Seizures in Pregnancy

Question 1

What are the appropriate investigations for seizures in pregnancy?

Answer 1

• Full neuro assessment
• Assess possible causes of seizures in pregnancy

Question 2

What are the causes of seizures in pregnancy?

Answer 2

• Epilepsy
• Eclampsia
• Encephalitis or meningitis
• SOL
• CVA
• Cerebral malaria or toxoplasmosis
• TTP
• Drug/alcohol withdrawal
• Toxic overdose
• Metabolic abnormalities (e.g. hypoglycaemia)

Question 3

What are the signs and symptoms of epilepsy in pregnancy?

Answer 3

• Seizures (1^st presentation) in the 2^nd half of pregnancy which can’t be attributed to epilepsy

Question 4

What is the management of epilepsy/seizures in pregnancy?

Answer 4

• Minimum possible dose of the optimal anticonvulsant
  
  • Lamotrigine - lowest rate of congenital malformations
  • Carbamazepine - least teratogenic of the old antiepileptics
  • No to Sodium valproate (neural tube defects) and Phenytoin (cleft palate)
  • Encourage breastfeeding (this is safe)

Question 5

What pre-pregnancy counselling should be given to epileptic patients prior to pregnancy?

Answer 5

• Alter medication according to seizure frequency and reduce to monotherapy where possible
  
  • Stress importance of compliance with medication
• Pre-conceptional folic acid 5mg
  
  • Especially if on antiepileptics
• Explain risk of congenital malformation
• Explain risk from recurrent seizures

Question 6

What are the complications of epilepsy in pregnancy?

Answer 6

• Epilepsy → increased risk of congenital abnormality caused by anticonvulsant medication (2-3x increase)
  
  • Neural tube defects
  • Facial clefts
  • Cardiac defects
  • Others: developmental delay, nail hypoplasia, IUGR and midface abnormalities
• Need to balance risk of AEDs with the effect of seizures → foetal and maternal hypoxia

Question 7

What counselling should be given to patients with epilepsy in pregnancy?

Answer 7

• Aim for monotherapy
• Risks of congenital abnormality - NTD, facial, cardiac
• Stress that despite these risks, the risks of frequent epileptic seizures are worse
• Take 5mg folic acid (until at least end of 1^st trimester) and vitamin K in last month of pregnancy
• Measures taken at delivery to avoid stress - e.g. epidural
• Invite to register to the UK Epilepsy and Pregnancy Register