\documentclass[twocolumn,twoside]{article}
\makeatletter\if@twocolumn\PassOptionsToPackage{switch}{lineno}\else\fi\makeatother

\usepackage{amsfonts,amssymb,amsbsy,latexsym,amsmath,tabulary,graphicx,times,xcolor}

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
% Following additional macros are required to function some 
% functions which are not available in the class used.
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
\usepackage{url,multirow,morefloats,floatflt,cancel,tfrupee}
\makeatletter


\AtBeginDocument{\@ifpackageloaded{textcomp}{}{\usepackage{textcomp}}}
\makeatother
\usepackage{colortbl}
\usepackage{xcolor}
\usepackage{pifont}
\usepackage[nointegrals]{wasysym}
\urlstyle{rm}
\makeatletter

%%%For Table column width calculation.
\def\mcWidth#1{\csname TY@F#1\endcsname+\tabcolsep}

%%Hacking center and right align for table
\def\cAlignHack{\rightskip\@flushglue\leftskip\@flushglue\parindent\z@\parfillskip\z@skip}
\def\rAlignHack{\rightskip\z@skip\leftskip\@flushglue \parindent\z@\parfillskip\z@skip}

%Etal definition in references
\@ifundefined{etal}{\def\etal{\textit{et~al}}}{}


%\if@twocolumn\usepackage{dblfloatfix}\fi
\usepackage{ifxetex}
\ifxetex\else\if@twocolumn\@ifpackageloaded{stfloats}{}{\usepackage{dblfloatfix}}\fi\fi

\AtBeginDocument{
\expandafter\ifx\csname eqalign\endcsname\relax
\def\eqalign#1{\null\vcenter{\def\\{\cr}\openup\jot\m@th
  \ialign{\strut$\displaystyle{##}$\hfil&$\displaystyle{{}##}$\hfil
      \crcr#1\crcr}}\,}
\fi
}

%For fixing hardfail when unicode letters appear inside table with endfloat
\AtBeginDocument{%
  \@ifpackageloaded{endfloat}%
   {\renewcommand\efloat@iwrite[1]{\immediate\expandafter\protected@write\csname efloat@post#1\endcsname{}}}{\newif\ifefloat@tables}%
}%

\def\BreakURLText#1{\@tfor\brk@tempa:=#1\do{\brk@tempa\hskip0pt}}
\let\lt=<
\let\gt=>
\def\processVert{\ifmmode|\else\textbar\fi}
\let\processvert\processVert

\@ifundefined{subparagraph}{
\def\subparagraph{\@startsection{paragraph}{5}{2\parindent}{0ex plus 0.1ex minus 0.1ex}%
{0ex}{\normalfont\small\itshape}}%
}{}

% These are now gobbled, so won't appear in the PDF.
\newcommand\role[1]{\unskip}
\newcommand\aucollab[1]{\unskip}
  
\@ifundefined{tsGraphicsScaleX}{\gdef\tsGraphicsScaleX{1}}{}
\@ifundefined{tsGraphicsScaleY}{\gdef\tsGraphicsScaleY{.9}}{}
% To automatically resize figures to fit inside the text area
\def\checkGraphicsWidth{\ifdim\Gin@nat@width>\linewidth
	\tsGraphicsScaleX\linewidth\else\Gin@nat@width\fi}

\def\checkGraphicsHeight{\ifdim\Gin@nat@height>.9\textheight
	\tsGraphicsScaleY\textheight\else\Gin@nat@height\fi}

\def\fixFloatSize#1{}%\@ifundefined{processdelayedfloats}{\setbox0=\hbox{\includegraphics{#1}}\ifnum\wd0<\columnwidth\relax\renewenvironment{figure*}{\begin{figure}}{\end{figure}}\fi}{}}
\let\ts@includegraphics\includegraphics

\def\inlinegraphic[#1]#2{{\edef\@tempa{#1}\edef\baseline@shift{\ifx\@tempa\@empty0\else#1\fi}\edef\tempZ{\the\numexpr(\numexpr(\baseline@shift*\f@size/100))}\protect\raisebox{\tempZ pt}{\ts@includegraphics{#2}}}}

