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You are an FY1 currently on placement in obstetrics. Your next patient is Kat Scan, a 28-year-old lady who has come today for review at the high risk pregnancy clinic. Please take a history and perform a relevant examination.

You are 28-year old female who has come to the high risk antenatal clinic for a review

HPC 8 week’s gestation. Very excited as this will be you and your partners first child and you haven’t told him the news yet! You’ve had epilepsy for over 20 years now and have been seizure free for 13 years. Unfortunately, last year you had a ‘fit’ when you went to the restaurant for your birthday. Your partner witnessed the events. You were started on lamotrigine. You’re quite anxious as you’ve read that having epilepsy can increase complications for the baby and you’re not quite sure what this all means or what you can do.

Antenatal care You weren’t able to attend the previous review appointment due to a busy work schedule, so you’re not sure of what to expect. Care is being delivered by the consultant. Haven’t had any difficulties during this pregnancy, though you are quite anxious that everything goes well. You planned this pregnancy and have been taking folic acid for 3 months prior to becoming pregnant.

Past obstetric history You’ve had a previous miscarriage 4 years ago, you think you were given misopro…misoprostol No urinary/ bowel symptoms Haven’t noticed any discharge

Past Gynae history Had a previous smear test which showed normal results last year Used to be on the combined oral contraceptive pill up until two years ago when started trying for a baby. No previous STIs

PMH Epilepsy which was diagnosed since the age of eight years No diabetes mellitus, asthma, thyroid disorders, clots or high blood pressure. Have not had any depression, though did feel a bit low when you had the miscarriage.

DH Pregnacare Folic acid 5mg Lamotrigine No known drug allergies or sensitivities

FH Mother had two previous miscarriages. No congenital problems running in the family

SH Live with partner in a 2-bedroom flat Currently work as a primary school teacher Previously smoked at the age of 18 for 3 years; smoked 10 a day Socially drinks 3-4 glasses of wine per week before becoming pregnant

ICE: You are quite worried as this is your first pregnancy and have had previous seizures. You hoping to have an ultrasound to check that the baby is doing okay. You are really worried about the impact that the epilepsy will have on your pregnancy. Don’t want to go through the stress that you faced with the miscarriage.

Please observe the student taking a history from this patient. A thorough history should be taken to determine what happened before, during and after the event. It is important to illicit the frequency of seizures as this will affect her ability to conceive and antenatal care.

You should ask them to present their findings to you, with a list of possible differentials if she were to have a seizure at her current gestation. For example, ‘my primary differentials would be a seizure given the patient’s background of epilepsy and epilepsy can worsen secondary to tiredness and fatigue. Other differentials would include: eclampsia (unlikely given her gestation) and transient ischaemic attack’.

Topics for discussion Describe what factors increase or decrease the likelihood of seizures in pregnancy? What precautions should a patient take who is planning to conceive? How does epilepsy management differ in pregnancy?