiac damage (toxic myocarditis, circulatory failure), pulmonary damage (pulmonary edema, respiratory failure), liver damage (jaundice, elevated aminotransferases), renal impairment (oliguria, elevated serum creatinine, and urea nitrogen), and hematologic and metabolic disorders (elevated leukocytes and metabolic acidosis).
The treatment of this disease still emphasizes active gastric lavage, catharsis to remove poisons, followed by a large number of rehydration, detoxification, symptomatic supportive treatment: the focus should be on controlling aspiration pneumonia, pulmonary edema, intractable hypotension, shock and convulsions, coma and other life-threatening toxic effects, respiratory failure and shock are important causes of death, should pay attention to early prevention and treatment.
Pregnancy with epilepsy
Features of pregnancy with epilepsy
Epilepsy, commonly known as "epilepsy" or "epilepsy", is a chronic disease in which brain neurons are suddenly and abnormally discharged, resulting in transient brain dysfunction.
The main goals of pregnancy management in women of childbearing age with epilepsy (WWE) are: maintenance of the lowest effective dose of antiepileptic drugs (AEDs), control of seizures, and reduction of fetal structural malformations and neurodevelopmental disorders.
- Women of childbearing age with epilepsy (WWE) have a 25%-35% lower chance of conception than the general population;
- In pregnant women, epilepsy can have a mortality rate of 10 times that of healthy pregnant women;
- Treatment with antiepileptic drugs may increase the risk of fetal malformations, but with standardized management, more than 90% of patients with epilepsy can have normal pregnancies;
Effects of pregnancy on epilepsy
- About 67% of women of childbearing age with epilepsy have stable pregnancy without seizures, and the duration of preconception seizures is the most important indicator to assess whether the condition worsens during pregnancy;
- Increased frequency of seizures during pregnancy may be associated with changes in drug metabolism, hormones, or blood during pregnancy;
- Pregnancy-related sleep deprivation, pain during labour, and hyperventilation may lower the seizure threshold and precipitate seizures;
- Self-discontinuation during pregnancy may also lead to inadequate antiepileptic drug treatment due to concerns about the teratogenic risk of antiepileptic drugs (AEDs), increasing the frequency of seizures.
Effects of pregnancy on the use of AEDs
In the state of pregnancy, the pharmacokinetics of AEDs in vivo differs greatly from that in the normal human population:
- Plasma drug concentrations of most AEDs during pregnancy, such as levetiracetam, oxcarbazepine, lamotrigine, and topiramate, are reduced, so patients treated with such AEDs need to be closely monitored during pregnancy for clinical status and plasma drug concentrations;
- AEDs are common teratogenic drugs, and the incidence of severe congenital malformations after use is 2-3 times that of ordinary pregnant women;
- The first 12 weeks of pregnancy is the first trimester, which is a critical period for the development and formation of embryonic organs, and major congenital malformations (MCMs) that threaten life or require surgical intervention often occur in this stage of MCMs including cardiac developmental malformations, neural tube defects, genitourinary tract malformations, bone malformations and cleft palate;
- Do not precipitously stop the anti-epileptic drugs being used during pregnancy, because stopping the drug may cause seizures and may also cause status epilepticus, and it has been reported that in the occurrence of status epilepticus during pregnancy, the mortality rate of the fetus is 50%, and the maternal is 30%;
Patients who choose to use antiepileptic drugs for a long time under anesthesia have certain particularities in their organ function
1. Most of the anti-epileptic drugs are liver metabolism enzyme promoters (enzymatic), the activity of liver enzymes increases after long-term use, the metabolism of drugs in the liver increases, so that the effective effect of drugs that play in the original form is weakened and the duration is shortened, and the effective effect of drugs that play a role in metabolites is enhanced, the duration may be prolonged, and the side effects are increased, and attention is needed when selecting anesthetics.
2. Anti-epileptic drugs are mostly central inhibitors, which have a synergistic effect with narcotic analgesics and sedatives.
3. There may be liver insufficiency, the degree of which should be understood. In severe insufficiency, some inhalation anesthetics (eg, metoflurane, halothane) should be used with caution to avoid central hepatic lobular necrosis.
4. Anti-epileptic drugs have certain inhibition of hematopoietic function, and the whole blood picture and coagulation function should be checked before surgery.
5. Patients with epilepsy may have other diseases, especially symptomatic or secondary epilepsy found due to acquired factors, often accompanied by various symptoms of the primary disease.
6. Pregnant women should also pay attention to their fetuses to assess whether there is a possibility of malformation.
Preparation before anesthesia
1. Before anesthesia, the patient's emotions must be stabilized, the explanation work should be done, and the patient should have sufficient rest and sleep a few days before the operation, and avoid the use of stimuli such as tobacco and alcohol.
2. Anti-epileptic drugs should be taken as routine, and sedatives should be added if necessary.
3. In order to prevent large seizures during the perianesthetic period, the dose of sedatives used before anesthesia should be appropriately increased, such as midazolam, diazepam, etc.
Anesthesia options
- For patients with frequent epilepsy and seizures without obvious triggers, general anesthesia is the first choice to do a good job in neonatal rescue.
- Drug selection: induction is based on propofol, non-depolarizing muscle relaxants such as vecuronium bromide, rocuronium bromide, etc., analgesia is mainly remifentanil, benzodiazepines such as midazolam can be used after the fetus is delivered, the dose should be increased, and opioids can be fentanyl or sufentanil.
- Etonomidate is rarely used for general anesthesia for cesarean section due to its inhibitory effect on neonatal cortisol synthesis, and is suitable for pregnant women who are haemodynamically unstable or have poor tolerance to hemodynamic fluctuations. Ketamine and esketamine can directly or indirectly excite various parts of the central nervous system to cause convulsions, and are not suitable for patients with epilepsy.
- cis-atracurium or pethidine is relatively contraindicated, and its metabolites have epileptogenic effects.
- After the end of general anesthesia, neostimemine antagonistic muscle relaxation is banned, because it belongs to retrograde anticholinesterase and acetylcholine accumulation and M-like and N-like effects, which can cause muscle tremor and induce seizures.
B. For patients who can still cooperate and have good epilepsy control, neuraxial anesthesia can be selected; for patients who choose transvaginal delivery, preoperative assessment and preparation for immediate cesarean section can be performed, and labor analgesia can be performed under epidural or lumbar rigidity.
- During the operation, anti-epileptic drugs, sedation, endotracheal intubation and other rescue items should be prepared.
- Rapid blockade of sensory and motor nerves by lumbar anesthesia may cause strong stimulation in epilepsy patients and induce seizures.
- Lumbar anesthesia may induce seizures by affecting intracranial pressure.
Reflection and summary
(1) Strengthen medical history collection;
(2) Weigh the pros and cons and make the best anesthesia plan according to the individual situation of the patient;
(3) Pay attention to the condition of the fetus and make full preparations for rescue work;
(4) Strengthen multi-disciplinary cooperation and fully communicate with obstetrics, pediatrics, and ICU;
Editor: Li Chuang Review: Shen Lei
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