%\renewcommand{\includegraphics}[1]{\ts@includegraphics[width=\checkGraphicsWidth]{#1}}
\AtBeginDocument{\def\includegraphics{\@ifnextchar[{\ts@includegraphics}{\ts@includegraphics[width=\checkGraphicsWidth,height=\checkGraphicsHeight,keepaspectratio]}}}

\DeclareMathAlphabet{\mathpzc}{OT1}{pzc}{m}{it}

\def\URL#1#2{\@ifundefined{href}{#2}{\href{#1}{#2}}}

%%For url break
\def\UrlOrds{\do\*\do\-\do\~\do\'\do\"\do\-}%
\g@addto@macro{\UrlBreaks}{\UrlOrds}



\edef\fntEncoding{\f@encoding}
\def\EUoneEnc{EU1}
\makeatother
\def\floatpagefraction{0.8} 
\def\dblfloatpagefraction{0.8}
\def\style#1#2{#2}
\def\xxxguillemotleft{\fontencoding{T1}\selectfont\guillemotleft}
\def\xxxguillemotright{\fontencoding{T1}\selectfont\guillemotright}

\newif\ifmultipleabstract\multipleabstractfalse%
\newenvironment{typesetAbstractGroup}{}{}%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

\usepackage[authoryear]{natbib}



\newif\ifnokeywords\nokeywordsfalse

\makeatletter\input{size10-pointfive.clo}\makeatother%
\definecolor{kwdboxcolor}{RGB}{242,242,242}
\usepackage[hidelinks,colorlinks=true,allcolors=blue]{hyperref}
\linespread{1}                 
\def\floatpagefraction{0.8}

\usepackage[paperheight=11.69in,paperwidth=8.26in,top=1in,bottom=1in,left=1in,right=.75in,headsep=24pt]{geometry}

\usepackage{multirow-custom}

\makeatletter

\def\hlinewd#1{%
  \noalign{\ifnum0=`}\fi\hrule \@height #1%
  \futurelet\reserved@a\@xhline}
\def\tbltoprule{\hlinewd{1pt}\\[-14pt]}
\def\tblbottomrule{\noalign{\vspace*{6pt}}\hline\noalign{\vspace*{2pt}}}
\def\tblmidrule{\hline\noalign{\vspace*{2pt}}}



\let\@articleType\@empty
\let\@journalDoi\@empty
\let\@journalVolume\@empty
\let\@journalIssue\@empty
\let\@crossMarkLink\@empty
\let\@receivedDate\@empty
\let\@acceptedDate\@empty
\let\@revisedDate\@empty
\let\@publishedDate\@empty
\let\@copyrightYear\@empty
\let\@firstPage\@empty
\def\articleType#1{\gdef\@articleType{#1}}
\def\journalDoi#1{\gdef\@journalDoi{#1}}
\def\crossMarkLink#1{\gdef\@crossMarkLink{#1}}
\def\receivedDate#1{\gdef\@receivedDate{#1}}
\def\acceptedDate#1{\gdef\@acceptedDate{#1}}
\def\revisedDate#1{\gdef\@revisedDate{#1}}
\def\publishedDate#1{\gdef\@publishedDate{#1}}
\def\copyrightYear#1{\gdef\@copyrightYear{#1}}
\def\journalVolume#1{\gdef\@journalVolume{#1}}
\def\journalIssue#1{\gdef\@journalIssue{#1}}
\def\firstPage#1{\gdef\@firstPage{#1}}
\let\@issuelogo\@empty%
\let\@issuelogoex\@empty%
\def\issuelogo#1{\gdef\@issuelogo{#1}}
\def\issuelogoex#1{\gdef\@issuelogoex{#1}}


\def\author#1{%
  \gdef\@author{%
    \hskip-\dimexpr(\tabcolsep)\hskip5pt%
    \parbox{\dimexpr\textwidth-1pt}%
    {\fontsize{11}{13}\selectfont\raggedright #1}%
  }%
}


\usepackage{pharmascope-abs}
\usepackage{caption}
\usepackage{lastpage}
\usepackage{fancyhdr}
\usepackage[noindentafter,explicit]{titlesec}
\usepackage{fontspec}

\setmainfont[%
BoldFont=cambriab.ttf,%
ItalicFont=CAMBRIAI.TTF,%
BoldItalicFont=CAMBRIAZ.TTF]{Cambria.ttf}
\lefthyphenmin = 3

