Amar M. Taksande, Krishna Vilhekar, Manish Jain, Mahaveer Lakra.
DEPARTMENT OF PEDIATRICS, MAHATMA GANDHI INSTITUTE OF MEDICAL SCIENCES, SEVAGRAM, WARDHA, MAHARASHTRA. | | Abstract | OBJECTIVE: To study the incidence, etiological factor, days of onset, clinical types and various biochemical abnormalities in neonatal seizures.
DESIGN: Prospective study
SETTING: MGIMS Rural hospital, Level II Neonatal intensive care unit
PARTICIPANTS: 110 neonates with neonatal seizures who were delivered at our hospital and developed seizures before 28 days of life. Onset of seizure activity more than 28 days of life and outborn babies are excluded from study.
RESULTS: The incidence of neonatal seizures was 16.69/1000 live births. The seizures were more common in male babies. 64 (58.2%) neonates were born to primigravida mothers while 46 (41.8%) neonates were born to multiparous women. In term babies (n=4650), 77 neonates had seizures out of that 24 (31.1%) had subtle seizure, 36 (46.7%) had clonic seizure, 15 (19.4%) had tonic seizures and 2 (2.5%) had myoclonic seizures. In birth asphyxia (n=47), the most common type of seizures observed were subtle seizure 15(31.9%), followed by focal clonic 12(25.5%) and multifocal clonic 10(21.2%). Among metabolic abnormalities, early hypocalcaemia was seen in 6 (46.1%) while late hypocalcaemia were detected in 7 (53.8%) babies. Hypoglycemia was more commonly seen after 3 days of life in 6 babies while in hypomagnesaemia 2 had seizures in first 2 days of life. Out of 110 babies, 21 (19.1%) neonates expired while 89 (80.9%) neonates were discharged. The most common causes of neonatal deaths were severe birth asphyxia seen in 9(42.8) neonates followed by IVH in 5 (23.8%), septicemia in 4 (23.8%) and meningitis in 3 (14.2%) neonates.
CONCLUSION: The commonest cause of seizure in term babies was birth asphyxia with majority presenting to us within the first 72hrs. IVH and sepsis contribute maximum to seizure in preterms. Subtle seizures were the commonest type of seizure observed in term and preterm neonates. Hypocalcaemia and hypoglycemia are the most common biochemical abnormality seen in neonates with seizures.
| | | | Introduction | | Seizures represent the most distinctive signal of neurological disease in the newborn period and these convulsive phenomena are the most frequent of the overt manifestations of neonatal neurological disorders.1 Recognition and classification of neonatal seizures remain problematic, particularly when clinicians rely only on clinical criteria. Seizures in a newborn are one of the few neonatal neurological emergencies where prompt diagnostic and therapeutic plans are necessary; a delay in therapy often results in poor neurological outcome. 2 Seizures during the neonatal period are relatively common, occurring in approximately 1.8 to 3.5 per 1000 live births, with greater frequency in premature or low birth weight babies as compared to term babies. 3 In the newborn, seizures are always due to an underlying cerebral or biochemical abnormality. 4 In the Neonatal Intensive Care Unit, the incidence goes as high as 10 to 25% out of which about 15% will die and 35 to 40% will have major neurological sequelae. 5 There is increasing evidence that neonatal seizures have an adverse effect on neurodevelopment and may predispose to cognitive, behavioural or epileptic complication later in life.6 Therefore, the aim of the study was to determine the incidence rate, aetiological factors, clinical types and various biochemical abnormalities in neonatal seizures. | | | | Methods & Materials | The present prospective, observational study was conducted in the Neonatal Intensive Care Unit level II Nursery at Mahatma Gandhi Institute of Medical Sciences, Sevagram, rural hospital from 1st April 2002 to 31st March 2004. All the neonates developing clinically identifiable seizures before 28 days of life were enrolled in the study. A detailed antenatal history ie gestational age, maternal education, socio-economic status, history of maternal illness during pregnancy, natal history, labour records for evidence of foetal distress and Apgar score, type of delivery and medication given to the baby were recorded. Baseline characteristics of convulsive neonate; including sex, gestational age, weight; head circumference and length, were recorded at admission.
