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Kuang H, Li Y, Lu Y, Zhang L, Wei L, Wu Y. Reproductive and fetal outcomes in women with epilepsy: a systematic review and meta-analysis. J Matern Fetal Neonatal Med 2024; 37:2351196. [PMID: 38735863 DOI: 10.1080/14767058.2024.2351196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 04/29/2024] [Indexed: 05/14/2024]
Abstract
OBJECTIVE Although early evidence shows that epilepsy can increase the risks of adverse pregnancy, some outcomes are still debatable. We performed a systematic review and meta-analysis to explore the effects of maternal and fetal adverse outcomes in pregnant women with epilepsy. METHODS PubMed, Embase, Cochrane, and Web of Science were employed to collect studies that investigated the potential risk of obstetric complications during the antenatal, intrapartum, or postnatal period, as well as any neonatal complications. The search was conducted from inception to November 16, 2022. The Newcastle-Ottawa Scale (NOS) was used to assess the quality of the included original studies. The odds ratio (OR) values were extracted after adjusting for confounders to measure the relationship between pregnant women with epilepsy and adverse maternal or fetal outcomes. The protocol for this systematic review is registered with PROSPERO ID CRD42023391539. RESULTS Of 35 articles identified, there were 142,577 mothers with epilepsy and 34,381,373 mothers without epilepsy. Our study revealed a significant association between pregnant women with epilepsy (PWWE) and the incidence of cesarean section, preeclampsia/eclampsia, gestational hypertension, induction of labor, gestational diabetes and postpartum hemorrhage compared with those without epilepsy. Regarding newborns outcomes, PWWE versus those without epilepsy had increased odds of preterm birth, small for gestational age, low birth weight (<2500 g), and congenital malformations, fetal distress. The odds of operative vaginal delivery, newborn mortality, and Apgar (≤ 7) were similar between PWWE and healthy women. CONCLUSION Pregnant women affected by epilepsy encounter a higher risk of adverse obstetric outcomes and fetal complications. Therefore, it is crucial to develop appropriate prevention and intervention strategies prior to or during pregnancy to minimize the negative impacts of epilepsy on maternal and fetal health.
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Affiliation(s)
- Huimin Kuang
- Department of Neurology, First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yixun Li
- Department of Radiology, Guangxi International Zhuang Medical Hospital, Nanning, China
| | - Yuling Lu
- Department of Neurology, First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Lin Zhang
- Department of Neurology, First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Lei Wei
- Department of Neurology, First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yuan Wu
- Department of Neurology, First Affiliated Hospital of Guangxi Medical University, Nanning, China
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Pegg EJ, Bromley R, Mirza F, Campbell E. Preconception counselling in women with epilepsy. Pract Neurol 2024:pn-2023-003902. [PMID: 38937091 DOI: 10.1136/pn-2023-003902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2024] [Indexed: 06/29/2024]
Abstract
Pregnancy and the postpartum period are potentially high-risk periods for women with epilepsy and their babies. All women with epilepsy should have the opportunity for preconception counselling with the aim of reducing risk, optimising outcomes for the potentially developing fetus and enabling informed decision-making. This article provides an evidence-based framework for preconception counselling discussion, including the review of diagnosis and of current antiseizure medication, the risk to the fetus in relation to antiseizure medication and maternal seizures, maternal morbidity, SUDEP risk, folic acid supplements, contraception, breastfeeding and safety advice.