\def\title#1{%
  \gdef\@title{%
      \vspace*{-40pt}%
       \ifx\@articleType\@empty\else{\fontsize{10}{12}\scshape\selectfont\hspace{8pt}\@articleType\hfill\mbox{}\par\vspace{2pt}}\fi%
       \minipage{\linewidth}
         \hrulefill\\[-0.7pt]%%{\includegraphics[width=75pt,height=50pt]{ijrps_logo.png}}\hfill
         \mbox{~}\hspace{5pt}\parbox{.1\linewidth}{\IfFileExists{images/\@issuelogo.\@issuelogoex}{\includegraphics[width=79pt,height=61pt]{images/\@issuelogo.\@issuelogoex}}{\includegraphics[width=75pt,height=50pt]{ijrps_logo.png}}}\hfill
         \fcolorbox{kwdboxcolor}{kwdboxcolor}{\parbox{.792\linewidth}{%
          \begin{center}\fontsize{17}{17}\selectfont\scshape\vskip-7pt International Journal of Research in Pharmaceutical Sciences\hfill\end{center}%
          \vspace*{-10pt}\hspace*{4pt}{\fontsize{8}{9}\selectfont Published by JK Welfare \& Pharmascope Foundation\hfill  Journal Home Page: \href{www.ijrps.com}{\color{blue}\underline{\smash{www.ijrps.com}}}}\hspace*{4pt}\mbox{}}}%
       \par\vspace*{-1pt}\rule{\linewidth}{1.3pt}%
       \endminipage%
    \par\vspace*{9.2pt}\parbox{.98\linewidth}{\linespread{.9}\raggedright\fontsize{14}{17}\selectfont #1}%
    \vspace*{-8pt}%
  }
}


\setlength{\parindent}{0pt}
\setlength{\parskip}{0.4pc plus 1pt minus 1pt}

\def\abbrvJournalTitle{Int. J. Res. Pharm. Sci.}

\fancypagestyle{headings}{%
  \renewcommand{\headrulewidth}{0pt}%
  \renewcommand{\footrulewidth}{0.3pt}
  \fancyhf{}%
  \fancyhead[R]{%
    \fontsize{9.12}{11}\selectfont\RunningAuthor,\ \abbrvJournalTitle,\ \ifx\@journalVolume\@empty X\else\@journalVolume\fi%
    \ifx\@journalIssue\@empty\else(\@journalIssue)\fi%
    ,\ \ifx\@firstPage\@empty 1\else\@firstPage\fi-\pageref*{LastPage}%
  }%
  \fancyfoot[LO,RE]{\fontsize{9.12}{11}\selectfont\textcopyright\ International Journal of Research in Pharmaceutical Sciences}%
  \fancyfoot[RO,LE]{\fontsize{9.12}{11}\selectfont\thepage}
}\pagestyle{headings}

                                                         
\fancypagestyle{plain}{%
  \renewcommand{\headrulewidth}{0pt}%
  \renewcommand{\footrulewidth}{0.3pt}%
  \fancyhf{}%
  \fancyhead[R]{%
    \fontsize{9.12}{11}\selectfont\RunningAuthor,\ \abbrvJournalTitle,\ \ifx\@journalVolume\@empty X\else\@journalVolume\fi%
    \ifx\@journalIssue\@empty\else(\@journalIssue)\fi%
    ,\ \ifx\@firstPage\@empty 1\else\@firstPage\fi-\pageref*{LastPage}%
  }%
  \fancyfoot[LO,RE]{\fontsize{9.12}{11}\selectfont\textcopyright\ International Journal of Research in Pharmaceutical Sciences}%
  \fancyfoot[RO,LE]{\fontsize{9.12}{11}\selectfont\thepage}
  \ifx\@firstPage\@empty\else\setcounter{page}{\@firstPage}\fi
}


\def\NormalBaseline{\def\baselinestretch{1.1}}
\usepackage{textcase}
\setcounter{secnumdepth}{0}

