A 2011 published paper showed first-trimester exposure to lamotrigine, oxcarbazepine, topiramate, gabapentin, or levetiracetam was not associated with an increased risk of major birth defects, compared with no exposure.²⁶

Airway, Oxygen, and RSI

To avoid fetal hypoxia, use high-concentration oxygen. In compromised respiratory settings, pregnant women have an increased tendency for rapid hypoxemia. Anticipate a higher potential for regurgitation of gastric contents and aspiration; antiemetics (such as ondansetron) and a nasogastric tube are strong considerations. Failed intubation is more common in pregnancy because of physiologic and anatomic changes that can lead to difficult intubation.²⁷ Mask ventilation may also be difficult because of increased intra-abdominal pressure and low chest compliance.²⁸

Neuromuscular blockade (such as succinylcholine, vecuronium, or atracurium) can be used in conventional doses. Transplacental passage is insignificant at the usual dose for intubation relaxation. If a paralytic agent is used, it crosses the placenta in dose-dependent fashion and will cause fetal heart rate tracing to become nonreactive.²⁹ Longer-acting agents can mask continuing seizure activity. Consider propofol or benzodiazepine drips during the stabilization period.

Analgesia

Pain control with narcotics can be given in any trimester as required to properly provide comfort to an injured mother.³⁰ Communicate doses and times to the physician caring for the newborn at delivery so that the effect on the fetus can be anticipated.

Risks

Maternal risks include death and other complications.³¹ Intracerebral hemorrhage is associated with the highest morbidity and mortality. Neonatal outcomes are generally good, with an increased rate of preterm delivery via cesarean. If pre-eclampsia/eclampsia is present, those risks would likely be additive.

References

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