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Affiliation(s)
- Emily J Pegg
- Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Salford, UK
- Division of Neuroscience, University of Manchester, Manchester, UK
| | - Rebecca Bromley
- Division of Neuroscience, University of Manchester, Manchester, UK
| | - Farhat Mirza
- Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Salford, UK
| | - Ellen Campbell
- Department of Neurology, Belfast Health and Social Care Trust, Belfast, UK
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3
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Razaz N, Igland J, Bjørk MH, Joseph KS, Dreier JW, Gilhus NE, Gissler M, Leinonen MK, Zoega H, Alvestad S, Christensen J, Tomson T. Risk of Perinatal and Maternal Morbidity and Mortality Among Pregnant Women With Epilepsy. JAMA Neurol 2024; 81:985-995. [PMID: 39102246 PMCID: PMC11385047 DOI: 10.1001/jamaneurol.2024.2375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/06/2024]
Abstract
Importance Maternal epilepsy is associated with adverse pregnancy and neonatal outcomes. A better understanding of this condition and the associated risk of mortality and morbidity at the time of delivery could help reduce adverse outcomes. Objective To determine the risk of severe maternal and perinatal morbidity and mortality among women with epilepsy. Design, Setting, Participants This prospective population-based register study in Denmark, Finland, Iceland, Norway, and Sweden took place between January 1, 1996, and December 31, 2017. Data analysis was performed from August 2022 to November 2023. Participants included all singleton births at 22 weeks' gestation or longer. Births with missing or invalid information on birth weight or gestational length were excluded. The study team identified 4 511 267 deliveries, of which 4 475 984 were to women without epilepsy and 35 283 to mothers with epilepsy. Exposure Maternal epilepsy diagnosis recorded before childbirth. Prenatal exposure to antiseizure medication (ASM), defined as any maternal prescription fills from conception to childbirth, was also examined. Main outcomes and measures Composite severe maternal morbidity and mortality occurring in pregnancy or within 42 days postpartum and composite severe neonatal morbidity (eg, neonatal convulsions) and perinatal mortality (ie, stillbirths and deaths) during the first 28 days of life. Multivariable generalized estimating equations with logit-link were used to obtain adjusted odds ratios (aORs) and 95% CIs. Results The mean (SD) age at delivery for women in the epilepsy cohort was 29.9 (5.3) years. The rate of composite severe maternal morbidity and mortality was also higher in women with epilepsy compared with those without epilepsy (36.9 vs 25.4 per 1000 deliveries). Women with epilepsy also had a significantly higher risk of death (0.23 deaths per 1000 deliveries) compared with women without epilepsy (0.05 deaths per 1000 deliveries) with an aOR of 3.86 (95% CI, 1.48-8.10). In particular, maternal epilepsy was associated with increased odds of severe preeclampsia, embolism, disseminated intravascular coagulation or shock, cerebrovascular events, and severe mental health conditions. Fetuses and infants of women with epilepsy were at elevated odds of mortality (aOR, 1.20; 95% CI, 1.05-1.38) and severe neonatal morbidity (aOR, 1.48; 95% CI, 1.40-1.56). In analyses restricted to women with epilepsy, women exposed to ASM compared with those unexposed had higher odds of severe maternal morbidity (aOR ,1.24; 95% CI, 1.10-1.48) and their neonates had an increased odd of mortality and severe morbidity (aOR, 1.37; 95% CI, 1.23-1.52). Conclusion and relevance This multinational study shows that women with epilepsy were at considerably higher risk of severe maternal and perinatal outcomes and increased risk of death during pregnancy and postpartum. Maternal epilepsy and maternal use of ASM were associated with increased maternal morbidity and perinatal mortality and morbidity.
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Affiliation(s)
- Neda Razaz
- Clinical Epidemiology Unit, Department of Medicine Solna, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Jannicke Igland
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Department of Health and Caring Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Marte-Helene Bjørk
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - K S Joseph
- Department of Obstetrics and Gynaecology, University of British Columbia and the Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Julie Werenberg Dreier
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- National Centre for Register-Based Research, School of Business and Social Sciences, Aarhus University, Aarhus, Denmark
- Centre for Integrated Register-based Research, CIRRAU, Aarhus University, Aarhus, Denmark
| | - Nils Erik Gilhus
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Mika Gissler
- Knowledge Brokers, Finnish Institute for Health and Welfare, Helsinki, Finland
- Region Stockholm, Academic Primary Health Care Centre, Stockholm, Sweden; Karolinska Institute, Department of Molecular Medicine and Surgery, Stockholm, Sweden
| | - Maarit K Leinonen
- Knowledge Brokers, Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Helga Zoega
- Centre of Public Health Sciences, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- School of Population Health, Faculty of Medicine and Health, UNSW Sydney, Sydney, Australia
| | - Silje Alvestad
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- National Center for Epilepsy, Member of the ERN EpiCARE, Oslo University Hospital, Oslo, Norway
