Jane Borden, age 24, is admitted to the women’s health unit with hyperemesis and dehydration. Nine weeks pregnant, she has a history of epilepsy with an onset at age 15. She takes carbamazepine 200 mg twice daily. Ms. Borden tells the emergency department physician she has missed a few doses in the last week because of nausea and vomiting.
History and assessment hints
When you assess Ms. Borden, you find a young Caucasian female who weighs 60 kg and is 64″ tall. Her blood pressure is 95/62 mm Hg; heart rate, 112 beats/minute and regular; and respiratory rate, 28 breaths/minute on room air. An I.V. line in her right forearm is infusing 0.9% normal saline solution at 150 mL/hour. The patient appears lethargic and mumbles that she is seeing spots. Her mother is in the room and states her daughter usually sees spots right before she has a seizure.
Call for help
Realizing Ms. Borden is probably experiencing an aura and may be about to have a seizure, you activate the rapid response team (RRT) and page the patient’s admitting physician. Without prompt treatment, a seizure can cause hypoxia, which could harm the fetus. If the patient isn’t adequately protected during the seizure, injury to her abdomen also could harm the fetus.
On the scene
The RRT nurse arrives just as Ms. Borden stiffens and her extremities begin to jerk. You turn the patient onto her right side to protect her airway. The RRT nurse anticipates the physician will order I.V. lorazepam and asks you to prepare it; shortly afterward, the physician arrives and orders the lorazepam. You administer the drug while the RRT nurse places the patient on a 40% oxygen mask. After several minutes, seizure activity subsides, and Ms. Borden answers questions sluggishly but correctly. Her vital signs are stable.
Ms. Borden’s neurologist orders a STAT carbamazepine blood level as well as STAT magnesium and calcium blood levels. Results show a sub-therapeutic carbamazepine level but normal magnesium and calcium levels. She receives an extra dose of carbamazepine that day and the next day, and is advised to see her neurologist for another carbamazepine level in 1 week.
You initiate diphenhydramine 25 mg P.O. every 8 hours p.r.n. for nausea and continue her multivitamin/mineral supplement and folic acid. Ms. Borden’s dehydration resolves after 48 hours of I.V. fluids. Her nausea abates with diphenhydramine therapy, and she is able to tolerate her carbamazepine dose without incident. She is discharged home, with follow-up visits arranged with her obstetrician and neurologist.
Education and follow-up
Epilepsy is a brain disorder that causes repeated, unpredictable seizure activity. During a seizure, brain cells become linked together abnormally, causing them to fire rapidly and excessively. Antiepileptic drugs (AEDs), such as lorazepam, are given to stop or prevent the spread of this abnormal electrical firing.
Although pregnancy isn’t contraindicated in patients with epilepsy, healthcare providers recommend pregnant women with epilepsy take multivitamin/mineral supplements and folic acid. They also recommend women receive only one AED during pregnancy if possible, because these drugs can cause birth defects.
To help prevent a seizure, encourage pregnant women with epilepsy to take their multivitamin/mineral supplements, because low calcium and magnesium levels have been linked to seizure development. Urge them to take folic acid as prescribed; it has been shown to prevent certain types of birth defects. Stress the importance of staying well-hydrated and reporting nausea and vomiting to the neurologist immediately. To reduce pregnancy-related nausea and vomiting, primary care providers may add antinausea medications and therapies, such as wrist acupressure.
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