New Onset Refractory Status Epilepticus Diagnosed in the Second Trimester: A Case Report

Abstract

Background New-onset refractory status epilepticus (NORSE) is a rare severe clinical condition in which a patient without a previous history of epilepsy presents with refractory status epilepticus (RSE) of no identifiable underlying cause. Health care providers face the clinical dilemma of minimizing teratogenic effects of antiseizure medication (ASM) while rapidly trying to attain seizure control. There is paucity of data regarding incidence, etiology, and treatment of NORSE in the pregnant population. Case presentation We report a case of 22-year-old women who presented with NORSE at 19 weeks of gestation after recurrent episodes of tonic-clonic seizure of unclear onset. Treatment was started with polytherapy regimen of Levetiracetam, Oxcarbazepine and Lacosamide which was progressively expanded to 2 more antiepileptics, Clobazam and Lamotrigine. The status epilepticus was super refractory, and she underwent intubation and sedation with Propofol and Midazolam. The patient was extubated after reaching seizure free status. After another breakthrough tonic-clonic seizure, she had suicide attempt and levetiracetam was changed to brivaracetam. Monthly growth scans indicated appropriate fetal growth and biophysical profile. Patient had an uncomplicated induction of labor at term and delivered a healthy neonate. Postpartum recovery was uneventful, and the neonate did not manifest neonatal sedation or withdrawal. Conclusion This case is the first to describe a pregnant individual with NORSE diagnosed in the second trimester, resulting in the delivery of a healthy term neonate. Management of NORSE in pregnancy is challenging and requires a multidisciplinary approach involving obstetricians, neurologists, intensivists, and neonatologists. Treatment must balance the need to control seizures with minimizing risks to both the mother and the fetus.