| | - Jakob Christensen
- National Centre for Register-Based Research, School of Business and Social Sciences, Aarhus University, Aarhus, Denmark
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Affiliated member of EpiCARE, Aarhus University, Aarhus, Denmark
| | - Torbjörn Tomson
- Department of Clinical Neuroscience, Karolinska Institutet, and Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
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Zhou X, Ding D, Wang W, Zhou D, Sander JW. Mortality of Epilepsy in Chinese Populations: A Comprehensive Review. Neuroepidemiology 2024:1-14. [PMID: 39074464 DOI: 10.1159/000540426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Accepted: 07/02/2024] [Indexed: 07/31/2024] Open
Abstract
BACKGROUND Premature mortality is a significant part of the epilepsy burden and may vary across populations, especially between high-income and lower- and middle-income countries. People with epilepsy in China are approximately a fifth of the global population with epilepsy. Previous studies were unlikely to represent the situation in China due to limitations in design, methods, sample size, follow-up time, and other inherent population heterogeneity. SUMMARY By summarising the evidence on the mortality characteristics in Chinese populations with epilepsy in the last 6 decades, we found a median mortality rate of 14.7 (6.8-74.4)/1,000 person-years and a median standardised mortality ratio (SMR) of 4.4 (2.6-12.9) in population-based studies, and a median mortality rate of 12.3 (9.5-101.5)/1,000 person-years and a median SMR of 3.0 (1.5-5.1) in hospital-based studies. Vascular diseases, complications of diabetes, and accidental injuries were the leading causes of death. Risk factors for mortality were reported as older age, male, longer duration, and higher frequency of seizures. Case fatality ratios of status epilepticus in adults were higher than in children, and both increased with follow-up time. Mortality in people with symptomatic epilepsy was high and varied across different primary diseases. KEY MESSAGES The highest mortality rate and sudden unexpected death in epilepsy (SUDEP) incidence were reported from the least developed areas in China. Accidental injuries were the most common causes of epilepsy-related deaths, while the incidence of SUDEP may be underestimated in Chinese populations. Further research is warranted to improve the understanding of premature mortality risk so that preventative measures can be introduced to improve the situation.
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Affiliation(s)
- Xiaowen Zhou
- Institute of Neurology, National Center for Neurological Disorders, National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China,
| | - Ding Ding
- Institute of Neurology, National Center for Neurological Disorders, National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Wenzhi Wang
- Beijing Neurosurgical Institute, Beijing, China
| | - Dong Zhou
- Department of Neurology, West of China Hospital, Sichuan University, Chengdu, China
| | - Josemir W Sander
- Department of Neurology, West of China Hospital, Sichuan University, Chengdu, China
- UCL Queen Square Institute of Neurology, London, UK
- Chalfont Centre for Epilepsy, Chalfont St Peter, UK
- Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, The Netherlands
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Sha L, Cao Z, Fu Y, Duan Y, Xia Y, Feng X, Tomson T, Xie X, Chen L. Global burden and management of women with epilepsy in pregnancy: A modeling study. MED 2024:S2666-6340(24)00264-2. [PMID: 39053463 DOI: 10.1016/j.medj.2024.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 04/10/2024] [Accepted: 07/02/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND Most pregnant women with epilepsy do not receive proper medical care, which creates a special burden worldwide. We aimed to qualify this special global burden and assess the impact of different clinical management strategies to reduce it. METHODS The data used in this study were extracted from articles published between 2005 and 2022. We calculated the economic costs associated with major burdens experienced by pregnant women with epilepsy. We developed a microsimulation model to estimate the different effects of various interventions and their combinations as integrated strategies for pregnant women with epilepsy and related burden reduction. We also compared the regional differences in disease burden and interventions. FINDINGS The total economic burden for pregnant women with epilepsy is estimated to reach $1.8 billion globally annually, which is more than three times the burden for epilepsy alone. Folic acid supplementation is projected to be the most effective intervention, with a 9.1% reduction in major congenital malformations, a 14.9% reduction in autism spectrum disorder, and a 10.8% reduction in offspring-related economic burden globally annually. Integrated strategies are associated with a reduced economic burden of up to $37.7 million annually globally. Folic acid supplementation is the most effective intervention in high- and upper-middle-income countries, whereas changes in antiseizure medication prescriptions are more effective in lower-middle- and low-income countries. CONCLUSION This study highlights the huge burden for pregnant women with epilepsy and actions that must be taken to improve their quality of life. FUNDING This work was supported by the Sichuan Science and Technology Program (2023YFS0047).
