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Neonatal Seizures

Neonatal Seizures

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Published by neeta rajesh bhide

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Published by: neeta rajesh bhide on Aug 31, 2010
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03/19/2013

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Neeta Rajesh Bhide, (M.Sc.N., M.A. Psyco., M.C.F.H., M.D.F.M. Page 1
Neonatal seizures, neonatal hypoglycemia, neonatal hypocalcaemia,hypomagnesemiaNeonatal seizures
Introduction
Neonatal convulsion are common life-threatening emergency in the newborn due to cerebral orbiochemical abnormality. Preterm babies are more prone to this problem.
Incidence
Incidence being 0.2-2.7/1000live births in term babies and 57.5-132/1000 live births in pretermbabies
.
Definition
A seizure is a paroxysmal behavior caused by hyper synchronous discharge of a group of neurons.Neonatal seizures are the most common overt manifestation of neurologicaldysfunction in the newborn.
 
It is a paroxysmal spell of altered neurological function (behavior, motor or autonomic function)occurring during the first 28 days in term infants or 44weeks gestational age in pre-term infants.
Classification of neonatal seizuresType characteristics
1.
 
Clonic
slow rhythmic jerky movements approximately 1-3 seconds
 
Focal involves upper or lower extremities on one side of body.
Mainly involves neck or trunk. Infant is conscious during event.
 
Multifocal may migrate from one part of the body to other.Movements may start at other times.2.
 
Tonic
extension/stiffening movements.
 
Generalized extension of all four limbs ( similar to decerebrate rigidity)Upper limbs are maintained in a stiffy flexed position
 
Focal sustained posturing of limbs, Asymmetric posturing of trunk or neck.3.
 
Subtle
May develop in full term or pre-term . common inpreterm Eye deviation (Term)Blinking, fixed stare (Preterm). Repetitive mouth & tonguemovements, Apnea, Pedaling, tonic posturing of limbs.4.
 
Myoclonic
rapid jerks that involve flexor muscle group.
 
Neeta Rajesh Bhide, (M.Sc.N., M.A. Psyco., M.C.F.H., M.D.F.M. Page 2
 
Focal involves upper extremity flexor muscle group.
 
Multifocal asynchronous twitching of several parts of the body.
 
Generalized bilateral jerks of upper and lower limbs.
Causes of neonatal seizures
 
1.
 
Metabolic problems
Hypoglycemia, Hypocalcaemia, Hyponatremia, Hypomagnesaemia, PyridoxineDeficiency
2.
 
Developmental neurological problems
Congenital hydrocephalus, microcephaly, cerebral dysgenesis, porencephaly,,Polymicrogyria, hydraencephaly, lissencephaly, Agenesis of corpus callosum
3.
 
Toxic
Uremia, Bilirubin encephalopathy
4.
 
Prenatal infections
Toxoplasmosis, syphilis, cytomegalovirus, herpes simplex, hepatitis
5.
 
Postnatal complications
Bacterial meningitis, viral meningoencephalitis, sepsis, brain abscess
6.
 
Trauma at birth
Hypoxic brain injury, intracranial hemorrhage, subarachnoid hemorrhage, subduralhemorrhage, intraventricular hemorrhage
7.
 
Miscellaneous conditions
a.
 
Neonates born to narcotic withdrawal or abstinence syndrome: the babies born tothe mother addicted to heroin alcohol, diamorphine, methadone. May manifest withcharacteristic withdrawal symptoms like irritability, high pitched cry, tremors,hyper tonicity, vomiting diarrhea after 48 hours of birth.b.
 
Local anesthetics: During paracervical block inadvertent injection of localanesthetics into fetal scalp may result in intractable convulsion.c.
 
Hypomagnesaemiad.
 
Pyridoxine dependency : prolonged maternal administration of vitamin B6duringpregnancy may predispose to this condition.
Benign seizures in neonates
1.
 
 Benign neonatal sleep myoclonus
: It has onset during first week of life and occur assynchronous myoclonic jerks during REM sleep. There are no seizures when the baby isawake. EEG is normal and seizures spontaneously disappear by 2 motnhs of age.2.
 
 Benign familial neonatal convulsions
occur as self limiting isolated clonic seizures onsecond and third day of life the recovery is within 1-6 months of life.3.
 
 Benign idiopathic “ fifth day seizures” 
: the multi focal clonic seizures occur on day 5 andusually disssapear on day 15 the cause is umknown though CSF zinc level is reported insome cases.
 
Neeta Rajesh Bhide, (M.Sc.N., M.A. Psyco., M.C.F.H., M.D.F.M. Page 3
Age of onset of convulsionFirst day:
Hypoxic-ischemic encephalopathy, cerebral contusion, first dayhypocalcaemia, pyridoxine dependency accidental injections of local anesthesia
 Between 1-3 days
: intracranial hemorrhage, hypoglycemia, narcotic withdrawal, inbornerror of metabolism.
Fourth to seventh day
: tetany, meningitis, torch infection developmentalmalformation,kernicterus.
Investigations
 
Family history of convulsion, history of maternal drug addiction and infections areimportant aspect of investigation.
 
Electroencephalography (EEG) is essential in diagnosis and management of neonatalseizures.
 
Neuroimaging: Imaging
the brain is essential in determining the etiology of neonatalseizures.MRI scanning is very effective for determining the presence and extent of hypoxic-ischemic injury and of parenchyma brain injury. If MRI scanning is not possibleacutely,
 
CT scan is effective for determining the presence of hemorrhage and calcification (
e.g.
,congenital infection, cortical dysplasia).
 
Blood examination fro calcium, sugar, phosphorus
 
Lumbar puncture for CSF study
 
Serology for STORCH
Management:A.Infant should be nursed in thermoneutral environment and special attention should be
given to the baby’s perfusion and ventilation.
 B. Stop feeds and start 10%dextroseC. Treating the primary cause
 
Hypoglycaemia
 – 
IV 10% dextrose 5ml-10 ml/kg as a bolus is given , then 2ml/kgdextrose 10% strated. The blood glucose should be maintained between 70-120 mg/dl.
 
Hypocalcemia (Ionised Ca <1.1)
 – 
IV 10% calcium gluconate 2ml/kg over 10mins
 
Hypomagnesemia (<1.0)
 – 
IV/IM 50% MgSO4 0.2ml/kg over 10minsD.
Anticonvulsant therapy
Parenteral dose of phenobarbitone 20m/kgis administered slowly intravenously over20 minute. If no response in 15 minutes additional dose of phenobarbitone 10mg/kgevery 15 minutes is administerd intravenously till seizures are controlled.If convulsions are still uncontrolled phenytoin is administered intravenously in aloading dose of 20 mg/kg .The maintenance therapy with phenobarbitone and phenytoin is started after 12hours of loading dose and given in a dose of 5mg/kg/day in two divided dose.If convulsions are intractable and baby is in status convulssicus give lorazepam50ug/kg IV slowly over 2-5 min. Alternately clonazepam 100-200 ug/kg can begiven IV 30 sec.Specific situation :a.
 
Pyridoxine dependent seizures ; give 100mg IV under EEG control and closeobservationb.
 
Exchange blood transfusion; In life threatening metabolic disorder , kernicterus,accidental injections.

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