Seizures

Question 1

Brand name: Phenytoin

Answer 1

Dilantin

Question 2

Brand name: Carbamazepine

Answer 2

Tegretol

Question 3

Brand name: Valproic acid

Answer 3

Depakote

Question 4

Brand name: Levetiracetam

Answer 4

Keppra

Question 5

General therapeutic recommendations for treatment of epilepsy in pregnancy

Answer 5

Smallest effective dose, monotherapy preferable
Folate supplementation of 4 mg daily

Question 6

History to document in the epileptic patient

Answer 6

Aura - present or absent
Seizure description by eyewitness, including duration
Postictal phase - description, duration
Exacerbating factors
Birth history, esp if seizure onset was neonatal or early childhood
History of febrile convulsions, CNS infections, or head trauma w/ LOC
Family history

Question 7

Fetal complications of epilepsy

Answer 7

Fetal loss
Perinatal death
Congenital malformations (4-8%, or twice baseline risk)
Low birth weight
Prematurity
Developmental delay
Childhood epilepsy

Question 8

Preconception counseling of the epileptic patient

Answer 8

There is a small risk of having a child with a malformation because of the sz disorder or the drugs used in its treatment. This risk is probably about double that for the nonepileptic patient (4-8%, compared with 2-3% for the general population), but there is still more than 90% chance that she will have a normal child.
Preconception folic acid (4 mg) may be considered to reduce the risk of major congenital malformations.

Question 9

Preconception counseling: when can an anticonvulsant be stopped, and when should the patient attempt conception

Answer 9

Consider neuro consultation regarding tapering off AEDs if the patient has been seizure free for > 2 years and has a nl EEG. The patient should be observed for 6-12 months off AED before attempting conception.

Question 10

Seizure freedom for at least __ months before pregnancy is associated with a high likelihood of remaining seizure-free during pregnancy

Answer 10

9 months

Question 11

Risk of epilepsy in offspring

Answer 11

2-3%

Question 12

Prenatal care of the epileptic patient

Answer 12

Folic acid 4 mg/day
Anatomic US at 11-13w to identify severe defects
AFP at 15-18w gestation for NTDs
Targeted US at 16-20w
Fetal echo at 22w
+/- growth US at 32w
Neonates should receive 1 mg IM Vit K at birth

Question 13

Which anticonvulsants should have levels monitored during pregnancy?

Answer 13

Lamotrigine
Carbamazapine
Phenytoin
Levetiracetam
Oxcarbazepine

Question 14

Anticonvulsants that interfere with oral contraceptives

Answer 14

Enzyme-inducing AEDS:
Phenytoin
Phenobarbital
Carbemazepine
Topiramate (>200 mg/day)
Primidone

Question 15

Drugs that may interfere with absorption of anticonvulsants

Answer 15

Folic acid may lower plasma phenytoin level
Antacids
Antihistamines

Question 16

Anticonvulsants that should be avoided in pregnancy, at least in first trimester

Answer 16

Valproic acid
Phenytoin
Carbamazepine
Phenobarbital
Topiramate
Primidone
Trimethadione

Question 17

Overall rate of major fetal malformations with phenobarbital

Answer 17

6%

Question 18

Overall rate of major fetal malformations with lamotrigine

Answer 18

3%

Question 19

Overall rate of major fetal malformations with carbamazepine

Answer 19

3%

Question 20

Fetal malformations associated with carbamazepine

Answer 20

Craniofacial
Fingernail hypoplasia
Developmental delay
Neural tube defects

Question 21

Overall rate of major fetal malformations with valproic acid

Answer 21

10%

Question 22

Fetal malformations associated with valproic acid

Answer 22

Neural tube defects (1-2%)
Cleft lip/palate
Developmental delay
Hypospadias
Cardiac malformations
Endocrine disorders

Question 23

Fetal malformations associated with phenytoin

Answer 23

Fetal hydantoin syndrome:
Prenatal & postnatal growth deficiency
Microcephaly
Dysmorphic facies
Mental deficiency
Cleft lip/palate

Question 24

How common is fetal hydantoin syndrome

Answer 24

May be seen in 11% of infants exposed to phenytoin in utero, but 30% may have lesser degrees of impairment

Question 25

Fetal malformations associated with topiramate

Answer 25

Oral clefts Increased risk of low birth weight

Question 26

Fetal malformations associated with lamotrigine

Answer 26

Facial clefts

Question 27

Which is more teratogenic: valproic acid or carbamazepine?

Answer 27

Valproic acid

Question 28

Valproic acid + ___ is particularly teratogenic.

Answer 28

Lamotrigine

Question 29

Does prenatal vitamin K in women with epilepsy reduce the risk of newborn hemorrhagic complications?

Answer 29

Evidence is inadequate to determine

Question 30

Postpartum considerations for mothers with epilepsy

Answer 30

Do not bathe child while home alone Avoid stair climbing while carrying the baby Portable changing bad on floor should be used Avoid using front or back carrier Women taking enzyme-inducing anticonvulsants who desire OCPs should take one w/ >50 mcg of ethinyl estradiol

Question 31

Is breastfeeding contraindicated in women taking anticonvulsants?

Answer 31

No. Monitor infants for sedation. Valproic acid, phenobarbital, phenytoin, and carbamazepine may be considered as not transferring into breast milk as much as levetiracetam, gabapentin, lamotrigine, and topiramate.

Question 32

Treatment of status epilepticus

Answer 32

IV diazepam (10-30 mg) IV lorazepam (4-8 mg)