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Affiliation(s)
- Leihao Sha
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Ze Cao
- Department of Industrial Engineering, Tsinghua University, Beijing 100084, China
| | - Yutong Fu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Yifei Duan
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Yilin Xia
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Xiaoru Feng
- School of Medicine, Tsinghua University, Beijing 100084, China
| | - Torbjörn Tomson
- Department of Clinical Neuroscience, Karolinska Institutet, 11351 Stockholm, Sweden
| | - Xiaolei Xie
- Department of Industrial Engineering, Tsinghua University, Beijing 100084, China.
| | - Lei Chen
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China.
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Mesraoua B, Brigo F, Lattanzi S, Perucca E, Ali M, Asadi-Pooya AA. Safe delivery, perinatal outcomes and breastfeeding in women with epilepsy. Epilepsy Behav 2024; 156:109827. [PMID: 38759429 DOI: 10.1016/j.yebeh.2024.109827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 05/04/2024] [Accepted: 05/06/2024] [Indexed: 05/19/2024]
Abstract
Safe delivery and optimal peripartum and postpartum care in women with epilepsy (WWE) is a major concern which has received limited attention in recent years. A diagnosis of epilepsy per se is not an indication for a planned cesarean section or induction of labor, even though epidemiological studies indicate that cesarean delivery is more common among WWE compared to the general population. Pregnancy in WWE is associated with an increased risk of obstetrical complications and increased perinatal morbidity and mortality, and these risks may be greater among WWE taking ASMs. Wherever feasible, pregnant WWE should be directed to specialist care. Risk minimization includes, when appropriate, dose adjustment to compensate for pregnancy-related changes in the pharmacokinetics of some ASMs. With respect to postpartum management, WWE should be advised that the benefits of breastfeeding outweigh the small risk of adverse drug reactions in the infant.
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Affiliation(s)
- Boulenouar Mesraoua
- Neurosciences Department, Hamad Medical Corporation and Weill Cornell Medical College, Doha, Qatar.
| | - Francesco Brigo
- Research Area Innovation, Research and Teaching Service (SABES- ASDAA), Bolzano-Bozen, Italy.
| | - Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy.
| | - Emilio Perucca
- Department of Medicine (Austin Health), University of Melbourne, and Department of Neuroscience, School of Translational Medicine, Monash University, Melbourne, Victoria, Australia.
| | - Musab Ali
- Neurosciences Department, Hamad Medical Corporation, Doha, Qatar.
| | - Ali A Asadi-Pooya
- Epilepsy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran; Jefferson Comprehensive Epilepsy Center, Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA.
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7
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McElrath TF, Druzin M, Van Marter LJ, May RC, Brown C, Stek A, Grobman W, Dolan M, Chang P, Flood-Schaffer K, Parker L, Meador KJ, Pennell PB. The Obstetrical Care and Delivery Experience of Women with Epilepsy in the MONEAD Study. Am J Perinatol 2024; 41:935-943. [PMID: 35253116 DOI: 10.1055/a-1788-4791] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE We examined mode of delivery among pregnant women with epilepsy (PWWE) versus pregnant controls (PC). We hypothesize that PWWE are more likely to deliver by cesarean. STUDY DESIGN The Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs (MONEAD) study is an observational, prospective, multicenter investigation of pregnancy outcomes funded by the National Institute of Health (NIH). MONEAD enrolled patients from December 2012 through January 2016. PWWE were matched to PC in a case:control ratio of 3:1. This analysis had 80% power to detect a 36% increase in cesarean frequency assuming a baseline rate of 30% among PC at an α = 0.05. RESULTS This report analyzed 331 PWWE (76%) and 102 PC (24%) who gave birth while enrolled in the study. PWWE and PC had similar rates of cesarean delivery (34.7 vs. 28.6%; p = 0.27). Of women with cesarean, rates of cesarean without labor were similar between groups for those delivering in recruitment hospitals (48.2 vs. 50.0%) but in nonrecruitment hospitals, cesarean rates without labor were over two-fold higher among PWWE than those of PC (68.8 vs. 30.8%; p = 0.023). Receipt of a cesarean after labor did not differ for PWWE compared to PC or by type of antiepileptic drug among the PWWE. CONCLUSION These findings suggest that the obstetrical experiences of PWWE and PC are similar. An interesting deviation from this observation was the mode of delivery with higher unlabored cesarean rates occurring among PWWE in nonrecruitment hospitals. As the study recruitment hospitals were tertiary academic centers and nonrecruitment hospitals tended to be community-based institutions, differences in perinatal expertise might contribute to this difference. KEY POINTS · Unlabored cesarean rates higher among women with epilepsy.. · Provider preference may influence delivery mode among women with epilepsy.. · Type and amount of antiepileptic drug was not associated with mode of delivery..