\titleformat{\section}[block]{\bfseries\boldmath\NormalBaseline\filright\fontsize{10.5}{13}\selectfont}
{\thesection}
{6pt}
{\MakeTextUppercase{#1}}
[]
\titleformat{\subsection}[block]{\bfseries\boldmath\NormalBaseline\filright\fontsize{10.5}{12}\selectfont}
{\thesubsection}
{6pt}
{#1}
[]
\titleformat{\subsubsection}[block]{\NormalBaseline\filright\fontsize{10.5}{12}\selectfont}
{\thesubsubsection}
{6pt}
{#1}
[]
\titleformat{\paragraph}[block]{\NormalBaseline\filright\fontsize{10.5}{10}\selectfont}
{\theparagraph}
{6pt}
{#1}
[]
\titleformat{\subparagraph}[block]{\NormalBaseline\filright\fontsize{10.5}{12}\selectfont}
{\thesubparagraph}
{6pt}
{#1}
[]

\titlespacing{\section}{0pt}{.5\baselineskip}{.5\baselineskip}  
\titlespacing{\subsection}{0pt}{.5\baselineskip}{.5\baselineskip}  
\titlespacing{\subsubsection}{0pt}{.5\baselineskip}{.5\baselineskip}  
\titlespacing{\paragraph}{0pt}{.5\baselineskip}{.5\baselineskip}  
\titlespacing{\subparagraph}{0pt}{.5\baselineskip}{.5\baselineskip}

\captionsetup[figure]{skip=1.4pt,font=bf,labelsep=colon,justification=raggedright,singlelinecheck=false}
\captionsetup[table]{skip=1.4pt,font=bf,labelsep=colon,justification=raggedright,singlelinecheck=false}

\def\bibyear#1{#1}
%\def\bibjtitle#1{#1}   %%Publisher request
\def\bibauand{}
\setlength\bibsep{3pt}
\setlength\bibhang{8pt}

\makeatother
\date{}


\begin{document}


\def\RunningAuthor{Varma A et al.}
\firstPage{5603}
\articleType{Original Article}
\receivedDate{03 May 2020}
\acceptedDate{08 Jun 2020}
\revisedDate{05 Jun 2020}
\journalVolume{2020, 11}
\journalIssue{4}
\journalDoi{ijrps.v11i4.3198}
\copyrightYear{2020}
\def\authorCount{6}
\def\affCount{1}

\def\journalTitle{International Journal of Research in Pharmaceutical Sciences}

\title{\textbf{Study of Clinical Profile of Neonatal seizures in a NICU of Rural Central India}}
\author{Varma~A\textsuperscript{*},  
            Meshram~R~J,  
            Darvhekar~N,  
            Patel~Z,  
            Damke~S~G, 
            Taksande~A~\\[5pt]{Department of Pediatrics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Sawangi, Wardha-442004, Maharashtra, India}}

\begin{abstract}
Seizures are common neonatal illness amongst neurological disorders\textbf{. } The study was conducted to determine the clinical profile of neonatal seizures. A hospital based prospective observational study was undertaken in the NICU of a rural set up in central India. A total of 82 neonates admitted with seizures or who developed seizures later during the stay in NICU were subject population of the study. Of 82 neonates with seizures, the overall mean for duration of stay was 14.34 (\ensuremath{\pm}10.41) days and the interquartile range was 1-32 days and male predominance. Majority of neonates included were extramural deliveries (62.19\%). The distribution of neonates in the study according to their gestational age, birth weight, route of delivery \& MSAF was found to be statistically insignificant (p Value {\textgreater}0.05). The vaginal route of delivery was more common than the caesarean section among neonates with seizures in the study. The overall mortality rate was 17.07\% (14/82). In most of the cases, the causes of neonatal seizures were present. Birth asphyxia was the main etiology identified. The antenatal services and intrapartum monitoring is important. 
\end{abstract}\def\keywordstitle{Keywords}

\begin{keywords}Neonatal Seizures,\newline Etiology,\newline Clinical Profile
\end{keywords}
\twocolumn[ \maketitle {\printKwdAbsBox}]
\makeatletter{\raggedright\textsuperscript{*}Corresponding Author\par Name:\ Varma~A~\\ Phone:\ ~\\  Email:\ avarma2055@gmail.com
        \par}\vspace*{-11pt}\hrulefill\par{\fontsize{12}{14}\selectfont ISSN: 0975-7538}\par% 
        \textsc{DOI:}\ \href{https://doi.org/10.26452/\@journalDoi}{\textcolor{blue}{\underline{\smash{https://doi.org/10.26452/\@journalDoi}}}}\par%
        \vspace*{-11pt}\hrulefill\\{\fontsize{9.12}{10.12}\selectfont Production and Hosted by}\par{IJRPS |~\href{www.ijrps.com}{www.ijrps.com}}\par%
        \vspace*{-2pt}{\fontsize{9.12}{10.12}\selectfont\textcopyright\ \@copyrightYear\ $|$ All rights reserved.}\par%
        \vspace*{-11pt}\rule{\linewidth}{1.2pt}
        \makeatother
        