Clinical details of each seizure episode reported by the mother and subsequently observed by resident doctors on duty were recorded, i.e. age at onset of seizures, seizure activity during occurrence of 1st seizure, duration of seizures, number and type of seizures. The neonatal seizures were classified according to Volpe's classification into subtle, multifocal, clonic, focal clonic, tonic and myoclonic.7 Complete blood count, septic screening, blood glucose, total and ionised serum calcium and magnesium levels were done, immediately after baby had seizures and before institution of any specific treatment. Various criteria for diagnosing metabolic abnormalities were defined as Hypoglycaemia: blood sugar <40 mg/dl, Hypocalcaemia: Total serum calcium < 7.0 mg/dl, Hypomagnesaemia: serum magnesium <1.5 mg/dl. 1 EEG & CSF study was carried out in selected cases whenever indicated to find out aetiology. An USG was done in high risk babies liable for Intraventricular hemorrhage (IVH) or periventricular hemorrhage (PVH). The data was analysed on EPI-6 software.
| | | | Results | Out of the total 6,590 intra-hospital live births during the study period, 110 neonates developed seizures. The incidence of neonatal seizures was 16.69/ 1000 live births. The term babies had mean weight of 2478 ± 174gms with a mean gestation of 38.6 weeks whereas preterm babies had mean weight of 1460 ± 176 grams with a mean gestational of 34.4 weeks. There were 73 (66.4%) males and 37 (33.6%) females and the male to female ratio was 1.97:1. The seizures were more common in male babies. 64 (58.2%) neonates were born to primigravida mothers while 46 (41.8%) neonates were born to multiparous women.
72(65.4%) neonates were delivered per vaginally, 33(29.9%) by LSCS and in 5 (4.7%) there was a history of instrumental delivery. The incidence of neonatal seizures in LBW babies was higher than the incidence in babies weighing more than 2500gm as shown in Table no. I.
Table I. Incidence of neonatal seizure according to weight.
| Weight of the neonates |
Total no. of neonates |
Neonates with seizure |
Percentage |
'p' value |
| <2500gms (LBW) |
2602 |
63 |
57.2% |
<0.0001 |
| 2500gms.) |
3988 |
47 |
42.7% |
In term babies (n=4650), 77 neonates had seizures out of that 24(31.1%) had subtle seizure, 36 (46.7%) had clonic seizure, 15 (19.4%) had tonic seizures and 2 (2.5%) had myoclonic seizures. 37(48.5%) neonates had seizures due to birth asphyxia, 15 (19.4%) due to septicaemia and 8 (10.3%) were due to meningitis. IVH was seen only in one (1.2%) case. Primary metabolic abnormalities were seen in 16 (20.8%) neonates, out of which hypocalcaemia was most common, found in 10 (12.9%) neonates followed by hypoglycaemia in 5 (6.4%) and hypomagnesaemia in 1 (1.2%) neonate.
In preterm babies (n=1940), 33 neonates had seizures out of that 16 (48.4%) had subtle seizures, 9 (27.2%) had clonic and 8 (24.2%) had tonic seizures. 10 (30.3%) neonates had seizures due to birth asphyxia, 7 (21.2%) due to septicaemia and 1 (3.0%) due to meningitis. IVH was seen in 6(18.1%) neonates followed by hypocalcaemia in 3 (9.09%), hypoglycaemia in 4 (12.2%) and hypomagnesaemia in 2 (6.06%) neonates.
Relation of type of convulsion with etiology of the seizure is depicted in Table II and time of onset of convulsion with etiology is depicted in Table III.