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Affiliation(s)
- Thomas F McElrath
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Maurice Druzin
- Division of Maternal-Fetal-Medicine, Department of Obstetrics and Gynecology, Stanford University, Palo Alto, California
| | - Linda J Van Marter
- Division of Newborn Medicine, Department of Pediatrics, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | | | | | - Alice Stek
- Department of Obstetrics-Gynecology, University of Southern California, Los Angeles, California
| | - William Grobman
- Division of Maternal-Fetal-Medicine, Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois
| | - Mary Dolan
- Division of Maternal-Fetal-Medicine, Department of Obstetrics and Gynecology, Emory University, Atlanta, Georgia
| | - Patricia Chang
- Department of Obstetrics-Gynecology, Minnesota Epilepsy Group, St. Paul, Minnesota
| | | | - Lamar Parker
- Department of Obstetrics-Gynecology, Wake Forest University, Winston-Salem, North Carolina
| | - Kimford J Meador
- Department of Neurology, Stanford University, Standford, California
| | - Page B Pennell
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Hébert J, Iyengar Y, Ng S, Liao J, Snelgrove JW, Bui E. Obstetrical Outcomes of Patients with Epilepsy in a Canadian Tertiary Care Center (2014-2020). Can J Neurol Sci 2024; 51:397-403. [PMID: 37458116 DOI: 10.1017/cjn.2023.254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
BACKGROUND There is a paucity of data on the obstetrical outcomes of Canadian pregnant patients with epilepsy, which may differ from the average Canadian pregnancy and from other populations of pregnant patients with epilepsy. METHODS Pregnant patients with epilepsy were identified from a prospectively collected database of patients seen at the maternal-fetal medicine obstetrics program of Mount Sinai Hospital (Toronto, Canada) between January 1, 2014, and November 20, 2020. Pregnancy, delivery, and neonatal outcome data were retrieved from this database and described using 95% binomial confidence intervals. Comparisons of obstetrical outcomes over the same period among the Canadian population average, obtained from publicly available national health data, were done using one-proportion Z-tests for nominal variables and one-sample t-tests for continuous variables. RESULTS In total, 282 pregnancies, from 224 patients, were included, which resulted in 274 live births. Mean maternal age was 32.8 years (s.d. = 4.6; population average [μ] = 30.9; p < 0.01), and 53% were primiparous (CI95% = 49%-61%; μ = 43%; p < 0.01). The observed rates of obstetrical complications were gestational hypertension 9% (CI95%=6%-13%; μ=7%; p=0.19), gestational diabetes 5% (CI95% = 3%-8%; μ = 9%; p = 0.02), cesarean section 44% (CI95% = 38%-50%; μ = 28%; p < 0.01), postpartum hemorrhage 5% (CI95% = 3%-8%; μ = 0.5%; p < 0.01), stillbirth 1% (CI95% = 0%-2%; μ=1%; p > 0.99), and prematurity 9% (CI95% = 6%-13%; μ = 8%; p = 0.44). CONCLUSION In this cohort of Canadian pregnant patients with epilepsy from an urban tertiary care center, observed rates of obstetrical complications were rare and no higher than in the Canadian population over the same period, with the exception of cesarean section and postpartum hemorrhage. Future prospective studies that include primary care and rural settings are needed to increase the generalizability of those results.
