Seizures Flashcards
Creasy, EB MFM
Brand name: Phenytoin
Dilantin
Brand name: Carbamazepine
Tegretol
Brand name: Valproic acid
Depakote
Brand name: Levetiracetam
Keppra
General therapeutic recommendations for treatment of epilepsy in pregnancy
Smallest effective dose, monotherapy preferable
Folate supplementation of 4 mg daily
History to document in the epileptic patient
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
Fetal complications of epilepsy
Fetal loss
Perinatal death
Congenital malformations (4-8%, or twice baseline risk)
Low birth weight
Prematurity
Developmental delay
Childhood epilepsy
Preconception counseling of the epileptic patient
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.
Preconception counseling: when can an anticonvulsant be stopped, and when should the patient attempt conception
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.
Seizure freedom for at least __ months before pregnancy is associated with a high likelihood of remaining seizure-free during pregnancy
9 months
Risk of epilepsy in offspring
2-3%
Prenatal care of the epileptic patient
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
Which anticonvulsants should have levels monitored during pregnancy?
Lamotrigine
Carbamazapine
Phenytoin
Levetiracetam
Oxcarbazepine
Anticonvulsants that interfere with oral contraceptives
Enzyme-inducing AEDS:
Phenytoin
Phenobarbital
Carbemazepine
Topiramate (>200 mg/day)
Primidone
Drugs that may interfere with absorption of anticonvulsants
Folic acid may lower plasma phenytoin level
Antacids
Antihistamines
Anticonvulsants that should be avoided in pregnancy, at least in first trimester
Valproic acid
Phenytoin
Carbamazepine
Phenobarbital
Topiramate
Primidone
Trimethadione
Overall rate of major fetal malformations with phenobarbital
6%
Overall rate of major fetal malformations with lamotrigine
3%
Overall rate of major fetal malformations with carbamazepine
3%
Fetal malformations associated with carbamazepine
Craniofacial
Fingernail hypoplasia
Developmental delay
Neural tube defects
Overall rate of major fetal malformations with valproic acid
10%
Fetal malformations associated with valproic acid
Neural tube defects (1-2%)
Cleft lip/palate
Developmental delay
Hypospadias
Cardiac malformations
Endocrine disorders
Fetal malformations associated with phenytoin
Fetal hydantoin syndrome:
Prenatal & postnatal growth deficiency
Microcephaly
Dysmorphic facies
Mental deficiency
Cleft lip/palate
How common is fetal hydantoin syndrome
May be seen in 11% of infants exposed to phenytoin in utero, but 30% may have lesser degrees of impairment
Fetal malformations associated with topiramate
Oral clefts
Increased risk of low birth weight
Fetal malformations associated with lamotrigine
Facial clefts
Which is more teratogenic: valproic acid or carbamazepine?
Valproic acid
Valproic acid + ___ is particularly teratogenic.
Lamotrigine
Does prenatal vitamin K in women with epilepsy reduce the risk of newborn hemorrhagic complications?
Evidence is inadequate to determine
Postpartum considerations for mothers with epilepsy
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
Is breastfeeding contraindicated in women taking anticonvulsants?
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.
Treatment of status epilepticus
IV diazepam (10-30 mg)
IV lorazepam (4-8 mg)
