2016 68 Epilepsy

Question 1

What are the long-term neurological outcomes associated with anti-epileptic drugs?

Answer 1

Sodium valproate high risk
Carbamazepine & lamotrigine no risk

Question 2

What steps should be taken to minimise the risk of congenital abnormalities in epilepsy?

Answer 2

1. Folic acid 5mg from 3 months prior to conception, to end 1st trimester
2. Lowest effective dose of AED
3. Medication optimisation prior to conception

Question 3

What is the effect of pregnancy on seizures?

Answer 3

2/3 no seizure deterioration
More likely if seizures in the year prior to conception

Question 4

How should antenatal care be managed for women with epilepsy?

Answer 4

1. Designated epilepsy care team
2. Urgent epilepsy specialist review if unexpected pregnancy
3. Invite to UK Epilepsy & Pregnancy Register

Question 5

What monitoring for AED levels is recommended in pregnancy?

Answer 5

No routine monitoring

Question 6

What risk factors for seizures should be monitored for in pregnancy?

Answer 6

1. Sleep deprivation
2. Stress
3. Non-adherence to AEDs
4. Seizure type & frequency

Question 7

With epilepsy in pregnancy, how should the fetus be monitored?

Answer 7

1. Normal dating & anomaly scan
2. Serial growth scans on SGA pathway
3. No routine CTGs

Question 8

What is the role of vitamin K with epilepsy in pregnancy?

Answer 8

1. 1mg IM vit K offered to all
2. Insufficient evidence for maternal vit K to prevent HDN or PPH

Question 9

How should seizures be prevented in labour in women with epilepsy?

Answer 9

1. Good care to reduce risk factors
2. Consider long-acting benzos such as clobazam if high risk for seizures
3. Continue AEDs during labour

Question 10

What are the recommendations for analgesia in labour for women with epilepsy?

Answer 10

1. Prioritise pain relief
2. TENS, Entonox, regional anaesthetic OK
3. Diamorphine instead of pethidine

Question 11

When should the AED dose be modified postpartum?

Answer 11

Within 10 days if it was increased in pregnancy

Question 12

What should be the neonatal management following epilepsy in pregnancy?

Answer 12

1. Monitor for adverse effects of AEDs
2. Encourage breastfeeding
3. Advise no impact of BF on cognitive outcomes

Question 13

What contraception can be safely offered with all AEDs?

Answer 13

1. Copper coil
2. Mirena
3. Medroxyprogesterone injection

Question 14

Which AED has levels lowered by combined contraception?

Answer 14

Lamotrigine

Question 15

Which AEDs are enzyme-inducing?

Answer 15

1. Phenytoin
2. Carbamazepine
3. Phenobarbital
4. Primidone
5. Oxcarbazepine
6. Eslicarbazepine

Question 16

Which AEDs are not enzyme-inducing?

Answer 16

1. Sodium valproate
2. Levetiracetam
3. Gabapentin
4. Pregabalin
5. Vigabatrin
6. Tiagabine

Question 17

Which emergency contraception should be offered with enzyme-inducing AEDs?

Answer 17

Copper coil

Question 18

What is the prevalence of epilepsy?

Answer 18

0.5-1%

Question 19

How does pregnancy impact on the risk of death from epilepsy?

Answer 19

10x
Majority SUDEP following poorly controlled seizures

Question 20

What are the 4 most common types of epileptic seizures?

Answer 20

1. Tonic-clonic
2. Absence
3. Juvenile myoclonic
4. Focal

Question 21

Which type of seizure are most associated with fetal hypoxia & SUDEP?

Answer 21

Tonic-clonic

Question 22

What are the differentials for seizures in pregnancy?

Answer 22

1. Epilepsy
2. Cerebral venous sinus thrombosis
3. Posterior reversible leucoencephalopathy syndrome
4. Space-occupying lesions
5. Reversible cerebral vasoconstriction syndrome
6. Syncope
7. Metabolic: hypoglycaemia, hyponatraemia, Addisonian crisis

Question 23

What are the most common major congenital malformations associated with AEDs?

Answer 23

1. Neural tube defects
2. Congenital heart disorders
3. Urinary tract abnormalities
4. Skeletal abnormalities
5. Cleft palate

Question 24

What congenital abnormalities does sodium valproate most commonly cause?

Answer 24

Neural tube defects
Facial cleft
Hypospadias

Question 25

Which AEDs are most commonly associated with fetal cardiac malformations?

Answer 25

Phenobarbital Phenytoin

Question 26

Which AEDs & at what doses are considered safe in pregnancy?

Answer 26

Lamotrigine 300mg Carbamazepine 400mg

Question 27

Which obstetric complications are more common in epilepsy?

Answer 27

1. Spontaneous miscarriage 2. APH 3. Hypertensive disorders 4. Induction of labour 5. Caesarean section 6. Any preterm delivery 7. Fetal growth restriction 8. PPH

Question 28

Which obstetric complications are higher in women on AEDs than women with unmedicated epilepsy?

Answer 28

1. Induction of labour 2. FGR 3. PPH 4. NICU admission

Question 29

How much higher are the odds of SGA with AEDs compared to women with unmedicated epilepsy?

Answer 29

3.5x

Question 30

How do enzyme-inducing drugs increase the risk of haemorrhagic disease of the newborn?

Answer 30

Competitively inhibit the precursors of clotting factors & affect fetal microsomal enzymes that degrade vitamin K

Question 31

What proportion of women with epilepsy have tonic-clonic seizures a) in labour, b) within 24 hours of birth

Answer 31

a) 1-2% b) 1-2%

Question 32

How is a seizure lasting more than 5 minutes managed?

Answer 32

1. Maintenance of airway & oxygenation 2. Left lateral tilt 3. IV lorazepam 4mg bolus, further dose after 10-20 mins Or PR diazepam 10-20mg, rpt 15 mins Or buccal midazolam 10mg 4. IV phenytoin 10-15mg/kg (1g) 5. Tocolytics if hypertonus 6. CS if vaginal birth not imminent

Question 33

What side effects of AEDs can be seen in neonates?

Answer 33

1. Lethargy 2. Difficulty feeding 3. Excessive sedation 4. Withdrawal symptoms 5. Inconsolable crying

Question 34

Which AEDs transfer most readily into breast milk?

Answer 34

Lamotrigine Levetiracetam Topiramate