Epilepsy in pregnancy GTG Flashcards
Prevalence of epilepsy?
0.6-1%
What proportion of women with epilepsy have good pregnancy outcome
96%
How much is the risk of death in pregnancy of a woman with epilepsy vs those who do not?
10 fold
Which women with epilepsy can be considered low risk?
Women who have been seizure free for 10 years (5 years off AEDs) and those with a childhood epilepsy syndrome who have reached adulthood.
Who with which type of seizures are most likely to suffer sudden unexpected death in epilpsy?
Uncontrolled tonic clonic seizures
Associated with variable period of fetal hypoxia
In juvenile myoclonic epilpsy when are the Myoclonic jerks most often to happen?
What are some risk associated with this?
Sudden, unpredictable but occurs more frequently when sleep deprivation.
Sudden jerks can lead to falls, dropping objects or baby.
Can develop into tonic-clonic.
An aura is typical of which type of epilepsy?
Focal seizure - primary focal seizure then can undergo secondary generalisation.
If 1st seizure in 2nd/3rd trimester, what is the main DD and how should be managed?
Eclampsia
MgSu
Are MRI head/CT head safe in pregnancy?
Yes - minimal exposure to fetus
What is the background risk of congenital malformations? (No AED)
2.8/100
What is the risk of congenital malformation with lamotrigene?
2/100
What is the risk of congenital malformation with carbamazepine?
3.4/100
What is the risk of congenital malformation with sodium valproate?
10/100
What is the risk of congenital malformation with poly therapy?
16/100
What is the risk of congenital malformation with previous congenital malformation?
16.8/100
Sodium valproate is associated with which congenital malformations?
spina bida/neural tube defects
Facial cleft
Hypospadias
Neurodevelopment - lower IQ, risk autism
What % of women taking sodium valproate will neurodevelopment disorders?
30-40%
Phenobarbital and phenytoin are associated with which congenital malformations?
cardiac malformations
Phenytoin and carbamazepine are associated with which congenital malformations?
cleft palate
Which medication should be offered to women with epilepsy in pre-conception period?
5mg folic acid until end of 1st trimester
How to optimise AED pre-conceptionall
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
When to advise to avoid pregnancy
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
What Qs to ask at 1st ANC with a women with epilepsy>
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?
What proportion of women experience seizure deterioration in pregnancy?
1/3
Main aspects of ANC for women with epilepsy
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
Women with epilepsy taking AED, risk of SGA?
3.5 x greater risk
What is the risk of seizure in labour?
Overall 3.5%
1-2 % in labour
1-2% in 24 hours after labour
How to prevent seizure in labour
Adequate analgesia
1 to 1 care
Good hydration
Continue AED in labour, consider IV if not tolerating PO
If high risk of seizure in labour can consider which medication
Clobazam
How to manage seizure in labour?
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
What analgesia should not be given to women with epilepsy?
Pethadine
If AED increased in pregnancy, when should this be review post partum?
Within 10 days
Can women taking AED breastfeed?
Yes, is present in breast milk but not known to be harmful. Caution if preterm
Any AED that says avoid in breast feeding?
Phenobarbital - causes drowsiness
What post partum safety advise should be given?
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
What is the risk of depressive disorders?
29% vs 11%
Enzyme inducing AEDs have what impact on which contractraception?
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.
Which methods of contraception can be used with enzyme inducing AED
Cu, hormonal coil, Depot medroxyprogesterone
Which AEDs dose if lowered with oestrogen based contraceptives/
Lamotrigene
Which is the preferred form of emergency contraception in women taking AED
Cu IUD
Which AEDs are enzyme inducing?
Phenobarbital
Phenytoin
Carbamazipine
Topirmate
Oxcarbazepine
What number of women have no seizures during pregnancy?
64%
What proportion of women with epilepsy have increased/decresed seizure acvitivty?
16% for both
Risk status epileptics in pregnancy
<2%
Factors contributing to deterioration of epilepsy during pregnancy
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)
