Review Article
For the Parturient, All that Seizes is not Eclampsia. A Review of Psychogenic Non-Epileptic Seizures in Pregnancy
Nnamani NP*, Nguyen L, and Sawyer S
Department of Anesthesiology, University of Texas at Southwestern Medical Center, USA
*Corresponding author: Nwamaka Pamela Nnamani MD, MSc, Department of Anesthesiology, and University of Texas at Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas TX 75390, USA, Tel: 214 648-6400; Fax: 214 648-5461; Email:
nwamaka411@yahoo.co.uk
Submitted: 19 February 2019; Accepted: 09 April 2019; Published: 19 April 2019
Cite this article: Nnamani NP, Nguyen L, Sawyer S (2019) For the Parturient, All
that Seizes is not Eclampsia. A Review of Psychogenic Non-Epileptic Seizures in Pregnancy. JSM Clin Anesthesiol 1: 5.
PNES: Psychogenic Nonepileptic Seizures
Seizures in the peripartum can be challenging to manage.
The parturient can be misdiagnosed with eclampsia and the
fetus delivered prematurely, on the other hand a diagnosis
could be associated with the risk of being placed on potentially
teratogenic medication. Seizures in pregnancy can be categorized
into these three groups: Known seizure disorder such as epilepsy
(Figure 1)[1] which is exacerbated during pregnancy, pregnancy
related causes of which eclampsia is the main culprit (Table 1)
and new onset seizures due to another non-pregnancy related
problem (Table 2). This classification of peripartum seizures can
be helpful to optimize management.
This review will focus on psychogenic non-epileptic seizures
(PNES) in pregnancy as it has not been well described in the literature.
Psychogenic nonepileptic seizures (PNES) are events
characterized by movements or behaviors that resemble epileptic
seizures but are not accompanied by abnormal cerebral electrical
activity. PNES are psychological in nature and are often associated
with stress or emotional triggers. According to the Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5),
PNES is a psychiatric disorder-more specifically; it is a conversion
disorder that falls under the category of somatic symptom
disorders. It involves the unconscious manifestation of motor
or sensory symptoms or deficits that resemble a neurological or
medical condition but is not recognized as neurological in nature,
not better explained by another medical or mental disorder, and
causes clinically significant distress or impairment in functional
status [2].
The prevalence of PNES in the general population ranges
from 2 to 33 cases per 100,000 people [3]. PNES are commonly
misdiagnosed as epilepsy and may represent a significant
percentage of patients referred to epilepsy centers-up to 20%
according to some studies [3,4]. Of patients presenting with
intractable seizures, approximately 10% are psychogenic
in nature [5]. It is often associated with multiple psychiatric
conditions such as major depressive disorders, anxiety or
bipolar disorder, post-traumatic stress disorder, and borderline
personality traits, and it can be a manifestation of psychological
detriment in response to childhood or sexual abuse [6,7]. Roy et
al., compared patients with psychogenic seizures with matched
cohorts of epileptic patients and found significant differences regarding history of psychiatric disorder, attempted suicide,
sexual maladjustment, and current affective syndromes [8]. It
is also more commonly seen in patients who have epilepsy or a
family history of epilepsy [9]. PNES is more prevalent in females,
who represent up to 80% of cases [10]. However, PNES during
pregnancy has not been well-described in the literature.
The lifetime incidence of non-PNES conversion symptoms has
been reported to be as high as 84%, and one study by Lempert et
al., reports that other conversion symptoms were present in 60%
of patients with PNES [11,12].
There are several clinical signs that can aide in diagnosis of
psychogenic versus epileptic seizures: gradual onset of seizures,
fluctuating course, side-to-side head movements, bilateral
asynchronous movements, arching of the back, violent thrashing
movements, and vocalizations are all suggestive of psychogenic
seizures (Table 3) [1].
The diagnosis of PNES can often be challenging, especially in
the setting of pregnancy. One of the differential diagnosis that
cause significant maternal and fetal morbidity and mortality is
eclampsia; a disorder of pregnancy characterized by seizures and
associated with hypertension, edema, and proteinuria [13,14].
