LABOR AND DELIVERYMost patients with epilepsy are able to labor normally and achive a vaginal delevery. Elective cesarean section may be considered in patients refractory to treatmeant during the thrid trimester or in those who exhibit status eoilepticus with significant stress. During labor, repeated seizures that cannot be controlled or status epilepticus may require an operative delivery. Fetal asphyxia can occur with prolonged or repeated or repeated seizures. Cesarean delivery may also be considered when repeated absence or psychomotor seizures limit maternal awarenessand ability to cooperate. Tonic- clonic seizures are seen in approximately 1% to 2% of women during labor. Lorazepam, a short-acting benzodiazepine, is the drug of choice for treating seizures acutely. The drug is administrered in 2 mg boluses every 5 minutes as necessary. Some use 5 to 10 mg boluses of diazepam as an alternative.POSTNATAlAntiepileptic drug levels must be monitored after delivery because of the physiologic alterations causing a decline in levels during gastation leads to a rise postpartum. If the medication dose was increased during pregnancy, the regimen should be returned to that used prior to pregnancy to avoid toxity. During the first postpartum day an additional 1% to 2% of women will have tonic-clonic convulsions. Again lorazepam is the agent of choice for acute control. New-onset seizures in the postpartum period require complate evaluation to ro rule out intracerebral hemorrhage, cortical vein thrombosis, infection, or eclampsia.Neonates should be given vitamin K 1mg IM after birth to prevent a coagulopathy. All AEDs can cross into the breast milk but breastfeeding is not contraindicated for most agents. The effects os diazepam on nursing infants are unknown, and it should be used with caution. Phenobarbital should only be used when no alternatives exist because neonatal sedation can occur along with neonatal withdrawal on weaning.STATUS EPILEPTICUSMaternal and Fetal RiskStatus epilepticus (SE) is defined as ongoing seizure activity lasting longer than 30 minutes or recurrent seizures without full recovery of consciousness between episodes. The actual incidence during pregnancy is unknown. The important causes are listed in table 49-4. Predisposing factors include poor compliance with AEDs, CNS infections, trauma, and illicit drug use. Status epilepticus represents a medical emergency. Most seizures are generalized tonic-clonic. During the tonic phase, contractions of the respiratory muscles impair adequate maternal oxygenation, leading to fetal hypoxia and asphyxia. #During the covulsive phase, metabolic acidosis ensues. Rhabdomyolosis occurs and can lead to acute renal failure. After 30 minutes of continuous brain electrical activity, even in the absence of the metabolic derangements, irreversible neuronal injury can occur. Te hippocampus and amygdala of the temporal lobe are particularly sensitive to permanent damage. Trauma from reccurent seizure activity can result in preterm labor, ruptureof membranes, abruptio placenta, and fetal death.Management optionsPRENATAL, LABOR AND DELIVARY, AND POSTNATAL.Diagnostic and therapeutic interventions should be performed simultaneously. A patent airway must be secured and supplemental oxygenation given. Hypotension should be avoided to prevent decreased cerebral perfusion pressure. Complate bloud count with differential, electrolyte profile, blood urea nitrogen, creatinine, urine toxycology screen, and AED levels should be obtained. Cerebrospinal fluid (CSF) analysis is performed if meningoencephalitis is suspected.Intravenous benzodiazepines are used acutely. Again lorazepam is the drug of choice. It is given in 2-mg boluses every 5 minutes. Simultaneously, the patient is loaded with phenytoin 18mg/kg administration at a rate not axceeding 50mg/min. The administration of intraveous valproic acid (20mg/kg loading dose) is an alternative if phenytoin is otherwise contraindicated. The combination of phenytoin and benzodiazepines is effective in controlling 75% to 85% cases of status epilepticus. In those patients with persistent seizures, higher levels of phenytoin can be achieved with an additional 5mg/kg. In refractory cases where barbiturates or a continuous infusion is required to protect the airway. Continuous electroencephalograpic monitoring should also be initiated. Once identified, the underlying cause should be treated.