Table II Relationship of etiology Versus type of seizure.
| Aetiology |
Total (n=110) |
Subtle (n=40) |
Focal clonic (n=26) |
Multifocal clonic (n=19) |
Tonic (n=23) |
Myoclonic (n=2) |
| Birth Asphyxia |
47(42.7%) |
15(31.9%) |
12(25.5%) |
10(21.2%) |
9(19.1%) |
1(2.1%) |
| Septicaemia |
22(20%) |
7(31.8%) |
5(22.7%) |
6(27.2%) |
4(18.1%) |
0 |
| Meningitis |
9(8.2%) |
1(11.1%) |
4(44.4%) |
1(11.1%) |
3(33.3%) |
0 |
| IVH |
7(6.4%) |
4(57.1%) |
1(14.2%) |
0 |
2(28.5%) |
0 |
| Hypocalcaemia |
13(11.8%) |
7(53.8%) |
2(15.3%) |
1(7.6%) |
3(23.1%) |
0 |
| Hypoglycaemia |
9(8.1%) |
5(55.5%) |
2(22.2%) |
0 |
1(11.1%) |
1(11.1%) |
| Hypomagnesemia |
3(2.7%) |
1(33.3%) |
|
1(33.3%) |
1(33.3%) |
0 |
Table III Relationship of etiology Versus type of seizure.
| Aetiology |
No. of cases |
0-1 days |
1-2 day |
3-7 days |
> 7 days |
| Birth Asphyxia |
47 |
27(57.4%) |
19(40.4%) |
1 (2.1%) |
0 |
| Septicemia |
22 |
1(4.5%) |
6(27.2%) |
8(36.3%) |
7(31.8%) |
| Meningitis |
9 |
1(11.1%) |
3 (33.3% |
3(33.3%) |
2 (22.2%) |
| IVH |
7 |
0 |
3 (42.8%) |
3(42.8%) |
1 (14.3%) |
| Hypocalcemia |
13 |
2(15.3%) |
4(30.7%) |
5(38.4%) |
2 (15.4%) |
| Hypoglycemia |
9 |
1(11.1%) |
2 (22.2%) |
5(55.5%) |
1 (11.1%) |
| Hypomagnesemia |
3 |
0 |
2(66.6%) |
1(33.3%) |
0 |
Out of 110 babies, 21 (19.1%) neonates expired while 89 (80.9%) neonates were discharged. The most common causes of neonatal deaths were severe birth asphyxia seen in 9(42.8) neonates followed by IVH in 5 (23.8%), septicaemia in 4(23.8%) and meningitis in 3 (14.2%) neonates.
| | | | Discussion | Neonatal seizure is an important cause of neonatal morbidity and mortality. The incidence of neonatal seizures in our study was 16.6/1000 live births. Holden KR et al8 found that the incidence of neonatal seizure were 63% in LBW and 37% in more than 2.5 kg. Similar results were found in our study. The classification of neonatal seizure has been based on clinical recognition of repetitive and stereotypic motor activity or behavioral phenomenon or both.7 Subtle seizures constitutes 50% of seizures in both term and preterm babies. This most frequent seizure is called 'subtle' because clinical manifestations are often mild and easily missed. There is usually mild paroxysmal alteration in motor, behaviour and autonomic function.9 Ross AL et al10 studied 118 babies ,out of which 48 (40.60%) had subtle, 42 (35.59%) had clonic seizures, 10 (8.9%) had generalized tonic and 28 (27.78%) had myoclonic type of seizures. Soni A et al11 reported that the commonest type of seizures in term group was tonic seizures seen in 15 babies (37.5%) and subtle seizures seen in 10 (25%) babies. In the preterm group also the commonest type of seizures observed was tonic (41.6%) seizures followed by subtle seizures (33.3%). Sood A et al12 and Kumar A et al13 reported that birth asphyxia as etiology of seizure was seen in 45.71% and 48.27% cases respectively which are comparable with the results of our study. Eriksson M et al14, Painter M J et al15 and Holden KR et al8 also showed similar results. A study conducted by Legido A et al16 reported that out of 40 babies, 2 (5%) developed septicemia and 5 (12.25%) had meningitis. Ross AL et al10 studied 144 babies of which 13 (9.5%) babies had septicemia. These results are comparable with the present study in which 23 term neonates had infection. 1(1.29%) term neonate and 6(18.18%) preterm neonates had intraventricular hemorrhage. The incidence of IVH was higher in preterm babies than term babies. Ross AL et al10 and Scher MS et al17 also reported higher incidence of IVH in preterm neonates. Periventricular hemorrhage or IVH is the most common cause of intracranial bleed and neurological damage in low birth weight and preterm babies.