    
\section{Introduction}
The neonatal period, unquestionably is the most hazardous period of life, never again in life individual is confronted with more dramatic changes than in transition from dependent intrauterine existence to independent post natal life. The new born brain responds in the form of convulsion even to minor insult, because of the immaturity of the nervous system. The presentation of a newborn with seizures represents a true emergency \unskip~\citep{843203:19919698} and frequently indicates significant neurological dysfunction or damage to the immature nervous system\unskip~\citep{843203:19919688}.

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 \unskip~\citep{843203:19919707}. The highest incidence of neonatal seizures occurs during the first 48 hours of life \unskip~\citep{843203:19919699}.

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. \unskip~\citep{843203:19919708}

The major causes of neonatal seizures are Hypoxic-Ischemic Encephalopathy (HIE), which represents about 50\% of the causes of neonatal seizures. Metabolic abnormalities, infection, intracranial hemorrhage, developmental anomalies are the other important causes \unskip~\citep{843203:19919700,843203:19919692}. Inborn errors of metabolism are amongst the rare causes of neonatal seizures.

The causes of seizures in preterm neonates is different from that seen in term neonates, where the HIE is the most frequent cause in term neonates, followed by cerebral malformations and metabolic disturbances, while in preterm neonates intraventricular hemorrhage and infections are the most frequent causes. \unskip~\citep{843203:19919693}

Neonates can have subtle seizures or tonic, focal, multifocal and myoclonic types of convulsions.

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. \unskip~\citep{843203:19919703}

Therefore, the aim of the study was to determine the clinical profile of neonatal seizures.
    
\section{Materials and Methods}
This was a prospective, observational study conducted over two years on the neonates with seizures admitted in NICU of a rural set up in central India.

\textbf{Inclusion Criteria}

All newborns of upto age {\textless}/= 28 days brought to NICU during the study period with clinically identified seizures, defined as- sudden abnormal repetitive, rhythmic movement of any part of the body with or without deviation of angle of eyes and frothing from mouth which were not suppressed by physical pressure alone or subtle convulsion. 

\textbf{Exclusion Criteria}


  
  \begin{enumerate}
  \item \relax Neonates with known congenital malformation of the CNS.
  \item \relax Neonates with Hypoglycemia, Hypocalcemia, Hypomagnesemia, Dyselectrolytemia 
  \item \relax Jitteriness in neonates. 
  \item \relax Tetanic spasms in neonates. 
  \end{enumerate}
  \textbf{Sample size}

All babies fulfilling the inclusion criteria who were brought for hospitalization during the study period were consecutively recruited. There were thus neonates included in the study.

\textbf{Study Method}

Ethical clearance was obtained for this study from the Institutional Ethics Committee. Babies who were reported with clinical seizures identified on history or observation by the neonatal intesivist at the time of hospitalization were included after obtaining written consent from parents. At the time of recruitment, a detailed history was recorded. Their mothers' previous obstetric history, family history, antenatal, natal and post natal risk factors which includes maternal drug addiction / withdrawal, maternal chronic disease, prolonged rupture of membranes, bleeding, pregnancy induced hypertension drugs taken during pregnancy, gestational age assessment by LMP, small for date, low birth weight baby, perinatal asphyxia, traumatic delivery, septicemia, meningitis, intracranial bleed and hyperbilirubinemia, The detailed history about age of occurrence of first seizure, duration of seizure, number of seizures, type of seizure. Clinical examination findings were noted including anthropometry. The course of illness was recorded and outcome noted. During hospitalization any relevant investigations done and treatment given as per protocol of NICU and was recorded in a prevalidated case record form. 

\textbf{Data Management and Statistical Analysis}

Statistical analysis was performed using percentage. The analysis of Student's t-test was used for comparisons. Categorical variables were compared using Chi square test and Fischer's exact test. A p-value 0.05 was considered significant.
    
