Refractory Status Epilepticus Spontaneously Resolved by Parturition
The patient was a 27-year-old primigravida who was diagnosed as epilepsy with cortical dysplasia 21 years before. Her previous seizures were reasonably controlled by topiramate, carbamazepine, and pregabalin. At 23 weeks of pregnancy, her seizure frequency progressively increased. She came to the ER in a confused mental state with intermittent convulsive movements in her arm that lasted for a few hours. On neurological examination, her mental status was stuporous, but there were no focal neurological deficits. Initial electroencephalography (EEG) revealed very frequent and sharp medium- to high-voltage waves in the left fronto-centro-parietal area that built up repetitive high-voltage, generalized sharp, and wave complexes for 10 to 20 sec, which suggested SE. These ictal rhythms were correlated with initial head and eyeball deviation that was secondary to generalized tonic-clonic seizures. Between the seizures, consciousness was not regained. Except for the pregnancy, there were neither precipitating factors nor laboratory abnormalities.\nShe was admitted to the ICU, and she was managed with a continuous infusion of intravenous midazolam under continuous EEG (c-EEG) monitoring. On the EEG, very frequent sharp waves with repetitive ictal rhythms appeared in the left centro-parieto-occipital area. Midazolam was titrated up to 5.5 mg/kg/h, but the ictal rhythms with clinical seizures were not successfully controlled. On the fifth hospital day (HD 5), midazolam was dosed up to 17 mg/kg/h, her blood pressure was reduced to 80/50, but the repeated seizures were not controlled. We added 3,000 mg of levetiracetam per day. Midazolam was tapered slowly from HD 10 to HD 16, and then her mental state and EEG findings were improved except for an occasional brief seizure. On HD 32, she was transferred to the ward with c-EEG monitoring. However, three days later, very frequent generalized seizures occurred again. Phenytoin, phenobarbital, and pentobarbital were sequentially loaded for a few days with intervals, but SE continued.\nOn HD 43, at 29 weeks of pregnancy, a cesarean section was performed. After the parturition, the EEG gradually improved. The EEG performed the day after parturition showed only intermittent median voltage sharp waves in the left centro-parietal area. Her mentality gradually improved, and accordingly, previous anti-SE drugs were gradually tapered out. She was discharged with an alert mental status, and the discharge medications were topiramate (300 mg), pregabalin (450 mg), levetiracetam (3,000 mg), and phenobarbital (180 mg). Her baby was raised in the newborn section because of premature and low birth weight. However, he did not show any other neonatal problems.