Objective:

To describe a patient with psychogenic non-epileptic spells (PNES) who underwent emergent caesarean section twice for suspected eclampsia and was subsequently found to have PNES.

Background:

Eclampsia is a common (0.3%) complication of pregnancy with high fatality rates without emergent early caesarean section reportedly between 3.7% and 8.3% and increased maternal and neonatal morbidity following. PNES are without known maternal or neonatal risk. Several features may be helpful in differentiating PNES from seizures especially forced eye closure (>95% specificity for PNES), jaw clenching during tonic extension, normal creatinine kinase, and lower-than-expected lactic acid for length of spell.

Design/Methods:

Case report and literature review. 

Results:

A 29-year-old woman, G5P3@34w5d, who underwent caesarean section during prior pregnancy for presumed eclampsia manifested as bilateral alternating tonic-clonic movements with forced eye closure and decreased responsiveness presented with spells of identical character initially thought to be recurrent eclamptic seizure and patient was started on high-dose magnesium infusion. Patient subsequently experienced a recurrent spell lasting 10 minutes unresponsive to deep sternal rub with forced eye closure. Labwork obtained 12 minutes after spell termination notable for lower-than-expected lactate of 5.2 mmol/L, normal protein:creatinine-ratio of 0.1, and therapeutic serum magnesium level of 5.2 mg/dL. The patient was taken for emergent caesarean section following which patient experienced three identical spells captured on continuous EEG revealing normal electrographic activity during events consistent with PNES.

Conclusions:

PNES should always be considered in the differential of seizure-like spells during pregnancy, especially in the 3rd trimester where emergent delivery is contemplated with concern for eclampsia. The lack of typical signs of eclampsia and the lack of response to appropriate medical therapy should raise the clinical suspicion of PNES. Stat EEG is an extremely helpful tool to make the distinction in challenging cases.