\section{Results}
Out of total 82 newborns that were included in the study, 56(68.29\%) were admitted within first 3 days of life with clinical seizures, 12(14.63\%) in between day of life 4 \&7, while 14 (17.07\%) were admitted after 7 days of life. The sex distribution showed that there was male preponderance in this study i.e., 49 out of 82(59.75\%). The overall mean for duration of stay was 14.34 (\ensuremath{\pm}10.41) days and the interquartile range was 1-32 days. The majority of newborns admitted were outborn i.e., 51 out of 82 (62.19\%) while only 31 were inborn (37.80\%). 48(58.53\%) newborn were term. This shows that maximum newborns were term neonates. Only 2(2.43\%) newborn were very low birth weight ({\textless}1.5 Kg), 46(56.09\%) were between 1.51 to 2.5 Kg, while 34(41.46\%) were {\textgreater}2.5Kg, whereas 50(60.97\%) had first episode of seizure within 3 days of life, while 20(24.39\%) had seizures between 4 to 7 days of life. Table~\ref{tw-90090470be07}


\begin{table*}[!htbp]
\caption{\boldmath {Maternal Diseases and neonatal seizures} }
\label{tw-90090470be07}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.50160000000000004\linewidth-2\tabcolsep}p{\dimexpr.31159999999999997\linewidth-2\tabcolsep}p{\dimexpr.1868\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}\cAlignHack Maternal Diseases & \cAlignHack Total, n=82 & \cAlignHack p value\\
\rowcolor{kwdboxcolor} & \cAlignHack (\%) & \\
\tblmidrule 
Preeclampsia/Eclampsia &
  \cAlignHack 11(13.41\%) &
  \multicolumn{1}{p{\dimexpr(.1868\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{\cAlignHack 0.624}}\\
Gestational Diabetes Mellitus &
  \cAlignHack 1(1,21\%) &
  \\
Others &
  \cAlignHack 5(6.09\%) &
  \\
None &
  \cAlignHack 65(79.27\%) &
  \\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}
Out of the total 82 mothers, 11(13.41\%) mothers had pre-eclampsia or impending eclampsia while 65(79.27\%) mothers had no antenatal history of any disease. 5 of the 82 mothers had different illnesses like hypothyroidism (3), Valvular heart disease (1) and Multiple sclerosis (1) while one mother suffered from gestational diabetes mellitus. 

Majority of the neonates, 46(56.09\%), were born via normal vaginal delivery.

A 34(41.46\%) of the total neonates required resuscitation in the form of tactile stimulation/ Bag \& mask ventilation while 12(14.63\%) required securing an alternate airway i.e., endotracheal intubation. It was inferred that a significant percentage, 56.09\% (46/82) of the newborn who had seizures later on had received some form of resuscitation. 

APGAR at 5 minutes of life, 15(18.29\%) neonates had score {\textless}7 while 67(81.70\%) neonates had score of 7 to 10. Out of the total 82 cases, 45 (54.87\%) newborn were diagnosed as HIE, 36(43.90\%) cases as CNS infection while only 1(1.2\%) case had an ischaemic stroke.

If the frequency of seizures occurring was considered; 35(42.68\%) neonates had only a single episode of seizures, while 47(57.31\%) neonates had multiple episodes of seizures. For multiple seizures, 25 cases required use of \ensuremath{\geq }2 antiepileptic drug (AED).

The types of clinical seizures were seen in the study; 14(17.07\%) neonates had subtle seizures, 57(69.51\%) had multifocal, 9(10.98\%) had focal, 2(2.44\%) had GTCS while no neonate was observed to have myoclonic seizures. Thus, multifocal seizures were the most common type of seizures followed by subtle seizures.

A Neonatal sepsis was common co-morbidity in the study as 45 (54.87\%) neonates had a positive blood culture report among all neonates. The overall mortality rate was 17.07\% (14/82) while survival rate was 82.92\% (68/82) in the present study.

In the present study many patterns of seizures were found with relation to patient characteristics, types of seizures, its causes and associations with the maternal and neonatal factors. 
    
\section{Discussion}
In the study carried out by \unskip~\cite{843203:19919702}, there were 41(68.33\%) males with female: male ratio of 1:2.15. In another study conducted by \unskip~\cite{843203:19919705} there was male preponderance as well with 56 (56\%) male neonates and 44(44\%) female neonates with female to male ratio of 1:1.27. 

