Scenario in a Nutshell
Patient has a seizure in triage. Emergency treatment of seizure, treated as eclampsia while considering other causes. When recovers, is in active labour.
Stage 1: Patient just admitted to triage and has a tonic–clonic seizure.
Stage 2: Immediate post-seizure care and treatment of severe hypertension.
Stage 3: Patient in active labour – plan made for labour and delivery.
Target Learner Groups
All members of the multidisciplinary obstetric team: anaesthetists, midwives and obstetricians.
| Specific learning opportunities |
|---|
| Demonstrate effective team management of eclampsia |
| Demonstrate knowledge of the differential diagnosis of a seizure in pregnancy |
| Demonstrate timely management of acute, severe hypertension |
| Suggested learners (to represent their normal roles) | In the room from the start | Available when requested |
|---|---|---|
| Anaesthetic ST3+ | √ | |
| Obstetric ST1-2/FY2 | √ | |
| Obstetric ST3+ | √ | |
| Midwife coordinator | √ | |
| Midwife in room | √ | |
| Suggested facilitators | ||
| Faculty to play role of midwife finishing shift (can be played by facilitator running scenario) | √ | |
| Faculty to play role of patient’s partner (comes in at start of stage 2) | √ |
Details for Facilitators
Patient Demographics
Name: Sarah Age: 19 Gestation: 38+4 Booking weight: 62 kg Parity: P0 |
Scenario Summary for Facilitators
Nulliparous 19-year-old, 38 weeks gestation. Attended with abdominal pain and headache and felt suddenly unwell upon arrival.
Seizure in triage room lasting 2 minutes.
Severe systolic hypertension requiring intravenous therapy.
Once stabilised found to be in labour (8 cm). Plan made for labour and delivery.
Set-up Overview for Facilitators
| Clinical setting | Triage room |
| Patient position | Semi-recumbent on triage trolley |
| Initial monitoring in place | None |
| Other equipment | None |
| Useful manikin functions | Seizures |
Medical Equipment
For core equipment checklist see Chapter 9.
| Additional equipment specific to scenario | ||
|---|---|---|
| Eclampsia box as per local guidelines including MgSO4 | Antihypertensive drugs according to local guidelines: labetalol, hydralazine | Pen torch |
| Tendon hammer | Arterial line | Local checklist for eclampsia |
Information Given to the Learners
| Information given to ST2 obstetric trainee and midwife. |
| Time: 23.00 |
| This handover is given by a facilitator playing the role of the midwife in the room already with the patient. |
The SBAR handover is as follows:
|
Scenario Schedule
Suggested Topics for Debrief Discussion
Did the team consider causes other than eclampsia for the seizure?
How easy was it to access: emergency checklist (if available locally), eclampsia box/trolley, syringe driver, antihypertensive drugs? Could this be improved?
Discussion
Acute Seizure Management in Pregnancy
A seizure occurring in pregnancy is an obstetric emergency requiring prompt management to avert or reduce maternal and fetal morbidity. Although the cause may not be immediately known, clinical management should always proceed via a systematic approach (ABCDE prioritisation) and include actions to minimise self-inflicted harm. Due to altered physiology in pregnancy – which increases the likelihood of aspiration, increases the metabolic oxygen demand and necessitates displacement of the gravid uterus from the vena cava – the risks associated with seizures are increased in pregnancy.
Acute management of a maternal seizure must include investigation to determine the likely cause. Some potential causes of seizures in pregnancy are provided in Table 17.1 but also, any pathology causing severe hypoxia or hypotension can present with a seizure due to inadequate oxygen delivery to the brain.
Table 17.1 Differential diagnosis of maternal seizure (alphabetical).
| Amniotic fluid embolus | Hyponatraemia |
| Cerebral venous sinus thrombosis | Infection |
| Dural puncture (iatrogenic – postpartum) | Intracerebral mass lesion |
| Eclampsia | Non-epileptic attack disorder |
| Epilepsy (primary, secondary or gestational) | Stroke: ischaemic or haemorrhagic |
| Hypocalcaemia | Thrombotic thrombocytopenic purpura |
| Hypoglycaemia | Withdrawal from substance of abuse |
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