2. Eclampsia/postpartum angiopathy epilepsy Cerebrovascular accidents Hemorrhage Ruptured aneurysm or malformation Arterial embolism or thrombosis Cerebral venous thrombosis Hypoxic ischemic encephalopathy Angiomas Eclampsia/postpartum angiopathy Congenital brain defects Infectious encephalitis: bacterial, viral, parasitic, tuberculosis Trauma Brain tumors: benign, neoplastic Primary Metastatic Liver/renal failure Metabolic derangement: hypoglycemia, hyponatremia, hyperosmolar states (hyperosmolar nonketotic hyperglycemia), and hypocalcaemia Drug overdose/withdrawal Thrombophilia: antiphospholipid syndrome Autoimmune disorders Systemic lupus erythematosus Thrombotic thrombocytopenic Table 1. Potential causes of seizures in pregnancy and postpartum.

3. Eclampsia In the Western world, incidence of eclampsia has decreased over the last 10 years and now ranges from 4 to 5 in 10,000 pregnancies. the World Health Organization reports an increase, 0.1% to 0.8%, in developing countries The incidence is higher in tertiary referral centers, in multifetal gestation, and in populations with no prenatal care.

4. Eclampsia is defined as the development of convulsions and/or unexplained coma during pregnancy or postpartum in patients with signs and symptoms of preeclampsia

5. Hypertension is considered to be the hallmark for the diagnosis of eclampsia The hypertension can be severe in 20–54% of cases mild in 30–60% of cases. absent in 16%

6. Several clinical symptoms may occur before or after the onset of convulsion persistent occipital or frontal headaches, blurred vision, photophobia, epigastric and/or right upper- quadrant pain, and altered mental status

7. The diagnosis of eclampsia is usually associated with proteinuria proteinuria (≥ 3+ on dipstick) was present in only 48% of the cases, proteinuria was absent in 14% of the cases

8. The onset of eclamptic convulsions antepartum, intrapartum, or postpartum. antepartum convulsions 38% to 53%. postpartum eclampsia 11% to 44%. The cases of eclampsia that occur after 48 h postpartum, but less than 4 weeks after delivery, are defined as late postpartum eclampsia

9. 56%of these women will demonstrate a clinical picture of preeclampsia during labor or immediately postpartum others(34%) will demonstrate these clinical findings for the first time more than 48 h after delivery

10. Cerebral imaging is indicated for patients with focal neurologic deficits prolonged coma. atypical presentation for eclampsia onset before 20 weeks of gestation or more than 48 h after delivery eclampsia refractory to adequate magnesium sulfate therapy.

11. Occurs in.5-1% women One of the leading cause s indirect mathernal death

12. The major pregnancy related risks increased seizure rates with mortality and fetal malformations Causes: Nausea and vomiting Antacid use Pregnancy hypervolemia Increased glomerular clearance Discontinued medication Sleep deprivation

13. Pre pregnancy manangment Seizure should be well controlled on the least number of AEDs and the lowest possible dose Sodium valporate should be change

14. Antenatal management Women on AEDs shoud commence folic acid 5 mg daily May need to increase dose Vit K prescribe from 36 weeks of gestation

15. Stroke

16. Incidence of stroke in pregnancy 1.5- 71 /100000pregnancy Almost 9% of pregnancy related mortality rate 1/3 associated with PIH 10%developed antepartum 40%developed intrapartum 50%developed postpartum

17. Risk factors Older age Migraine Hypertension obesity Cardiac disease Smoking GDM C/S Obstetric hemorrhage

18. The most common risk factors Pregnancy associated hypertensive disorders(3-8) C/s (1.5 fold)

19. Vascular thrombosis and embolism are subdivided into two categories: arterial and venous. Cerebral hemorrhage is also subdivided into intracerebral and subarachnoid hemorrhage. 112 112

22. Preeclampsia syndrom Sub cortical peri-vascular edema and petechial hemorrage

23. Cerebral embolism More common during the latter half of pregnancy and early puerperium Diagnosis Exclude thrombosis and hemorrhage and identify embolic source

24. Cerebral venous thrombosis The prevalence of this phenomenon is estimated to be 1–2 per 10,000 to 40–50 per 10,000 childbirths. more common in the puerperium than during pregnancy, with more than 75% of total cases presenting postpartum Headaches (severe, diffuse, constant, and progressing in intensity) and seizures are common presenting symptoms, but most patients are not hypertensive 1/3 of patient have convulsion Diagnosise with MR venograghy

25. Hemorrhagic stroke Intra-cerebral stroke : bleeding into the brain parenchyma Often associated with chronic hypertension /superimposed preeclampsia Subarachnoid hemorrhage Bleeding from A-V malformation and aneursmysms