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Affiliation(s)
- Julien Hébert
- Division of Neurology, University of Toronto, Toronto, ON, Canada
- Comprehensive Epilepsy Center, Columbia University Medical Center-New York Presbyterian Hospital, New York, NY, USA
| | - Yajur Iyengar
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Sharon Ng
- Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - Jenny Liao
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - John W Snelgrove
- Department of Obstetrics & Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, ON, Canada
| | - Esther Bui
- Division of Neurology, University of Toronto, Toronto, ON, Canada
- Toronto Western Hospital, University Health Network, Toronto, ON, Canada
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9
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Liu R, Xiao L, Liu X, Xiao C. Dose adjustment strategy of levetiracetam in pregnant patients with epilepsy: Case report and literature review. Medicine (Baltimore) 2024; 103:e37977. [PMID: 38669358 PMCID: PMC11049779 DOI: 10.1097/md.0000000000037977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 04/01/2024] [Indexed: 04/28/2024] Open
Abstract
RATIONALE Pregnant patients with epilepsy are prone to preterm delivery, stillbirth, or cesarean section, and their mortality rate is almost 10 times higher than that of normal pregnant women. The potential negative influences of antiepileptic drugs (AEDs) on the fetus are weighed against the necessity for achieving optimal control of seizures. Treatment with AEDs during pregnancy is a major challenge for pregnant women and healthcare teams. PATIENT CONCERNS This paper reports two cases of young women diagnosed with pregnancy and epilepsy. INTERVENTION The dose of levetiracetam was adjusted under the guidance of therapeutic drug monitoring to reduce the effects of seizures on the fetus and the incidence of reproductive toxicity caused by adverse drug reactions. OUTCOMES Epilepsy was well controlled in the two pregnant patients, and the newborns had no genetic disorders. LESSONS It is recommended to regularly monitor the serum LEV level in pregnant patients with epilepsy. This practice serves as a foundation for adjusting the drug treatment plan and offering more precise guidance for medication management during pregnancy.
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Affiliation(s)
- Renzhu Liu
- Department of Clinical Pharmacy, Xiangtan Central Hospital, Xiangtan, China
| | - Lu Xiao
- Department of Children Health Care, The Maternity And Children Health Hospital of Xiangtan City, Xiangtan, China
| | - Xiang Liu
- Department of Clinical Pharmacy, Xiangtan Central Hospital, Xiangtan, China
| | - Can Xiao
- Department of Clinical Pharmacy, Xiangtan Central Hospital, Xiangtan, China
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10
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Xia Y, Duan Y, Sha L, Lai W, Zhang Z, Hou J, Chen L. Whole-cycle management of women with epilepsy of child-bearing age: ontology construction and application. BMC Med Inform Decis Mak 2024; 24:101. [PMID: 38637746 PMCID: PMC11027401 DOI: 10.1186/s12911-024-02509-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 04/15/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND The effective management of epilepsy in women of child-bearing age necessitates a concerted effort from multidisciplinary teams. Nevertheless, there exists an inadequacy in the seamless exchange of knowledge among healthcare providers within this context. Consequently, it is imperative to enhance the availability of informatics resources and the development of decision support tools to address this issue comprehensively. MATERIALS AND METHODS The development of the Women with Epilepsy of Child-Bearing Age Ontology (WWECA) adhered to established ontology construction principles. The ontology's scope and universal terminology were initially established by the development team and subsequently subjected to external evaluation through a rapid Delphi consensus exercise involving domain experts. Additional entities and attribute annotation data were sourced from authoritative guideline documents and specialized terminology databases within the respective field. Furthermore, the ontology has played a pivotal role in steering the creation of an online question-and-answer system, which is actively employed and assessed by a diverse group of multidisciplinary healthcare providers. RESULTS WWECA successfully integrated a total of 609 entities encompassing various facets related to the diagnosis and medication for women of child-bearing age afflicted with epilepsy. The ontology exhibited a maximum depth of 8 within its hierarchical structure. Each of these entities featured three fundamental attributes, namely Chinese labels, definitions, and synonyms. The evaluation of WWECA involved 35 experts from 10 different hospitals across China, resulting in a favorable consensus among the experts. Furthermore, the ontology-driven online question and answer system underwent evaluation by a panel of 10 experts, including neurologists, obstetricians, and gynecologists. This evaluation yielded an average rating of 4.2, signifying a positive reception and endorsement of the system's utility and effectiveness. CONCLUSIONS Our ontology and the associated online question and answer system hold the potential to serve as a scalable assistant for healthcare providers engaged in the management of women with epilepsy (WWE). In the future, this developmental framework has the potential for broader application in the context of long-term management of more intricate chronic health conditions.
