Epilepsy in Pregnancy Flashcards
What aspects of diagnosis are specific to pregnancy and the puerperium, including the definition of
seizures for the obstetrician?
The diagnosis of epilepsy and epileptiform seizures should be made by a medical practitioner with
expertise in epilepsy, usually a neurologist.
Women with a history of epilepsy who are not considered to have a high risk of unprovoked seizures
can be managed as low-risk women in pregnancy
What is the importance of classifying seizure type and epilepsy syndrome?
Women with epilepsy (WWE), their families and healthcare professionals should be aware of the
different types of epilepsy and their presentation to assess the specific risks to the mother and baby
What other conditions in pregnancy should be considered in the differential diagnosis of epileptic seizures?
In pregnant women presenting with seizures in the second half of pregnancy which cannot be clearly
attributed to epilepsy, immediate treatment should follow existing protocols for eclampsia
management until a definitive diagnosis is made by a full neurological assessment.
Other cardiac, metabolic and intracranial conditions should be considered in the differential diagnosis.
Neuropsychiatric conditions including non-epileptic attack disorder should also be considered.
What are the risks of congenital malformations in the fetus of pregnant women with epilepsy (WWE)
exposed and not exposed to antiepileptic drugs (AEDs)?
WWE who are planning their pregnancy should have a clinician competent in the management of
epilepsy take responsibility for sharing decisions around choice and dose of AEDs, based on the risk
to the fetus and control of seizures.
WWE should be reassured that most mothers have normal healthy babies and the risk of congenital
malformations is low if they are not exposed to AEDs in the periconception period.
Women should be informed that the risk of congenital abnormalities in the fetus is dependent on the
type, number and dose of AEDs.
What are the long-term neurodevelopmental outcomes of exposure toAEDs and maternal seizure in infants
born to WWE?
WWE and their partners need to be informed about the possible adverse impact on long-term
neurodevelopment of the newborn following in utero exposure to sodium valproate.
Based on limited evidence, in utero exposure to carbamazepine and lamotrigine does not appear to
adversely affect neurodevelopment of the offspring. There is very little evidence forlevetiracetam and
phenytoin. Parents should be informed that evidence on long-term outcomes is based on small
numbers of children.
To what extent can congenital abnormalities be minimised in WWE?
AllWWE should be advised to take 5 mg/day of folic acid priorto conception and to continue the intake
until at least the end of the first trimester to reduce the incidence of major congenital malformation.
Prepregnancy folic acid 5 mg/day may be helpful in reducing the risk of AED-related cognitive deficits.
The lowest effective dose of the most appropriate AED should be used.
Exposure to sodium valproate and other AED polytherapy should be minimised by changing the
medication priorto conception, as recommended by an epilepsy specialist after a careful evaluation of
the potential risks and benefits.
What is the effect of pregnancy on seizures in WWE?
WWE should be informed that two-thirds will not have seizure deterioration in pregnancy.
Pregnant women who have experienced seizures in the year prior to conception require close
monitoring for their epilepsy
How should risks be communicated to WWE?
verbal and written information on
1- prenatal screening and its implications,
2- risks of self-discontinuation of AEDs and
3- effects of seizures and AEDs on fetus & pregnancy, breastfeeding and contraception.
- introduction of few safety precautions may significantly reduce risk of accidents and minimise anxiety.
- HCP acknowledge concerns of WWE and be aware of effect of such concerns on adherence to AEDs.
What are the recommended models for antenatal care of WWE and what are the benefits of joint obstetrics and neurology clinics?
- access to regular planned antenatal care with designated epilepsy care team.
- WWE taking AEDs unexpectedly pregnant able to discuss therapy with epilepsy specialist on an urgent basis. It is never recommended to stop or change AEDs abruptly without an informed discussion.
- All pregnant WWE provided with information about UK Epilepsy and Pregnancy Register and invited to register.
What is the optimum method and timing of screening for detection of fetal abnormalities?
- Early pregnancy can be an opportunity to screen for structural abnormalities.
- fetal anomaly scan at 18+0–20+6 wks can identify major cardiac defects in addition to neural tube defects.
