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14- Epilepsy in Pregnancy > Green top Guideline > Flashcards

Green top Guideline Flashcards

1
Q

What is the prevalence of epilepsy in pregnancy? What is the major risk in pregnancy?

A

0.5 - 1 % of pregnancies
1 /3 of WWW are at reproductive age
📌 risk of death increased 10 folds compared with women without the condition

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2
Q

How many infants are born to women with epilepsy each year?

A

2500 infants/ year in UK

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3
Q

What are the conditions considered low risk in pregnancy & no longer have epilepsy?

A

1- seizure free for at least 10y ( with the last 5 y off AEDs)
2- childhood epilepsy syndrome who have reached the adulthood seizure & treatment free

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4
Q

What imaging modalities that are considered safe in pregnancy to asses a woman with seizures?

A

MRI + CT scan

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5
Q

What are the classifications of epilepsy syndrome ?

A

1- tonic clonic seizures ( grand Mal)
* associated with variable period of fetal hypoxia
🚩* associated with the higher risk of SUDES
2- absence seizures ( worsening absence seizures 👉high risk of tonic clonic seizures)
3- Juvenile myoclonic epilepsy : ( after waking/ tired) 👉dropping objects
4- focal seizures can undergo generalization 👉fetal hypoxia + SUDEP

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6
Q

What is the main cause of death in pregnant women with epilepsy?

A

SUDEP : sudden, unexpected, witnessed or unwitnessed, nontraumatic, nondrowning death with or without evidence of seizure & excluding status of epilepticus.
Postmortem examination: doesn’t reveal a toxicologic or anatomic cause of death.

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7
Q

What is the strongest risk factor for SUDEP?

A

Uncontrolled tonic clonic seizures

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8
Q

What is the differential diagnosis of epilepsy in pregnancy?

A

1- eclampsia:seizure in the 2nd half of pregnancy 👉treatment with MGSO4 then make the neurological assessment
2- cerebral venous sinus thrombosis
3- space occupying lesions
4- syncope associated with cardiac arrhythmias & aortic stenosis
5- carotid sinus sensitivity
6- vasovagal syncope
7- metabolic: hypoglycemia/ hyponatremia/ addison’s crisis
8- psychogenic non epileptic seizures: may co exist with epilepsy

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9
Q

How are AEDs classified?

A

📌Enzyme inducing AEDs : carbamazepine phenytoin phenobarbital topiramate
📌 non enzyme inducing AEDs:
Sodium valproate gabapentin
Levetiracetam lamotrigine

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10
Q

What is the teratogenicity associated with AEDs?

A

1- NTDs
2- cleft lip and palate
3- cardiac defects
4- urogenital defects
5- neonatal coagulopathy
6- skeletal abnormalities
📌the risk increased with a previous child with major congenital malformation

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11
Q

Which AED has the worst teratogenic profile?

A

VALPROATE:
1- long term neurodevelopmental delay of the newborn
2- FGR
3- NTDs , craniofacial, urogenital, limb defects
4- lower IQ in the children
5- increased rates of childhood autism

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12
Q

What are the malformations associated with phenytoin?

A

Fetal anticonvulsant syndrome:
* cleft lip & palate
* microcephaly
* cardiac abnormalities
* mental retardation
NOT ASSOCIATED WITH NTDs
[ mainly due to alterations in folate metabolism]

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13
Q

What is the safest AED in pregnancy?

A

1-Carbamazepine monotherapy
Rarely cause similar effects to phenytoin +NTDs
2- lamotrigine

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14
Q

What is the AED that most causes NTDs?

A

Valproate

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15
Q

What is the AED that most causes cardiac defects?

A

Phenobarbital + phenytoin

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16
Q

What is the AED that most causes cleft lip?

A

Phenytoin + carbamazepine

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17
Q

How is status epilepticus defined?

A

30 min of continual seizures activity or a cluster of seizures without recovery
📌 diazepam is used in the treatment

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18
Q

What is the risk of diazepam when given in pregnancy?

A

Diazepam is highly lipid soluble 👉 cross the placenta/ exerted into milk
📌 causes: neonatal benzodiazepine withdrawal syndrome ( floppy infant syndrome) when taken in the 3rd trimester

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19
Q

Which AEDs does not appear to adversely affect neurodevelopmental of the offspring?

A

Carbamazepine + lamotrigine

20
Q

What is the effect of pregnancy on seizures in WWE?

A

📌2/3 of the women will not have seizures deterioration in pregnancy
📌those who experienced seizures in the year prior to conception require close monitoring

21
Q

How to minimize the risks of congenital abnormalities in WWE?

A

5mg folic acid/ day prior to conception

22
Q

What are the adverse effects of AEDs in pregnancy on the mother & how can they be minimized?

A

1- depression 2- anxiety
3- low esteem
👉referral to mental health team if
Any concerns regarding cognitive functions ( attention + memory) in combination with mood disturbance

23
Q

What are the risks of obstetric complications in pregnant WWE, including those taking AEDs?

A

1- spontaneous miscarriage
2- antepartum haemorrhage
3- hypertensive disorders
4- induction of labour
5- CS
6- preterm delivery
7- FGR
8- postpartum hemorrhage

24
Q

How should WWE be monitored in pregnancy?

