Epilepsy in Pregnancy - GT68

Question 1

What is the prevalence of epilepsy in pregnancy?

Answer 1

0.5-1%

Question 2

How many infant are born to women with epilepsy every year in the UK?

Answer 2

2500

Question 3

How many deaths in 2009-2012 were attributable to epilepsy in MBBRACE 2014?

Answer 3

14

12 were SUDEP - poorly controlled seizures contributing factor (tonic clonic highest risk)

Question 4

When are women no longer considered to have epilepsy?

Answer 4

• Seizure free last 10 years (5 years off AEDs)

- Childhood epilepsy syndrome that reached adulthood seizure- and treatment-free

Question 5

Which type of epilepsy occurs more frequently after sleep deprivation?

Answer 5

Juvenile myoclonic epilepsy - sudden jerks may cause falls/dropping objects including baby

Question 6

What are the differential diagnoses for first seizures in pregnancy?

Answer 6

• Eclampsia
• Cerebral venous sinus thrombosis
• Posterior reversible leucoencephalopathy syndrome
• Space occupying lesions
• Reversible cerebral vasoconstriction syndrome
• Cardiac - Syncope 2dry to arrhythmia, aortic stenosis,
  carotid sinus sensitivity etc
• Metabolic - hypoglycaemia, hyponatremia, Addisonian
  crisis
• Non epileptic attack disorder

Question 7

Which AEDs have the lowest risk of congenital anomalies in the fetus?

Answer 7

Lamotrigine
Carbemazepine
monotherapy

Question 8

What are the associated congenital anomalies with sodium valproate?

Answer 8

Neural tube defects
Facial cleft
Hypospadias
Lower IQ
Increased rates of childhood autism

Question 9

What are the associated congenital anomalies with phenobarbital and phenytoin?

Answer 9

Cardiac malformations

Question 10

What are the associated congenital anomalies with phenytoin and carbemazepine?

Answer 10

Cleft palate

Question 11

What are the generalised congenital anomalies associated with AEDs?

Answer 11

Congenital heart disorders
Neural tube defects
Urinary tract abnormalities
Skeletal abnormalities

Question 12

What is the incidence of congenital malformations in women taking a) valproate and b) on polytherapy?

Answer 12

a) 10.7/100
b) 16.8/100

(Background 2.3%)

Question 13

What is the risk of recurrence for women with epilepsy with a previous child with a major congenital malformation?

Answer 13

16.8/100

Question 14

What % of women with epilepsy do not experience a seizure in pregnancy?

Answer 14

67%

Question 15

How many women with epilepsy are estimated to discontinue AEDs when pregnant?

Answer 15

15% (may be higher with valproate)

Question 16

By how much do levels of lamotrigine fall in pregnancy?

Answer 16

70%

Routine monitoring not recommended but take individual circumstances into account

Question 17

What are the pregnancy outcomes in WWE compared to without?

Answer 17

Spontaneous miscarriage (1.54 OR)
APH (1.49)
Hypertensive disorders (1.37)
IOL (1.67)
CS (1.40)
PTD (1.16)
FGR (1.26)
PPH (1.29)

If taking AEDs further increase in: IOL, FGR, PPH, NICU admission

Question 18

How frequent are tonic-clonic seizures in labour in women with WWE?

Answer 18

1-2%
then in a further 1-2% in the first 24 hours after delivery
Can consider clobezam (long acting benzo) if very high risk of seizures

1% of pregnant women with epilepsy status epilepticus

Question 19

How should status epilepticus (>5mins) be treated in WWE?

Answer 19

Left tilt, O2

IV lorazepam - 0.1 mg/kg (usually a 4 mg bolus, with a further dose after 10−20 minutes) or diazepam IV slowly 5-10mg

If no accesss - PR 10-20mg diazepam repeated once after 15 mins or buccal midazolam 10mg

Consider IV phenytoin if not settling; tocolytics if hypertonic and expedite delivery if FH not recovered after 5 mins

Inform neonatal team

Question 20

Which intrapartum analgesic should be avoided in WWE?

Answer 20

Pethidine - metabolised to norpethidine which is epileptogenic in high doses

Question 21

Which GA agents should be avoided in WWE?

Answer 21

Pethidine, ketamine - lower seizure threshold

Sevoflurane - epileptogenic

Question 22

How should the dose of AED be modified postnatally?

Answer 22

Usually taper down gradually to prepregnancy dose over 10/7

Question 23

What is the advice re: WWE on AEDs and breastfeeding?

Answer 23

To be encouraged - risk of adverse congenital outcome not increased

Question 24

Which contraceptives are not affected by enzyme-inducing AEDs?

Answer 24

Cu IUDs
LNG-IUS
DMPA

Question 25

Which are the enzyme-inducing AEDs and which contraceptives may be rendered less effective with their use?

Answer 25

• Carbemazepine
• Phenytoin
• Phenobarbital
• Primidone
• Oxcarbazepine
• Topiramate
• Eslicarbazepine

May affect COCP, POP, Transdermal patches, vaginal ring, progesterone only implants

Question 26

Which are the non-enzyme inducing AEDs and which contraceptives can be used?

Answer 26

Valproate
Levitiracetam
Gabapentin
Vigabatrin
Tiagabine
Pregabalin

All methods OK

Question 27

Which AED levels can be affected by oestrogen-containing contraceptives and can increase the number of seizures?

Answer 27

Lamotrigine monotherapy