- All WWE offer detailed ultrasound in line with National Health Service Fetal Anomaly Screening Programme standards.
How should women taking AEDs be monitored to avoid worsening of seizures?
- WWE taking AEDs, dose escalation better than expectant management?
- Based on current evidence, routine monitoring of serum AED levels in pregnancy is not recommended
- although individual circumstances may be taken into account.
What are the adverse effects of AEDs in pregnancy on the mother and how can they be minimised?
HCP alert to signs of depression, anxiety and any neuropsychiatric symptoms in mothers exposed to AEDs.
What are the risks of obstetric complications in pregnant WWE, including those taking AEDs?
- small but significant increase in obstetric risks to WWE and exposed to AEDs, and to incorporate this in counselling of women and planning of management.
How should WWE be monitored in pregnancy?
- antenatal period, WWE should be regularly assessed for following:
1- risk factors for seizures, as sleep deprivation & stress;
2- adherence to AEDs; and
3- seizure type and frequency.
-If admission required antenatally, WWE at reasonable risk of seizures in environment continuous observation by a carer, partner or nursing staff.
How should the fetus be monitored in pregnancy? What are the effects of AEDs on cardiotocography?
- Serial growth scans to detect SGA and to plan further
MX in WWE exposed to AEDs. - no role for routine antepartum fetal surveillance with CTG in WWE taking AEDs.
What is the role of vitamin K in preventing haemorrhagic disease of the newborn and maternal haemorrhage in WWE taking AEDs?
All babies born to WWE taking enzyme-inducing AEDs offer 1 mg of IM vitamin K to prevent haemorrhagic d/s of newborn.
- insufficient evidence to recommend routine maternal use of oral vitamin K to prevent haemorrhagic disease of newborn in WWE taking enzyme-inducing AEDs.
- insufficient evidence to recommend giving vitamin K to WWE to prevent postpartum haemorrhage.
What is the optimal timing and mode of delivery for WWE based on seizure control?
- most have uncomplicated labour and delivery.
- diagnosis of epilepsy per se is not indication for planned CS or iIOL.
How should women with non-epileptic attack disorder be counselled in pregnancy and how should their
non-epileptic seizures be managed?
- Inappropriate medical intervention, including AED administration & iatrogenic early delivery, should be avoided when firm diagnosis of non-epileptic attack disorder.
Where required, what dose of antenatal corticosteroids should be given to WWE on enzyme-inducing
AEDs?
- WWE taking enzyme-inducing AEDs, at risk of preterm delivery, doubling of antenatal corticosteroid dose for prophylaxis against RDS in newborn not recommended.
What are the risks and risk factors for seizures in labour in WWE and how can they be minimised?
- risk of seizures in labour is low.
- Adequate analgesia and appropriate care in labour provided to minimise risk factors for seizures such as insomnia, stress and dehydration.
- Long-acting benzodiazepines such as clobazam can be considered if very high risk of seizures in peripartum.
- AED intake continued during labour. If not tolerated orally, parenteral alternative should be administered
What is optimum management of epileptic seizures in labour?
- Every obstetric unit: written guidelines on MX of seizures in labour.
- Seizures in labour terminated ASAP to avoid maternal and fetal hypoxia and fetal acidosis. Benzodiazepines drugs of choice.
- Continuous fetal monitoring recommended in high risk of seizure in labour, and following intrapartum seizure.
What are the recommended methods of analgesia in labour for WWE?
- Pain relief in labourprioritised in WWE, with options including TENS, Entonox, and regional analgesia.
- Pethidine used with caution in WWE for analgesia in labour.
- Diamorphine used in preference to pethidine.
What are the effects of induction of labour on WWE and do AEDs affect induction agents?
- no known contraindications to use of any induction agents in WWE taking AEDs.
What is the most suitable place of delivery for WWE?
- WWE at risk of peripartum seizures delivery in consultant-led unit with facilities for one-to-one midwifery care and maternal and neonatal resuscitation.
- decision to use water for analgesia and birth made on individual basis.
WWE not taking AEDs and been seizure free for significant period may be offered a water birth after discussion with their epilepsy specialist.