In yet another study by \unskip~\cite{843203:19919687}, there was again male preponderance among neonates with seizures. In another study conducted in the NICU of a tertiary care hospital in Nasik\ensuremath{^{156}}, out of the 127 neonates studied, 118(92.91\%) neonates were full term while 7(5.51\%) were preterm. Among the neonates studied by \unskip~\cite{843203:19919705}, the mean birth weight values were 2.56(\ensuremath{\pm}0.64)Kg. 

\unskip~\cite{843203:19919688} found that the incidence of neonatal seizure were 63\% in normal weight and 37\% in less than 2.5 kg.

\unskip~\cite{843203:19919691} in his study of neonatal seizures Clinico-biochemical profile of Neonatal Seizures studied 90 babies , found that the percentage of neonatal seizure was more in normal weight babies 66\% than the babies whose weight was less than 2.5 kg. i.e. 33\%.  Similar results were found in our study.

In another study conducted by \unskip~\cite{843203:19919695}, onset of seizures was found to be within first 3 days of life in 101(79.5\%) neonates while after 3 days of life, only 26 (20.5\%) neonates developed seizures. It was also concluded that, onset of seizures within first 3 days of life of had statistically significant correlation with birth asphyxia being the causative factor with p{\textless}0.001

In the study done by \unskip~\cite{843203:19919690}, the onset of seizures on the first two days of life was seen in 62 (59.6\%) neonates,

In the study conducted by \unskip~\cite{843203:19919706}, there was a strong association between preeclampsia, chronic hypertension and PIH with neonatal seizures.

In the study undertaken for analysis of antenatal risk factors for seizures in term newborns by \unskip~\cite{843203:19919697} unadjusted analysis showed maternal hypertension was associated with seizures; however, in the adjusted analysis, which included all antenatal, intrapartum, and infant covariates, the risk of maternal hypertension was no longer significant. Each of the variables was evaluated individually in a regression with hypertension and found that no single variable had a significant effect. Although the p value was not significant in this study for maternal diseases but a significant percentage of neonates had mothers with pre Eclampsia. This could be attributed to the fact that preeclampsia/eclampsia leads to decreased utero-placental perfusion.

\unskip~\cite{843203:19919704}, 78.89\%(86/109) newborn had seizures accountable for perinatal insult while CNS infections was accountable for 16.51\%(18/108) of cases. thus leading to adverse neonatal neurological outcome including seizures.

\unskip~\cite{843203:19919694}, most common type of seizures were subtle (51\%) followed by focal clonic(42\%), multifocal clonic(30\%) and generalized tonic (23\%)\ensuremath{^{}}

In another study, evaluating the safety \& efficacy of LEV in neonatal seizures, \unskip~\cite{843203:19919686} found subtle seizures to be the most common type (42.10\%)\ensuremath{^{}}

\unskip~\cite{843203:19919696} having 18.35\% (35/109) neonates who died , and our study had got near similar(17.07\%) percentage of died neonates. that is 65(26\%) can be due to the severity of the etiological factors in newborns with neonatal seizures.

But when compared with the study done by \unskip~\cite{843203:19919689} found that 24.7\% of the cases died in the neonatal period; higher than the current study. Study in same setup by \unskip~\cite{843203:19919696} showed mortality of 26\%. It can be due to the severity of the maternal risk factors in newborns with neonatal seizures.

The study was not without limitations, first the neurodevelopmental outcome of neonates could not be done at later stages of life for assessment of long term effect of seizures on CNS development. Another shortcoming was EEG could not be done because of infrastructural limitations in the hospital. EEG monitoring is important to identify non-convulsive seizures and non obvious seizures in predisposed neonates.
    
\section{Conclusion  }
The distribution of neonates in the study according to their gender, gestational age, birth weight, route of delivery, place of delivery, meconium stain of amniotic fluid, age of presentation, duration of stay, maternal factors and cause of seizure was found to be statistically insignificant. The most common cause of seizures and death was birth asphyxia. In the present study, multifocal seizures were most common type of neonatal seizures was observed.

\textbf{Conflict of interest}

The authors declare that they have no conflict of interest for this study.

\textbf{Source of funding}

The authors declare that they have no funding support for this study.
    

\bibliographystyle{pharmascope_apa-custom}

\bibliography{\jobname}
\end{document}