Brady and Huff describe a case of a female patient at 33 weeks
gestation who initially presented with new-onset convulsive
activity which was initially treated with benzodiazepines and
AEDs despite a probable diagnosis of psychogenic seizures,
but with the background of peripheral edema, intermittent
hypertension, and proteinuria, eclampsia had not yet been
ruled out. Eventually, EEG obtained during the seizure activity
prompted the diagnosis of PNES [15].
Diagnosis can often be challenging given the often paroxysmal
nature of the seizures and the lack of an unequivocal, infallible
sign or symptom that definitively distinguishes PNES from an
epileptic seizure [16]. The average time to diagnosis of PNES is
about 7.2 years [1]. As a consequence, patients with PNES are
initially misdiagnosed and are treated for presumed epilepsy;
approximately 80% of patients with video-electroencephalogram (v-EEG) confirmed PNES were taking at least one antiepileptic
drug (AED) at the time of PNES diagnosis [17]. Unfortunately,
these patients tend to utilize significant healthcare resources and
suffer more iatrogenic adverse effects than patients with epilepsy
[16]. About a tenth of patients presenting with intractable
seizures have a psychogenic cause and are often inappropriately
treated with potentially toxic anticonvulsant drugs [5]. Further
complicating the issue is that patients who have EEG-confirmed
epilepsy can have PNES concurrently, and therefore the diagnosis
of PNES should not be one of exclusion [9]. Although not without
its limitations, v-EEG in concordance with a thorough history and
physical is the gold standard for diagnosis of PNES [18].
De Toledo et al., reported five cases of recurrent, persistent
psychogenic seizures during pregnancy with multiple emergency
room visits and continued intake of antiepileptic drugs (AEDs)
from various sources, despite the awareness of the psychogenic
nature of the seizures and knowledge of the risks associated
with AED use during pregnancy [19]. There have also been case
reports of patients who developed PNES during pregnancy,
with the presenting symptoms being severe enough to warrant
treatment with benzodiazepines, AEDs, barbiturates, opioids, and
even intubation for airway protection [20,21,22]. PNES can also
present as sudden collapse or unresponsiveness, which can often
be mistaken for orthostatic hypotension or vasovagal reactions
[23,24]. There has been a case reported of PNES as well as pseudo
labor in a pregnant patient, eventually diagnosed after fetal
fibronectin, fetal non-stress test, and external tocodynamometry
were inconsistent with premature labor and uterine contractions [25].
29 yo G3P2 at 30 weeks gestation with significant past
medical history of seizure disorder (on oxcarbazepine), migraines
(on Fioricet prn), Bipolar Disorder, ADHD, and dissociative
identity disorder (on Lurasidone, Fluoxetine, Trazodone and
Buspirone) presented for management of uncontrolled seizure
disorder versus possible pseudo seizures. The patient reported
having increased seizure activity over the past 2 weeks with
multiple episodes occurring daily. The patient described the
seizures as being either tonic-clonic episodes or periods of what
she described as “starring spells.” During evaluation by the OB
team, the patient had a tonic-clonic episode involving the upper
and lower extremities. Immediately after the episode resolved,
the patient was alert and oriented to person, place and time;
and could answer all questions about her medical history in
detail. Neurology team was consulted and they recommended
continuing her anticonvulsants and a psychiatry consult. Prior to
her evaluation by the psychiatry service, the patient had 2 more
episodes of tonic-clonic activity (each lasting approximately 1
minute in duration) and was given 5 mg of Midazolam by the
anesthesiology team as well as being loaded with Leviteracetam
by the obstetrics team. Again, each of these episodes was followed
by no obvious post-ictal state. Shortly after resolution of these
episodes the patient signed out against medical advice (AMA)
and was lost to follow up.
