Neurosurgery for intractable epilepsy in pregnancy: A case report.

We describe the management of a 39-year-old woman with intractable focal epilepsy whose condition deteriorated during pregnancy and who required emergency neurosurgery. A literature search did not identify any previous reports of epilepsy surgery in pregnancy. To our knowledge, this is the first time surgery was planned and executed in rapid order with a successful outcome, without obstetrical or surgical complications and seizure freedom achieved. The value of rapid communication between established women's health advanced nurse practitioner clinics, the multidisciplinary Epilepsy Surgery Group and specialist Obstetrical Epilepsy service is highlighted. A care cycle for pregnant women with refractory epilepsy is proposed.

Hypoglycaemic events resembling focal seizures -A case report and literature review.

PURPOSE: To review the literature, for cases of hypoglycaemia misdiagnosed as epilepsy, including our interesting case of a patient with Type 1 Diabetes Mellitus, diagnosed with focal epilepsy. METHODS: A literature search was completed. 20 of 473 studies, with a total of 22 cases found using specified search terms were relevant to this review. The papers identified and reviewed were those that dealt with hypoglycaemia misdiagnosed as epilepsy. The majority are isolated case reports given the rarity of this entity. RESULTS: An underlying insulinoma is the most common cause for hypoglycaemic episodes to be misdiagnosed as epilepsy. Early morning seizures were prominent in 9 of the 22 cases. CONCLUSION: Although rare, hypoglycaemia is an important differential diagnosis for drug-resistant epilepsy and early morning events may be an indication. We report the first case of recurrent hypoglycaemia from exogenous insulin, misdiagnosed as focal epilepsy with an available video EEG. The unusual presentation appeared clinically indistinct from recurrent focal seizures.

How accurate are placental growth factor, urate, lactate dehydrogenase and proteinuria in diagnosing preeclampsia and its severity?

OBJECTIVE: The objective was to assess the diagnostic accuracy of serum and urinary placental growth factor (sPlGF and uPlGF, respectively), urate, lactate dehydrogenase (LDH), and proteinuria for diagnosing and differentiating between women with preeclampsia and women with a normal healthy pregnancy, gestational hypertension, and gestational proteinuria. STUDY DESIGN: Urine and blood samples were taken from pregnant women diagnosed with late-onset severe preeclampsia (30 patients), mild preeclampsia (30 patients), gestational hypertension without meeting the criteria for preeclampsia (30 patients), gestational proteinuria without meeting the criteria for preeclampsia (30 patients), and healthy pregnant control women (30 patients). A receiver operating characteristic (ROC) curves analysis was performed to evaluate the diagnostic accuracy and to select the optimal cutoff points for different markers. RESULTS: sPlGF is the best test for differentiating women with severe preeclampsia from women in all of the other groups (p=0.001). However, there was no significant difference between sPlGF and proteinuria in the 24-h urine collection (p=0.329) in this differentiation. uPlGF can be used to differentiate women with severe preeclampsia from women in all of the other groups. However, proteinuria in the 24-h urine collection is better than uPlGF for this differentiation (p=0.013). CONCLUSION: sPlGF and uPlGF can be used to diagnose women with severe preeclampsia and should be considered at least as important as proteinuria in the diagnosis of preeclampsia. A large study that considers the cost-effectiveness of adding these markers to the diagnosis of preeclampsia should be conducted before our recommendation is applied.

The use of cervical length and change in cervical length for prediction of spontaneous preterm birth in asymptomatic twin pregnancies.

