Epilepsy

Question 1

What is the impact of pregnancy on epilepsy

Answer 1

• in most women, pregnancy does not affect frequency of seizures
• those with poorly controlled epilepsy are more likely to deteriorate in pregnancy
• risk of seizures is highest peripartum

Question 2

What is the effect of epilepsy on pregnancy?

Answer 2

Maternal:

• SUDEP
• Injuries
• Miscarriage
• HTN
• APH and PPH
• CS

Fetal:

• IUGR
• IUD
• PTB
• Hypoxic injury

Question 3

What are the main side-effects of AEDs for the fetus?

Answer 3

• *Neural tube defects** (particularly valproate, 1-3.8%)
• *Orofacial clefts** (particularly phenobarbitone)
• *Congenital heart defects** (particularly phenytoin phenobarbitone and valproate)

Fetal AED syndrome:

• Dysmorphic features: V-shaped eyebrows, low-set ears, broad nasal bridge, irregular teeth.
• Hypertelorism
• Hypoplastic nails and distal digits.
• Mid-face hypoplasia
• Abnormal neurodevelopment (sodium valproate): lower IQ, development quotient and increased autism.

Neonatal haemorrhagic disorder secondary to enzyme-inducing AED vit K deficiency: carbamazepine, phenytoin.

Question 4

What are the features of fetal anticonvulsant syndrome

( Minor malformations associated with anticonvulsant use in pregnancy)

Answer 4

Dysmorphic features (V-shaped eyebrows, low-set ears, broad nasal bridge, irregular teeth)
Hypertelorism
Hypoplastic nails and distal digits
Hypoplasia of the midface could be a marker for cognitive dysfunction

Question 5

Outline your approach to anti-epileptic medications preconceptually:

Answer 5

• Avoid polytherapy and aim for lowest possible dose to achieve symptom control.
• If possible, change to less teratogenic AEDs: carbamazepine, lamotrigine, levetiracetam.
• If possible, stop sodium valproate and switch to another AED OR reduce dose to <=600 mg in 3-4 divided doses daily.

Question 6

Outline preconceptual counselling to epileptic woman

Answer 6

• Stabilise epilepsy before conception
• Reliable contraception
• Counsel on risks to mum and baby from epilepsy
• Modify AEDs
  
  • Counsel on risks and benefits of AEDs
• High dose folic acid 3 months
• MDT care

Question 7

Outline antepartum, intrapartum and postpartum management for an epileptic woman

Answer 7

Antepartum:

• MDT care: neurologist, MFM, obstetric physician, MW
• High dose folic acid
• Anatomy scan
• Serial growth scans in third trimester.
• Regular review: AED adherence, triggers and seizure sx.
• Monitor for psychiatric issues

Intrapartum:

• In hospital, continue AED in labour.
• Pain relief, sleep, hydration
• Avoid hyperventilation
• CEFM
• Manage seizures with benzodiazepines.

Postpartum:

• IM Vitamin K to neonate.
• Continue AED; review dose within 10 days postpartum if increased in pregnancy.
• Minimise sleep deprivation, stress and pain.
• Breastfeeding support
• Safety strategies for caring for baby.
• Monitor for psychiatric issues
• Reliable contraception: copper IUD, Mirena and depoprovera not affected by enzyme inducing AEDs.