28 yo G8P5A2 with intrauterine pregnancy complicated by
asthma, iron deficient anemia and psychogenic non-epileptic
seizures (PNES) (diagnosed by video-electroencephalogram
(v-EEG) at approximately 17 weeks gestation), she presented
at 25 weeks gestation with presumed status epilepticus during
pregnancy. According to the patient’s family, she had an episode
at home that was described as shaking of her upper and lower
extremities in a tonic-clonic manner and tongue biting, but no
loss of consciousness. Patient was treated with a total of 25 mg
of Ativan (15 mg was given by EMS and an additional 10 mg
after arrival to the hospital). In addition, she was given a 3g
magnesium load as treatment to prevent eclamptic seizures. The
patient had required intubation for inability to protect her airway
prior to arrival at our facility. The patient was admitted to the
Neurological Intensive Care unit and continuous EEG monitoring
was performed. After approximately 24 hours of continuous EEG
monitoring, no epileptic form activity could be appreciated. The
Psychiatry service was consulted and after another evaluation
using video-electroencephalogram (v-EEG), she was diagnosed
with PNES. This diagnosis may have been manifested due to Post-
Traumatic Stress Disorder (PTSD) and anxiety disorder resulting
from the loss of a pregnancy in the past. The patient was taken
off all anti-epileptic medications and referred for manualized
cognitive behavior therapy in the PNES Clinic.
PNES in pregnancy has a complex presentation, diagnostic
criteria and subsequent management plan. The differential
diagnosis for PNES in pregnancy include: Epilepsy, Eclampsia,
metabolic derangements such as hypoglycemia, intracranial
occupying lesions and vascular malformations.
The two cases described convey the challenges the patients
and medical professionals encounter. The first patient left
against medical advice likely due to frustration surrounding her
diagnosis and treatment plan. The second patient had videoelectroencephalogram
(v-EEG) performed twice during her
gestation to ensure diagnosis and tailor individualized treatment
plan. These two cases show the importance of engaging patients
in short and long-term treatment plan.
Treatment and Long-Term Management
Anesthesia management of acute seizure: Individualized
psychiatric interventions are the hallmark treatment for
psychogenic seizures. Anesthetic management in the seizing
parturient should include techniques that involve short acting
agents in addition to peri-operative psychological support and
constant reassurance for the patient. For acute management of
a seizing patient, the patient’s airway should be assessed and
managed as deemed necessary. Patient should be oxygenated with
a face mask if immediate intubation is not necessary. Vitals signs
should be continually monitored. Peripheral intravenous should
be placed and a fluid bolus can be commenced. Blood glucose
should be checked to rule out the possibility of hypoglycemia.
To stop the seizure, benzodiazepines such as midazolam and
lorazepam can be titrated. If seizure persists, propofol can be
used to help terminate the seizure and for induction to enable intubation and ventilation. Further management should be based
on the neurological recommendations.
The mainstay of treatment for PNES is psychotherapy,
particularly manualized cognitive-behavioral therapy, insightoriented
therapy, and mindfulness technique, and the treatment
of comorbid conditions such as anxiety or depression can help
decrease the incidence of PNES and lead to an improvement in
the overall prognosis [26]. The focus should be on treating the
underlying trigger while attempting to stabilize the frequency of
seizures [27].
Long term management
The long-term outcome in patients with PNES has been shown
to be dependent on early diagnosis. McKenzie et al., showed that
approximately one third of patients became spell-free after the
diagnosis of PNES was made, but 18.7% of patients had a marked
increase in the frequency of seizures after diagnosis [29]. Reuber
et al., saw that 71% of patients continued to have seizures after
diagnosis, 51% were dependent on state benefits, and seizure
remission was not a good measure of medical or psychosocial
outcome in PNES [30]. Walczak et al., also found that patients
continued to have psychosocial issues and be dependent on state
benefits despite the diagnosis and cessation of seizures, and 80%
of patients had either no change or deterioration in occupational
status. Even with complete remission of psychogenic seizures,
studies have shown that quality of life does not necessarily
improve, and patients can continue to suffer from an unproductive
occupational status or significant psychiatric symptoms such as
depression, suicidal ideation, and suicide attempts [31].
Nwamaka Nnamani wrote a portion of the manuscript and
was involved in the management of the 2 cases described. Le
Nguyen wrote a portion of the manuscript. Stephen Sawyer
wrote a portion of the manuscript.