OBJECTIVE: To assess the association between cervical length (CL) and change of CL over two measurements and preterm birth (PTB) at <32 weeks in asymptomatic twin pregnancies. STUDY DESIGN: This study was undertaken in the multiple pregnancy antenatal clinic at the Security Forces Hospital (SFH), a tertiary care hospital in Riyadh, Saudi Arabia, between November 2005 and October 2010. This study involved 420 women with asymptomatic twin gestations, but only 209 unselected patients completed the study and met the inclusion criteria. All patients had a CL measurement by transvaginal ultrasound at 20-23 weeks, and a second CL measurement was done within 3-5 weeks of the initial measurement. Patients were classified into two groups, group A with significant shortening of CL, and group B without significant shortening of CL. Comparisons between the groups were performed using a chi-square test or a Fisher exact test for categorical variables, whereas Student's t-test or Wilcoxon's rank-sum test was used for continuous variables. We employed ROC curves to compare the diagnostic accuracy of actual cervical length and percent change in cervical length in predicting preterm birth events. All analyses were performed using the SAS/STAT software. RESULTS: There were 35 (16.7%) patients whose CL shortened by ≥25% (group A), and 174 (83.3%) whose CLs either did not shorten or shortened by <25% (group B). Preterm birth at <28, <30, <32, and <34 weeks gestation was higher in group A than in group B even if the CL was >25mm. The use of CL shortening was superior, but not statistically significantly, to the use of CL for the prediction of PTB at <32 (P=0.0524) and <34 weeks (P=0.281), but CL was preferred for the prediction of PTB at <28 (P=0.037) and <30 weeks (P=0.0457). CONCLUSION: The test of two CL measurements, the first between 20 and 23 weeks gestation and another CL measurement 3-5 weeks later, with a difference of ≥25%, is a good predictor for preterm birth in asymptomatic twin pregnancies, even if the CL is >25mm.

Outcomes of an isolated single umbilical artery in singleton pregnancy: a large study from the Middle East and Gulf region.

OBJECTIVE: To assess the frequency and accuracy of prenatal diagnosis of a single umbilical artery (SUA) and to compare the fetal and neonatal outcome of isolated SUA to that of a normal three-vessel umbilical cord in a population from the Middle East and Gulf region. STUDY DESIGN: Data were collected from 37,500 singleton pregnancies that were scheduled for antenatal care and delivered at Security Forces Hospital in Riyadh, Saudi Arabia, between May 2004 and December 2012. Comparisons between the groups were performed using a chi-square test or a Fisher exact test for the categorical variables, and Student's t test or Wilcoxon's rank-sum test were used for continuous variables. The Kappa statistic was used to study the agreement between the antenatal and final neonatal diagnosis of SUA. A univariable analysis was used to calculate the unadjusted and adjusted ORs and the 95% CIs expressing the relationship of the normal three-vessel umbilical cord, the isolated SUA, and each outcome. RESULTS: A total of 35,249 cases completed the study, including 35,026 cases with normal neonatal three-vessel umbilical cords (Group B). SUA was present in 223 (0.63%) neonates (0.45% isolated SUA (Group A) and 0.18% non-isolated SUA). The sensitivity, specificity, positive predictive value and negative predictive value of using prenatal ultrasound for the diagnosis of SUA were 90.58%, 99.9%, 98.5% and 99.94%, respectively. Neonatal anomaly was present in 2.6% of the fetuses with isolated SUA. A pregnancy with isolated SUA was more likely to be complicated with polyhydramnios (OR 3.32; CI 1.22-9.04), preterm delivery <34 weeks (OR 4.662; CI 2.346-9.195), birth weight <10th percentile (OR 2.1; CI 1.44-2.93), cesarean delivery for fetal distress (OR 2.72; CI 1.53-4.81), perinatal death (OR 3.31; CI 1.34-8.12), admission to NICU (OR 2.71; CI 1.87-3.91), and placental abnormalities (OR 3.25; CI 2.14-4.93; p value 0.0001) compared to a pregnancy with a fetal and neonatal three-vessel cord. CONCLUSION: Isolated SUA is associated with anomalies at birth and with an increased risk of adverse pregnancy outcomes even in the absence of other anomalies. A pregnancy with this complication should receive close fetal monitoring for growth and fetal wellbeing.