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Affiliation(s)
- Yilin Xia
- Department of Neurology, West China Hospital, Sichuan University, #37 Guoxue Alley, Wuhou District, 610041, Chengdu, Sichuan Province, China
| | - Yifei Duan
- Department of Neurology, West China Hospital, Sichuan University, #37 Guoxue Alley, Wuhou District, 610041, Chengdu, Sichuan Province, China
| | - Leihao Sha
- Department of Neurology, West China Hospital, Sichuan University, #37 Guoxue Alley, Wuhou District, 610041, Chengdu, Sichuan Province, China
| | - Wanlin Lai
- Department of Neurology, West China Hospital, Sichuan University, #37 Guoxue Alley, Wuhou District, 610041, Chengdu, Sichuan Province, China
| | - Zhimeng Zhang
- Department of Neurology, West China Hospital, Sichuan University, #37 Guoxue Alley, Wuhou District, 610041, Chengdu, Sichuan Province, China
| | - Jiaxin Hou
- Department of Neurology, West China Hospital, Sichuan University, #37 Guoxue Alley, Wuhou District, 610041, Chengdu, Sichuan Province, China
| | - Lei Chen
- Department of Neurology, West China Hospital, Sichuan University, #37 Guoxue Alley, Wuhou District, 610041, Chengdu, Sichuan Province, China.
- Pazhou Lab, Guangzhou, China.
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11
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Shahla M, Aytan M. Clinical characteristics, seizure control, and delivery outcomes in pregnant women with focal and generalized epilepsies. Seizure 2024; 117:67-74. [PMID: 38335875 DOI: 10.1016/j.seizure.2024.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 01/13/2024] [Accepted: 01/26/2024] [Indexed: 02/12/2024] Open
Abstract
OBJECTIVE To prospectively investigate the course of epilepsy and assess seizure control during pregnancy in women with focal epilepsy (FE) compared with generalized epilepsy (GE), to ascertain the effects of epilepsy and its types on delivery and neonatal outcomes, and to compare adverse outcomes between pregnancies complicated by epilepsy and normal pregnancies. METHODS 124 pregnant women with epilepsy (WWE) were enrolled in a prospective study. Obstetric and neonatal outcomes were compared with those of 277 healthy women in the control group. RESULTS Occurrence of seizures during pregnancy was more often in FE (77.1 %) compared with GE (50.0 %) (Odds ratio [OR] 2.08; 95 % confidence interval [CI] 0.97-4.46, p = 0.06); the overall seizure freedom was significantly higher in women with GE compared with women with FE (p = 0.0038). Poor seizure control one year prior to the pregnancy and nonadherence to treatment were significantly associated with presence of seizures during pregnancy (p < 0.0001). Compared with pregnancies of women without epilepsy, WWE were at increased risk of cesarean section (CS) (p < 0.0001) and preterm birth (p = 0.03). Offspring of mothers with epilepsy were at higher risks of Apgar scores at 5 min ≤7 (p < 0.0001) and perinatal hypoxia (p = 0.03) compared with infants of unaffected women. Seizures during pregnancy were significantly correlated with the higher rate of CS, Apgar scores at 5 min ≤7, and perinatal hypoxia (p = 0.0069; p = 0.0098; and p = 0.0045, respectively). The risks of adverse outcomes were not significantly increased in women with FE compared to women with GE. CONCLUSION Epileptic seizures in pregnancy are associated with increased risks of adverse delivery and neonatal outcomes. Hence, early assessment of seizure disorder, adequate seizure control prior to and during pregnancy, and effective treatment are required to prevent potential seizure-related complications and improve maternal and fetal outcomes.
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Affiliation(s)
- Melikova Shahla
- Department of Neurology, Azerbaijan Medical University, Secretary General of Azerbaijan League Against Epilepsy, Mardanov Gardaslar 100, Baku, Azerbaijan.
| | - Mammadbayli Aytan
- Department of Neurology, Azerbaijan Medical University, The President of Azerbaijan League Against Epilepsy, Mardanov Gardaslar 100, Baku, Azerbaijan.
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12
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Gaus V, Ilyas-Feldmann M, Schmitz B. [Epilepsy and pregnancy]. DER NERVENARZT 2024; 95:335-341. [PMID: 38451327 DOI: 10.1007/s00115-024-01626-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/05/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND Regarding treatment of women of childbearing potential with epilepsy, several aspects of family planning and desire to have children have to be taken into account. OBJECTIVE Overview of current data on mutual implications of epileptic seizures, antiseizure medication (ASM), pregnancy and child development. METHOD Review of the current literature, discussion and presentation of resulting treatment recommendations. RESULTS Many ASMs bear the potential for clinically relevant interactions with both contraceptives and altered concentrations of sexual hormones and modified pharmacokinetics during pregnancy. All ASMs show an increased risk for congenital malformations; however, due to seizure-related risks for the mother and child effective ASM treatment during pregnancy is crucial. CONCLUSION When considering the special aspects of consultation and treatment of women of childbearing potential with epilepsy most pregnancies are uncomplicated.
