2016 68 Epilepsy Flashcards
What are the long-term neurological outcomes associated with anti-epileptic drugs?
Sodium valproate high risk
Carbamazepine & lamotrigine no risk
What steps should be taken to minimise the risk of congenital abnormalities in epilepsy?
- Folic acid 5mg from 3 months prior to conception, to end 1st trimester
- Lowest effective dose of AED
- Medication optimisation prior to conception
What is the effect of pregnancy on seizures?
2/3 no seizure deterioration
More likely if seizures in the year prior to conception
How should antenatal care be managed for women with epilepsy?
- Designated epilepsy care team
- Urgent epilepsy specialist review if unexpected pregnancy
- Invite to UK Epilepsy & Pregnancy Register
What monitoring for AED levels is recommended in pregnancy?
No routine monitoring
What risk factors for seizures should be monitored for in pregnancy?
- Sleep deprivation
- Stress
- Non-adherence to AEDs
- Seizure type & frequency
With epilepsy in pregnancy, how should the fetus be monitored?
- Normal dating & anomaly scan
- Serial growth scans on SGA pathway
- No routine CTGs
What is the role of vitamin K with epilepsy in pregnancy?
- 1mg IM vit K offered to all
- Insufficient evidence for maternal vit K to prevent HDN or PPH
How should seizures be prevented in labour in women with epilepsy?
- Good care to reduce risk factors
- Consider long-acting benzos such as clobazam if high risk for seizures
- Continue AEDs during labour
What are the recommendations for analgesia in labour for women with epilepsy?
- Prioritise pain relief
- TENS, Entonox, regional anaesthetic OK
- Diamorphine instead of pethidine
When should the AED dose be modified postpartum?
Within 10 days if it was increased in pregnancy
What should be the neonatal management following epilepsy in pregnancy?
- Monitor for adverse effects of AEDs
- Encourage breastfeeding
- Advise no impact of BF on cognitive outcomes
What contraception can be safely offered with all AEDs?
- Copper coil
- Mirena
- Medroxyprogesterone injection
Which AED has levels lowered by combined contraception?
Lamotrigine
Which AEDs are enzyme-inducing?
- Phenytoin
- Carbamazepine
- Phenobarbital
- Primidone
- Oxcarbazepine
- Eslicarbazepine
Which AEDs are not enzyme-inducing?
- Sodium valproate
- Levetiracetam
- Gabapentin
- Pregabalin
- Vigabatrin
- Tiagabine
Which emergency contraception should be offered with enzyme-inducing AEDs?
Copper coil
What is the prevalence of epilepsy?
0.5-1%
How does pregnancy impact on the risk of death from epilepsy?
10x
Majority SUDEP following poorly controlled seizures
What are the 4 most common types of epileptic seizures?
- Tonic-clonic
- Absence
- Juvenile myoclonic
- Focal
Which type of seizure are most associated with fetal hypoxia & SUDEP?
Tonic-clonic
What are the differentials for seizures in pregnancy?
- Epilepsy
- Cerebral venous sinus thrombosis
- Posterior reversible leucoencephalopathy syndrome
- Space-occupying lesions
- Reversible cerebral vasoconstriction syndrome
- Syncope
- Metabolic: hypoglycaemia, hyponatraemia, Addisonian crisis
What are the most common major congenital malformations associated with AEDs?
- Neural tube defects
- Congenital heart disorders
- Urinary tract abnormalities
- Skeletal abnormalities
- Cleft palate
What congenital abnormalities does sodium valproate most commonly cause?
Neural tube defects
Facial cleft
Hypospadias
Which AEDs are most commonly associated with fetal cardiac malformations?
Phenobarbital
Phenytoin
Which AEDs & at what doses are considered safe in pregnancy?
Lamotrigine 300mg
Carbamazepine 400mg
Which obstetric complications are more common in epilepsy?
- Spontaneous miscarriage
- APH
- Hypertensive disorders
- Induction of labour
- Caesarean section
- Any preterm delivery
- Fetal growth restriction
- PPH
Which obstetric complications are higher in women on AEDs than women with unmedicated epilepsy?
- Induction of labour
- FGR
- PPH
- NICU admission
How much higher are the odds of SGA with AEDs compared to women with unmedicated epilepsy?
3.5x
How do enzyme-inducing drugs increase the risk of haemorrhagic disease of the newborn?
Competitively inhibit the precursors of clotting factors & affect fetal microsomal enzymes that degrade vitamin K
What proportion of women with epilepsy have tonic-clonic seizures a) in labour, b) within 24 hours of birth
a) 1-2%
b) 1-2%
How is a seizure lasting more than 5 minutes managed?
- Maintenance of airway & oxygenation
- Left lateral tilt
- IV lorazepam 4mg bolus, further dose after 10-20 mins
Or PR diazepam 10-20mg, rpt 15 mins
Or buccal midazolam 10mg - IV phenytoin 10-15mg/kg (1g)
- Tocolytics if hypertonus
- CS if vaginal birth not imminent
What side effects of AEDs can be seen in neonates?
- Lethargy
- Difficulty feeding
- Excessive sedation
- Withdrawal symptoms
- Inconsolable crying
Which AEDs transfer most readily into breast milk?
Lamotrigine
Levetiracetam
Topiramate
