Women and Epilepsy Flashcards
How might long term use of antiseizure medication affect bone health?
May reduce bone density and vitamin D levels, particularly is enzyme inducing and sodium valproate
Also at increased risk of:
▪️ Osteomalacia
▪️ Osteoporosis
▪️ Fractures
What risk factors place a woman at higher risk of losing bone density on ASM?
▪️ Living in the UK where vitamin D levels are already low
▪️ Women already have lower bone density than men
▪️ Bone density reduces following menopause
How can you be proactive about optimising bone health in the management of women with epilepsy?
Consider vitamin D and calcium supplements, as well as dietary and lifestyle advice
Which medications are associated with the highest risk of fractures and lower bone density?
▪️ Phenobarbital
▪️ Carbamazepine
▪️ Clonazepam
▪️ Sodium valproate
What can you conduct if someone with epilepsy is at risk of osteoporosis?
A fracture risk assessment using:
▪️ FRAX tool
▪️ QFracture tool
What is catamenial epilepsy?
The cyclic exacerbation of seizures in relation to the menstrual cycle
When are seizures most likely to occur during the menstrual cycle?
When progesterone levels drop
What are the three commonly recognised patterns of catamenial seizures?
▪️ C1 = Perimenstrual (Day -3 to +3)
▪️ C2 = Peri-ovulatory (Day 10 to 13)
▪️ C3 = Entire luteal phase in anovulatory cycles (Day 10 to 3)
What could you consider in the management of catamenial seizures?
▪️ Additional medication during at-risk periods (e.g., benzodiazepines) (BUT cannot take long-term)
▪️ Contraception (e.g., pessaries)
What should you consider when prescribing contraception to women with epilepsy?
▪️ Effect of ASM on contraceptive efficacy
▪️ Effect on contraception on ASM levels
What epilepsy medications are associated with higher contraceptive failure?
Enzyme inducing ASM
What must you consider when a woman with epilepsy stops taking contraception?
If ASM levels were reduced by the contraceptive so dose was increased, this may then become toxic on cessation of contraceptive
What factors may contribute to the slight reduction in fertility seen with epilepsy?
▪️ Associated morbidities
▪️ Social factors
▪️ ASM effects on libido or polycystic ovary syndrome
▪️ Personal choice
What is essential when a woman with epilepsy wants to have a baby preconception?
▪️ Planned pregnancy
▪️ Folic acid supplements
▪️ ASM review - may need to adjust to minimise teratogenic risk whilst keeping mother safe
What should be consider when a woman with epilepsy is pregnant?
▪️ Regular monitoring of both mother and foetus to maximise safety
▪️ Monitor ASM levels
▪️ Small risk of seizures during labour
What factors should be considered postpartum for women with epilepsy?
▪️ Depression or fear of seizure when holding or caring for baby
▪️ Sleep-deprivation worsening seizures
▪️ Breastfeeding - generally okay if not on high doses of phenobarbital (watch for drowsiness or withdrawal signs in baby)
What poor outcomes are women with epilepsy at higher risk for when pregnant?
▪️ Major malformations
▪️ Minor malformations
▪️ Lower birth weight
▪️ Developmental delay/ASD/LD
▪️ Injury or falls increasing risk of miscarriage
▪️ SUDEP
What factors may be considered when a women with epilepsy is deciding to have children?
▪️ Risk of offspring inheriting epilepsy or related condition
▪️ Risk of pregnancy complications
▪️ Risk of teratogenicity from ASM
▪️ Control of epilepsy during pregnancy (risk of seizures or status?)
▪️ Ability of mother/family to look after baby if epilepsy is uncontrolled
What is the risk of inheriting epilepsy?
▪️ Different depending on underlying condition
▪️ Generally low risk, but higher than general population
▪️ If genetic basis is know, consider incomplete penetrance and variable severity
What medications are the safest for women of childbearing age?
▪️ Lamotrigine
▪️ Levetiracetam
▪️ Oxcarbazepine
What must be considering when prescribing sodium valproate?
▪️ Women must be very careful not to fall pregnant on it
▪️ Have to sign form understanding the risks
▪️ Must be using the implant or coil contraceptive so cannot be forgotten (or had uterus removed)
What factors increase the risk of epilepsy being passed on to the child?
▪️ Greater if mother has epilepsy compared to the father
▪️ Greater if child is female
▪️ Idiopathic generalised epilepsy (compared to focal)
▪️ Onset of epilepsy before age 20
▪️ Potentially higher if both parents have epilepsy
What pregnancy complications are women with epilepsy, particularly on AEDS, at higher risk of?
▪️ Induction
▪️ Caesarean section
▪️ Post-partum haemorrhage
▪️ Infant with Apgar score lower than 7 (general health of newborn)
▪️ Severe pre-eclampsia
▪️ Bleeding early on
▪️ Offspring malformations
What teratogenic effects can AEDs have on the foetus?
▪️ Foetal loss
▪️ Intrauterine growth retardation
▪️ Congenital malformations
▪️ Impaired postnatal development
▪️ Behavioural problems
What is the relationship between sodium valproate and risk of foetus malformation?
Dose-dependent - it increased with higher doses
e.g., 6.7% of pregnancies on 400mg
54.5% on more than 2800mg
Is there a recurrence risk of congenital malformations in infants exposed to AEDs in utero?
Yes - 16.8% risk for those who’s first child had malformations compared to 9.8% for those who’s didn’t
Genetic influence?
What can you do to reduce the risk of pregnancy complications and malformations from in utero AED exposure?
▪️ Adjust or change medication, particularly in those with a history of malformation
▪️ Consider monotherapy as opposed to polytherapy
▪️ BUT careful not to compromise safety of the mother
What factors are associated with increased likelihood of seizures occurring/worsening in pregnancy?
▪️ Greater preconception seizure frequency
▪️ Changes in behaviour
▪️ Biological changes leading to increase clearance of some ASM
How does presence of seizures in the 2 years before pregnancy effect risk of seizures during pregnancy and labour?
Increases the risk
With seizures in year before = 75.2%
Without seizures in year before = 19.8%
How might seizure risk change during pregnancy in those with catamenial epilepsy?
Its appears to decrease (gets better!)
Which ASM show significant drops in levels during pregnancy and what is the risk associated with this?
▪️ Lamotrigine, oxcarbazepine, levetiracetam
▪️ Must be careful when increasing dose to compensate as may induce toxicity following birth
What happens to lamotrigine plasma levels during and after pregnancy?
▪️ Evidence it decreases during pregnancy, risking loss of seizure control
▪️ May increase rapidly following birth, risking dose-related AEs
What happens to levetiracetam plasma levels during pregnancy?
Appear to decrease, particularly in the third trimester
What happens to oxcarbazepine plasma levels during pregnancy?
Levels of the active metabolite (MHD) may decrease gradually
What is the best predictor of seizure control during pregnancy?
How well it was controlled before pregnancy
What is the second most common indirect cause of maternal death?
Neurological causes such as epilepsy and stroke
How has maternal mortality due to SUDEP changed in recent years?
Statistically significant increase
Low proportion of women whose medications are optimised before or during pregnancy - lower standard of care?
What is the government guidelines for prescribing valproate to women?
▪️ Cannot be prescribed unless there is a pregnancy prevention programme in place
▪️ Signed risk acknowledgement form at least annually
▪️ Banned for migraines and bipolar during pregnancy
▪️ Banned for epilepsy during pregnancy unless no other effective treatment
