Green top Guideline Flashcards by Siba Kherbek

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

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

2500 infants/ year in UK

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

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

MRI + CT scan

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What are the classifications of epilepsy syndrome ?

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

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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What is the strongest risk factor for SUDEP?

Uncontrolled tonic clonic seizures

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What is the differential diagnosis of epilepsy in pregnancy?

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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How are AEDs classified?

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

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What is the teratogenicity associated with AEDs?

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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Which AED has the worst teratogenic profile?

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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What are the malformations associated with phenytoin?

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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What is the safest AED in pregnancy?

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

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What is the AED that most causes NTDs?

Valproate

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What is the AED that most causes cardiac defects?

Phenobarbital + phenytoin

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What is the AED that most causes cleft lip?

Phenytoin + carbamazepine

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How is status epilepticus defined?

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

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What is the risk of diazepam when given in pregnancy?

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

Carbamazepine + lamotrigine

What is the effect of pregnancy on seizures in WWE?

📌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

How to minimize the risks of congenital abnormalities in WWE?

5mg folic acid/ day prior to conception

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

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

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

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

How should WWE be monitored in pregnancy?

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

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

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)

When to consider elective CS in WWE?

* DETERIORATION in seizures * recurrent prolonged seizures * high risk of status epilepticus

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

Same as usual Doubling the dose is not recommended

What is the risk of seizures in labour in WWE ?

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%

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

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

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

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

When to consider long acting benzodiazepine in labour in WWE?

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.

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

Phenytoin phenobarbital sodium valproate levetiracetam

What is the management of epileptic seizures in labour?

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

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

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

What are the options of analgesia in labour for WWE?

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

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

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

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

Pithidine ketamine sevoflurance

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

Immediate Postpartum

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

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

How to prevent hemorrhagic disease of the newborn in WWE ?

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

What psychiatric disorder the WWE are at increased risk for?

Depression 29% vs 11% in controls

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

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

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

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

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

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

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

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

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

All methods

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

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