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MRCOG Maternal Medicine > Epilepsy in pregnancy GTG > Flashcards

Epilepsy in pregnancy GTG Flashcards

1
Q

Prevalence of epilepsy?

A

0.6-1%

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2
Q

What proportion of women with epilepsy have good pregnancy outcome

A

96%

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3
Q

How much is the risk of death in pregnancy of a woman with epilepsy vs those who do not?

A

10 fold

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4
Q

Which women with epilepsy can be considered low risk?

A

Women who have been seizure free for 10 years (5 years off AEDs) and those with a childhood epilepsy syndrome who have reached adulthood.

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5
Q

Who with which type of seizures are most likely to suffer sudden unexpected death in epilpsy?

A

Uncontrolled tonic clonic seizures

Associated with variable period of fetal hypoxia

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6
Q

In juvenile myoclonic epilpsy when are the Myoclonic jerks most often to happen?

What are some risk associated with this?

A

Sudden, unpredictable but occurs more frequently when sleep deprivation.

Sudden jerks can lead to falls, dropping objects or baby.

Can develop into tonic-clonic.

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7
Q

An aura is typical of which type of epilepsy?

A

Focal seizure - primary focal seizure then can undergo secondary generalisation.

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8
Q

If 1st seizure in 2nd/3rd trimester, what is the main DD and how should be managed?

A

Eclampsia
MgSu

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9
Q

Are MRI head/CT head safe in pregnancy?

A

Yes - minimal exposure to fetus

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10
Q

What is the background risk of congenital malformations? (No AED)

A

2.8/100

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11
Q

What is the risk of congenital malformation with lamotrigene?

A

2/100

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12
Q

What is the risk of congenital malformation with carbamazepine?

A

3.4/100

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13
Q

What is the risk of congenital malformation with sodium valproate?

A

10/100

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14
Q

What is the risk of congenital malformation with poly therapy?

A

16/100

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15
Q

What is the risk of congenital malformation with previous congenital malformation?

A

16.8/100

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16
Q

Sodium valproate is associated with which congenital malformations?

A

spina bida/neural tube defects
Facial cleft
Hypospadias
Neurodevelopment - lower IQ, risk autism

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17
Q

What % of women taking sodium valproate will neurodevelopment disorders?

A

30-40%

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18
Q

Phenobarbital and phenytoin are associated with which congenital malformations?

A

cardiac malformations

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19
Q

Phenytoin and carbamazepine are associated with which congenital malformations?

A

cleft palate

20
Q

Which medication should be offered to women with epilepsy in pre-conception period?

A

5mg folic acid until end of 1st trimester

21
Q

How to optimise AED pre-conceptionall

A

Aim mono therapy with lowest effective AED dose
If SV consider weaning off to alternative AED, if SV change to moderate realise or increase daily frequency doses >800mg/day higher teratogenicity

22
Q

When to advise to avoid pregnancy

A

Uncontrolled seizures (particularly tonic clonic)

Taking high doses of AEDs
Polytherapy: multiple AEDs
Drug resistant epilepsy/uncontrolled epilepsy
Non-compliance with medication

Poor general health or other medical comorbidities

23
Q

What Qs to ask at 1st ANC with a women with epilepsy>

A

Who is the neurologist overseeing the care?

When was epilepsy diagnosed (childhood or teenage onset)?

What types of seizures are experienced? (e.g. a) focal, b) generalised, c) non-convulsive or d) unclassified)

What is the frequency of seizures?

When was the last seizure?

What AEDs are taken and at what dose?

What other features of seizures (triggers, aura, activity during seizure) occur?

Is there a history of status epilepticus or ITU admission?

24
Q

What proportion of women experience seizure deterioration in pregnancy?

A

1/3

25
Q

Main aspects of ANC for women with epilepsy

A

Regular ANC with designated epilepsy team
5mg folic acid
Fetal anomaly USS + Cardiac USS
Assess risk of seizures
Serial growth USS - if AEDS
Vit K 1 mg to baby if AED

26
Q

Women with epilepsy taking AED, risk of SGA?

A

3.5 x greater risk

27
Q

What is the risk of seizure in labour?

A

Overall 3.5%

1-2 % in labour
1-2% in 24 hours after labour

28
Q

How to prevent seizure in labour

A

Adequate analgesia
1 to 1 care
Good hydration
Continue AED in labour, consider IV if not tolerating PO

29
Q

If high risk of seizure in labour can consider which medication

A

Clobazam

30
Q

How to manage seizure in labour?

A

L lateral
IV access - lorazepam 4mg bolus every 10-20mins or diazepam 10mg PR

If not controlled consider phenytoin/fosphenytoin 10-15mg/kg IV

If hypertonic consider tocolytics

CTG after mother recovered, if FH not recovered after 5 mins of seizure, or seizure recurrent - expedite delivery

31
Q

What analgesia should not be given to women with epilepsy?

A

Pethadine

32
Q

If AED increased in pregnancy, when should this be review post partum?

A

Within 10 days

33
Q

Can women taking AED breastfeed?

A

Yes, is present in breast milk but not known to be harmful. Caution if preterm

34
Q

Any AED that says avoid in breast feeding?

A

Phenobarbital - causes drowsiness

35
Q

What post partum safety advise should be given?

A

Nurse baby on floor, shallow baths, lay baby down if aura, no bathing unaccompanied, wear ID tag, avoid triggers, family & friends know 1st aid, driving

36
Q

What is the risk of depressive disorders?

A

29% vs 11%

37
Q

Enzyme inducing AEDs have what impact on which contractraception?

A

Higher risk of failure rate (3/1000) using oral contraceptions, transdermal patch, vaginal mins, implants

If choosing oral contraception increase the oestrogen dose = 50 micrograms and 4 days interval not 7.

38
Q

Which methods of contraception can be used with enzyme inducing AED

A

Cu, hormonal coil, Depot medroxyprogesterone

39
Q

Which AEDs dose if lowered with oestrogen based contraceptives/

A

Lamotrigene

40
Q

Which is the preferred form of emergency contraception in women taking AED

A

Cu IUD

41
Q

Which AEDs are enzyme inducing?

A

Phenobarbital
Phenytoin
Carbamazipine
Topirmate
Oxcarbazepine

42
Q

What number of women have no seizures during pregnancy?

A

64%

43
Q

What proportion of women with epilepsy have increased/decresed seizure acvitivty?

A

16% for both

44
Q

Risk status epileptics in pregnancy

A

<2%

45
Q

Factors contributing to deterioration of epilepsy during pregnancy

A

oorly controlled epilepsy prior to pregnancy
Seizure frequency of >1 per month
Multiple seizure types
Drug-resistant epilepsy
High-dose polytherapy
Poor compliance with AEDs
Reduced drug concentration in pregnancy due to increased renal clearance and metabolism
Pregnancy specific triggers: nausea and vomiting (reduced AED concentration), sleep deprivation, labour (pain and hyperventilation)

MRCOG Maternal Medicine (41 decks)

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