Epilepsy 2: Pregnancy and breast-feeding

Question 1

There is an increased risk of teratogenicity associated with the use of antiepileptic drugs in which stage of pregnancy?

Answer 1

First trimester and particularly if the patient takes two or more antiepileptic drugs

Question 2

which drug is associated with the highest risk of serious developmental disorders and congenital malformations in pregnancy?

Answer 2

valporate

1) Developmental disorders: 30–40% risk
2) Congenital malformations: 10% risk

Question 3

Valproate must not be used in females of childbearing potential unless what criteria is met?

Answer 3

1) Conditions of the Pregnancy Prevention Programme are met and alternative treatments are not suitable
2) During pregnancy, it must not be used for epilepsy, unless it is the only possible treatment.

Question 4

Apart from valporate, there is also an increased risk of teratogenicity associated with which other drugs?

Answer 4

1) Phenytoin, primidone, phenobarbital,

2) lamotrigine, carbamazepine

Question 5

Topiramate carries an increased risk of congenital malformations if taken in which trimester of pregnancy?

Answer 5

First trimester

Question 6

Women of child-bearing potential who take antiepileptic drugs should be given what advice about the need for an effective contraception. Why should special care be taken with hormonal contraceptives?

Answer 6

Some antiepileptic drugs can reduce the efficacy of hormonal contraceptives, and the efficacy of some antiepileptics may be affected by hormonal contraceptives

Question 7

How should women who want to become pregnant whilst on antiepileptic drugs be managed and what changes might occur with regards to their medication?

Answer 7

1) Referred to a specialist for advice before conception
2) Drug withdrawal may be considered; usually resumed after the first trimester
3) If therapy must continue monotherapy is preferable at the lowest effective dose

Question 8

Once an unplanned pregnancy is discovered it is usually too late for changes to be made to medication. what is the likelihood of a woman having a baby with no malformations?

Answer 8

at least 90%- so it is important that women do not stop taking essential treatment

Question 9

To reduce the risk of neural tube defects what supplementation can be given during pregnancy?

Answer 9

Folate supplementation is advised before conception and throughout the first trimester

Question 10

Explain the management of an unplanned pregnancy in patients taking sodium valporate or valporic acid

Answer 10

urgent consultation is required to reconsider the benefits and risks of valproate therapy

Question 11

The concentration of antiepileptic drugs in the plasma can change during pregnancy. the doses of which drugs should be adjusted based on plasma-drug concentration?

Answer 11

Phenytoin, carbamazepine, and lamotrigine

Question 12

In patients taking topiramate or levetiracetam what should be monitored during pregnancy?

Answer 12

recommended that fetal growth should be monitored.

Question 13

Women who have seizures in the second half of pregnancy should be assessed for what before changes are made to their treatment?

Answer 13

Eclampsia

Question 14

The risk of neonatal haemorrhage associated with antiepileptics can be reduced by administering what at birth?

Answer 14

Routine injection of vitamin K

Question 15

Withdrawal effects in the newborn may occur with some antiepileptic drugs. which two drugs are most likely to cause this?

Answer 15

benzodiazepines and phenobarbital

Question 16

All pregnant women with epilepsy, whether taking medication or not should be advised to notify which register?

Answer 16

UK Epilepsy and Pregnancy Register

Question 17

Should women taking antiepileptic therapy be advised to breast feed?

Answer 17

1) Encouraged to breast-feed if taking monotherapy
2) If a woman is on combination therapy or if there are other risk factors, such as premature birth, specialist advice should be sought

Question 18

What should be monitored in breast-feed infants

Answer 18

1) Sedation
2) Feeding difficulties
3) Adequate weight gain
4) Developmental milestones

Question 19

what should be undertaken in infants if suspected adverse reactions develop and how should this be managed?

Answer 19

1) Serum-drug concentration monitoring
2) if toxicity develops it may be necessary to introduce formula feeds to limit the infant’s drug exposure, or to wean the infant off breast-milk altogether

Question 20

Withdrawal effects may occur in infants if a mother suddenly stops breast-feeding, particularly if she is taking which drugs? (3)

Answer 20

1) Phenobarbital
2) Primidone
3) Lamotrigine

Question 21

Which three drugs require caution, as they are associated with an established risk of drowsiness in breast-fed babies?

Answer 21

Primidone, phenobarbital and benzodiazepines