A

Regularly assessment:
1- risk factors for seizures: fasting, sleep deprivation, stress
2- adherence to AEDs
3- seizures type, frequency, auras
4- mother ‘s wellbeing
5- symptoms: dizziness, tiredness

25
Q

For WWE taking AEDs is dose escalation better than expectant management?

A

Routine monitoring of serum AEDs levels in pregnancy IS NOT RECOMMENDED but based on clinical features
📌PS: most AEDs levels are known to fall during pregnancy ( lamotrigine fall by up to 70% in pregnancy)

26
Q

When to consider elective CS in WWE?

A
  • DETERIORATION in seizures
  • recurrent prolonged seizures
  • high risk of status epilepticus
27
Q

What is the corticosteroid dosage in WWE those who are taking enzyme inducing AEDs ?

A

Same as usual
Doubling the dose is not recommended

28
Q

What is the risk of seizures in labour in WWE ?

A

The risk of seizures is low
📌Occurrence of seizures during labour: 3.5 % of WWE
Tonic clonic seizures occurrence
in labour: 1-2%
Postpartum: 1-2%

29
Q

What is the major risk of seizures during labour in WWE?

A

maternal hypoxia ( due to apnea)
Fetal hypoxia & acidosis (due to uterine hypertonus)

30
Q

What are the risk factors for seizures in labour in WWE?

A

1- insomnia
2- stress
3- dehydration
4- pain & tiredness
5- non intake of AEDs

31
Q

When to consider long acting benzodiazepine in labour in WWE?

A

Such as CLOBAZAM :
1- recent convulsive seizures
2- recent history of seizure provocation by stress or sleep deprivation
3- history of seizures in previous labour
📌 risk of use: respiratory depression in the newborn.

32
Q

What are the AEDs that may be given parenterally during labour if this cannot be tolerated orally?

A

Phenytoin phenobarbital sodium valproate levetiracetam

33
Q

What is the management of epileptic seizures in labour?

A

1- seizures in labour should be terminated as soon as possible to avoid maternal & fetal hypoxia
[ any seizure > 5min 👉 high risk of status epilepticus: life threatening]
2- left lateral tilt
3- maintain: airway + oxygenation
4- benzodiazepines : lorazepam or diazepam
5- if the seizures are not controlled 👉 phenytoin
6- continuous CTG [ if the FHR does not begin to recover after 5min 👉expedite delivery
7- consider tocolytic agents if persistent uterine hypertonus

34
Q

What are the drugs that may be used to terminate the epileptic seizure during labour?

A

Of choice: IV LORAZEPAM 0.1 mg /kg
Or DIAZEPAM 5-10 mg IV
If no IV access: diazepam 10-20mg rectally or midazolam 10 mg buccal preparation
If not controlled: phenytoin 10-15 mg / kg

35
Q

What are the options of analgesia in labour for WWE?

A

Pain relief: nitrous oxide
Regional analgesia ( epidural- spinal)
Transcutaneous electrical nerve stimulation ( TENS)

36
Q

Why is pithidine should be used with caution in WWE for analgesia?

A

Known to be epileptogenic
Diamorphine should be used in preference to pithidine

37
Q

What are the medications that should be avoided in WWE If they are undergoing general anesthesia ?

A

Pithidine ketamine sevoflurance

38
Q

What is the period that has the highest risk of seizures?

A

Immediate
Postpartum

39
Q

Is there any need to modify the dose of AEDs after delivery?

A

If the dose was increased in pregnancy it should be reviewed within 10 days of delivery to avoid postpartum toxicity

40
Q

How to prevent hemorrhagic disease of the newborn in WWE ?

A

1mg Vit k IM
In women taking enzyme inducing AEDs
📌 NO recommendations about giving the mother Vit k orally to prevent the hemorrhagic disease in the newborn

41
Q

What psychiatric disorder the WWE are at increased risk for?

A

Depression
29% vs 11% in controls

42
Q

What are the reliable methods of contraception that are not affected by enzyme inducing AEDs?

A

1- copper T
2- mirena ( LIN-IUS)
3- medroxyprogesterone acetate injections

43
Q

What contraceptions that may be affected by enzyme inducing AEDs ( risk of failure)?

A

1- oral contraceptives ( combined + POP )
2- transdermal patches
3- vaginal ring
4- progesterone only implants

44
Q

In case of a woman on enzyme inducing AEDs and chooses oral contraception , how to improve the contraceptive efficiency?

A

1- increase the estrogen component to 50 mcg( maximum 70mcg)
2- reducing the pill free period from 7 to 4 days
3- tricycleing
4- additional barrier contraception should be used

45
Q

What is the best choice for emergency contraception in WWE on enzyme inducing AEDs?

A

Copper T
📌 [ levonorgestrel + ulipristal acetate are affected by enzyme inducing AEDs]

46
Q

What are the methods of contraception may be offered to WWE on non enzyme inducing AEDs?

A

All methods

47
Q

What is the risk of offering estrogen containing pills to WWE on lamotrigine [ non enzyme inducing AEDs]?

A

Potential increase risk of seizures due to a fall in the levels of lamotrigine

14- Epilepsy in Pregnancy (1 decks)

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