In the present study, hypocalcemia was observed in 13(11.8%) neonates, hypoglycemia in 9(8.1%) and hypomagnesaemia in 3 (2.7%). Early onset hypocalcaemia occurs in premature babies and babies in whom asphyxia or trauma has occurred and infants of mothers with hypoparathyroidism. Kumar A et al13 studied 35 neonates of which 22(62.8%) had biochemical abnormalities. Hypocalcaemia detected in 7(31.8%), hypoglycemia in 11(50%) and hypomagnesaemia in 3 (13.63%). Sood A et al12 studied 59 neonates of which 29 (49.15%) had biochemical abnormalities. Hypocalcaemia detected in 14(48.27%), hypoglycemia in 14(48.27%) and hypomagnesaemia in 5 (17.24%) neonates. The study conducted by Kumar A et al13 and Sood A et al12 showed that biochemical abnormalities were seen in cases of HIE, intracranial bleeding, infections and metabolic disorder. Moreover Sood A et al12 also demonstrated that hypocalcaemia and hypoglycemia were most common metabolic abnormality. The above results were comparable with finding of the present study.
Coen RW et al18 found that 81% of babies had early onset seizures (< 72hrs). Ross AL et al10 also found early onset seizures in 75 (50.33%) babies whereas in our study, 94 (85.45%) neonates had seizures with in 72hrs. Brown JK et al19 observed that 60 (43%) neonates had seizures in the first 4 days of life while Ronen GM et al20, reported 83% of seizures in the 1st week of the life. The study conducted by Kumar A et al13 and Ronen GM et al20 found that birth asphyxia was the commonest cause of seizure in first 48 hrs of life which was similar to our finding. Holden KR et al8 reported that 36 (13%) babies had convulsions after 8 days, which were due to sepsis and meningitis. In the present study, most of the mothers had history of premature rupture of membrane or multiple per vaginal examinations before hospitalization or trial of labour by local practitioner and poor personal hygiene which contributed towards the incidence of septicemia. In our study, 13 (11.83%) babies had convulsions after 8 days of life, out of which 7 (53.84%) babies had septicemia. Among the metabolic seizures, 11 babies (44.44%) presented as an early onset seizure while 14 (56 %) developed seizures after 3 days of life. There was a biphasic distribution of seizures with first peak formed by birth asphyxia and second peak formed by metabolic abnormalities and septicemia at the end of first week.
In conclusion, the commonest cause of seizure in term babies was birth asphyxia with majority presenting within the first 72hrs. IVH and sepsis contribute maximum to seizure in preterms. Subtle seizures were the commonest type of seizure observed in term and preterm neonates. Hypocalcaemia and hypoglycemia are the most common biochemical abnormality seen in neonates with seizures. A significant high mortality rate was associated with intraventricular hemorrhage; on the other hand no mortality was seen with metabolic abnormality which carries a good short term outcome. | | | | Compliance with Ethical Standards | | Funding None | | | | Conflict of Interest None | | |
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| Cite this article as: | | Taksande A M, Vilhekar K, Jain M, Lakra M. CLINICO-BIOCHEMICAL PROFILE OF NEONATAL SEIZURES. Pediatr Oncall J. 2005;2: 68. |
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