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Seizures are a common manifestation of serious CNS disease in the newborn, and Indicate serious underlying disease (90%-95% of cases).
85% of neonatal seizure occurs in the first two weeks of life 65% occurs between 2-5 days after birth 25% in NICU in preterm neonates. And 0.8% In term infant.
Neonatal seizures may have a deleterious effect on the developing brain by depleting cerebral glucose levels, which , in turn, may interfere with deoxyribonucleic acid (DNA) synthesis and myelination.
Seizures also causes to deficiency in cell brain numbers and repeated seizures causes brain Injery.
Clinical features • Neonatal seizures differ considerably from seizures observed in older children , because the immature brain is less capable of propagating generalized electrical discharges, so primary generalized seizures are very rare in the newborn.
Diagnosis: • Maternalal History : • History of drug abuse • History of intrauterine infection • History of Genetic or metabolic conditions • Use of local anesthetic drugs during labour. • History of previous child with seizures
Nconatal Ph ex: • General ex • Neurological ex • Retinal ex • Skin ex
3- Laboratory testes: • Evaluation of metabolic diseases (Bs- ca p-Mg) • evaluation of Infectious diseases (BC-LP-Torch) • Evaluation of Electrolit disorders (Na- K)
4- Neuroimaging studies • Scalp sonography (I.V. H. …) • Ct scan or MRI (focal seizures) • EEG Monitoring (for prognosis & duration of therapy.
ACUTE THERAPY OF NEONATAL SEIZUES • HYPOGLYCEMIA • Glucose 10% solution: 2 ml/kg. I.V. • NO HYPOGLYCEMIA • Phenobarbital: 20 Mg/kg (10-15 min) If necessary additional Phenobarbital: 5mg /kg(10-15 min) I.V. to a maximum of 20 mg/kg (consider omission of this additional Phenobarbital if infant is severely “asphyxiated”)
Phenytoin: 20 mg/kg. I.V. (1 mg/kg/min) lorazepam: 0.05 -0.10 mg/kg. I.V. • Fosphenytoin:my be a preferred form of phenytion
Cont. OTHER (AS INDICATED) • Caicium gluconate, 5% solution: 4 ml/kg, I.V. • Magnesium sulfate, 50%solution: 0.2ml/kg, I.M. • Pyridoxine: 50-100 mg, I.V.
Determinants of duration of Anticonvulsant Drug therapy for Neonatal seizures
If neonatal neurological examination is persistently abnormal, consider etiology and obtain electroencephalogram (EEG) Continue Phenobarbital Discontinue phenytoin Reevaluate in 1 month
ONE MONTH AFTER DISCHARGE • If neurologic examination has become normal, discontinue phenobarbital
Porognosis • Dependent to three major predictors: • the underlying aetiology • EEG features • Gestational age
Other useful predictors: a- neurologic examination b- neuroimaging finding
cont Normal EEG neurological sequelae 10% Moderate abnormal EEG Neurological sequelae = 50% Severe abnormal EEG Neurological sequelae ≥ 90%
cont The inedience of neurological sequelae (mental retardation – motor deficits – epilepsy)=25%-35%) M.R , Motor deficits (C.P) are more common than Epilepsy=15%-20%
cnot • Neanatal seizures in infants <32 weeks high mortality (80%)& higher risk of adverse neurological outcome • Overall , presentation of seizures at the first hours of life & prolonged seizures that do not respond to therapy have worse prognosis
Other anticonvulsant drugs for treatment of refractory neonatal seizures: • Diazepam drip (continuous infusion) 0.1-0.3 mg/kg/hour • Midazolam drip (continuous infusion) 0.06-0.4mg/kg/hour • Carbamazepine10mg/kg.NG No adverse effects , but more data are needed
cont • Valproic Acid Hepatotoxic • LidocainIv infusion 4-6mg/kg/hour cardiac toxicity-BP • Thiopental BP (more data are needed) • Paraldehyde 0.3ml/kg/dose / PR BPrespiratory disturbance • Primidone( more data are needed) • Lamotrigine& topiramate (more data are needed)