Status epilepticus due to brain tumor during pregnancy

Status epilepticus in pregnancy: a literature review and a protocol proposal

INTRODUCTION

Status epilepticus (SE) in pregnancy represents a life-threatening medical emergency for both mother and fetus. Pregnancy-related pharmacokinetic modifications and the risks for fetus associated with the use of antiseizure medications (ASMs) and anesthetic drugs complicate SE management. No standardized treatment protocol for SE in pregnancy is available to date.

AREAS COVERED

In this review, we provide an overview of the current literature on the management of SE in pregnancy and we propose a multidisciplinary-based protocol approach.

EXPERT OPINION

Literature data are scarce (mainly anecdotal case reports or small case series). Prompt treatment of SE during pregnancy is paramount and a multidisciplinary team is needed. Benzodiazepines are the drugs of choice for SE in pregnancy. Levetiracetam and phenytoin represent the most suitable second-line agents. Valproic acid should be administered only if other ASMs failed and preferably avoided in the first trimester of pregnancy. For refractory SE, anesthetic drugs are needed, with propofol and midazolam as preferred drugs. Magnesium sulfate is the first-line treatment for SE in eclampsia. Termination of pregnancy, via delivery or abortion, is recommended in case of failure of general anesthetics. Further studies are needed to identify the safest and most effective treatment protocol.

Patterns of Interaction Between Diffuse Low-Grade Glioma and Pregnancy: An Institutional Case Series

BACKGROUND

The occurrence of pregnancy in patients with low-grade glioma (LGG) constitutes a unique therapeutic challenge. Owing to the rarity of cases, there is a dearth of information in existing literature.

METHODS

We retrospectively identified all patients with a diagnosis of LGG and pregnancy at some point during their illness. Clinical course and obstetrical outcomes were reviewed. A volumetric analysis of tumor growth rate in association with pregnancy was performed.

RESULTS

Of 15 women identified, 13 (86.7%) had a prepregnancy LGG diagnosis. Of the 2 patients in whom LGG was diagnosed during pregnancy, one underwent upfront surgery, and the other had watchful waiting with resection after 60 weeks. Nine patients (60.0%) remained asymptomatic during pregnancy, while 5 (33.3%) experienced recurrence of seizures. There was one case of transformation of an astrocytoma to glioblastoma during the third trimester, which was resected emergently. In 10 cases, progression occurred after pregnancy at a median interval of 24.2 months (interquartile range 6.6-37.5 months), with progression within 6 months of delivery in 2 cases. Mean (SD) growth rate during pregnancy was 7.8 (22.2) mm/year compared with 0.62 (1.12) mm/year before pregnancy and 0.29 (1.18) mm/year after pregnancy; the difference did not reach statistical significance (P = 0.306).

CONCLUSIONS

Pregnancy was associated with clinical deterioration in one third of patients. No significant change in growth rate was identified. Time to progression and malignant dedifferentiation were unaffected. Patients with LGG wishing to pursue pregnancy should be counseled regarding the risk of complications, and if pregnancy is pursued, close neurological and obstetrical follow-up is recommended.

The course of epilepsy and seizure control in pregnant women

To investigate the course of epilepsy and seizure control during pregnancy. 105 pregnant women with epilepsy were studied prospectively during the period from 2013 to 2017. The average age at the onset of epilepsy was 17.4 ± 0.5 years. Seizures during pregnancy were observed in 76 (72.4 ± 4.4%) women. Eleven (10.5 ± 3.0%) women had their first seizure during current pregnancy. Among those 94 women who were diagnosed with epilepsy before pregnancy, 29 (30.9 ± 4.8%) remained seizure free; seizure frequency increased in 27 (28.7 ± 4.7%), decreased in 24 (25.5 ± 4.5%) women, in 14 (14.9 ± 3.7%) remained unchanged. Among 15 women who were seizure free for the 1 year prior to pregnancy 11 (73.3 ± 11.4%) women remained seizure free during pregnancy. The worsening in seizure control during pregnancy occurred in 22 (35.5 ± 6.1%) of 62 women with focal epilepsy and 5 (15.6 ± 6.4%) of 32 with idiopathic generalized epilepsy (OR 2.97, 95% CI 1.0-8.81). Non-compliance with the antiepileptic drug therapy was observed in 20 (19.0 ± 3.8%) pregnant women, seizure frequency increased in 18 (90.0 ± 6.7%) of them compared with 5 (9.8 ± 4.2%) of 51 of those who followed correct antiepileptic drug regimen (p < 0.001). The risk of seizures during pregnancy was lower in women who were seizure-free for the 1 year prior to pregnancy; focal epilepsy was associated with an increased risk of seizure relapse during pregnancy; non-compliance with the antiepileptic drug therapy and inappropriate treatment may lead to worsening of seizure control and to the status epilepticus during pregnancy.

Clinical challenges of glioma and pregnancy: a systematic review

INTRODUCTION

This review aims to summarize challenges in clinical management of concomitant gliomas and pregnancy and provides suggestions for this management based on current literature.

METHODS

PubMed and Embase databases were systematically searched for studies on glioma and pregnancy. Observational studies and articles describing expert opinions on clinical management were included. The strength of evidence was categorized as arguments from observational studies, consensus in expert opinions, or single expert opinions. Risk of bias was assessed by the Newcastle-Ottawa Scale (NOS).

RESULTS

27 studies were selected, including 316 patients with newly diagnosed (n = 202) and known (n = 114) gliomas during pregnancy. The median sample size was 6 (range 1-65, interquartile range 1-9). Few recommendations originated from observational studies; the remaining arguments originated from consensus in expert opinions.

CONCLUSION

Findings from observational studies of adequate quality include (1) There is no known effect of pregnancy on survival in low-grade glioma patients; (2) Pregnancy can provoke clinical deterioration and tumor growth on MRI; (3) In stable women at term, there is no benefit of cesarean section over vaginal delivery, with respect to adverse events in mother or child. Unanswered questions include when pregnancy should be discouraged, what best monitoring schedule is for both mother and fetus, and if and how chemo- and radiation therapy can be safely administered during pregnancy. A multicenter individual patient level meta-analysis collecting granular information on clinical management and related outcomes is needed to provide scientific evidence for clinical decision-making in pregnant glioma patients.

Status epilepticus due to brain tumor during pregnancy

There is no consensus on the timing of delivery of an infant with nonreassuring fetal status that is associated with maternal status epilepticus. We herein describe a case of status epilepticus due to brain tumor at 28 weeks of gestation.