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Affiliation(s)
- Verena Gaus
- Epilepsie-Zentrum Berlin-Brandenburg, Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland.
| | - Maria Ilyas-Feldmann
- Epilepsie-Zentrum Berlin-Brandenburg, Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland
| | - Bettina Schmitz
- Klinik für Neurologie und Zentrum für Epilepsie, Vivantes Humboldt Klinikum Berlin, Berlin, Deutschland
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13
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Leite MDL, Topocov TN, de Oliveira TL, Almeida DDS, Mota Ortiz SR, da Silva JC. Obstetric and neonatal outcomes, antiseizure medication profile, and seizure types in pregnant women in a vulnerability state from Brazil. PLoS One 2024; 19:e0291190. [PMID: 38558080 PMCID: PMC10984515 DOI: 10.1371/journal.pone.0291190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 08/24/2023] [Indexed: 04/04/2024] Open
Abstract
This retrospective cohort study described the obstetric and neonatal outcomes, antiseizure medication (ASM) use, and types of seizures in pregnant women with epilepsy (PWWE). Data collected from the medical records of 224 PWWE aged < 40 years with controlled or refractory seizures and 492 pregnant women without epilepsy (PWNE) control group from high-risk maternity hospitals in Alagoas between 2008 and 2021 were included in this study. The obstetric and neonatal outcomes observed in PWWE were pregnancy-related hypertension (PrH) (18.4%), oligohydramnios (10.3%), stillbirth (6.4%), vaginal bleeding (6%), preeclampsia (4.7%), and polyhydramnios (3%). There was a greater likelihood of PrH in PWWE with generalized tonic-clonic seizures (GTCS) and that of maternal intensive care unit (ICU) admissions in those with GTCS and status epilepticus, and phenytoin and lamotrigine use. PWWE with GTCS had a higher risk of stillbirth and premature delivery. PWWE with status epilepticus were treated with lamotrigine. Phenobarbital (PB) with diazepam were commonly used in GTCS and status epilepticus. Total 14% patients did not use ASM, while 50.2% used monotherapy and 35.8% used polytherapy. Total 60.9% of patients used PB and 25.2% used carbamazepine. This study described the association between the adverse obstetric and neonatal outcomes and severe seizure types in PWWE.
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Affiliation(s)
- Magnúcia de Lima Leite
- Universidade Estadual de Ciências da Saúde Alagoas (UNCISAL), Maceió, AL, Brazil
- Universidade de São Paulo (USP), São Paulo, SP, Brazil
| | | | | | | | - Sandra Regina Mota Ortiz
- Universidade Municipal de São Caetano do Sul (USCS), São Paulo, SP, Brazil
- Universidade São Judas Tadeu (USJT), São Paulo, SP, Brazil
| | - José Claudio da Silva
- Faculdade de Medicina do Centro Universitário(CESMAC), Maceió, AL, Brazil
- PPGSF/RENASF/FIOCRUZ/UNCISAL, Maceió, AL, Brazil
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14
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Devinsky O, Elder C, Sivathamboo S, Scheffer IE, Koepp MJ. Idiopathic Generalized Epilepsy: Misunderstandings, Challenges, and Opportunities. Neurology 2024; 102:e208076. [PMID: 38165295 PMCID: PMC11097769 DOI: 10.1212/wnl.0000000000208076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 10/19/2023] [Indexed: 01/03/2024] Open
Abstract
The idiopathic generalized epilepsies (IGE) make up a fifth of all epilepsies, but <1% of epilepsy research. This skew reflects misperceptions: diagnosis is straightforward, pathophysiology is understood, seizures are easily controlled, epilepsy is outgrown, morbidity and mortality are low, and surgical interventions are impossible. Emerging evidence reveals that patients with IGE may go undiagnosed or misdiagnosed with focal epilepsy if EEG or semiology have asymmetric or focal features. Genetic, electrophysiologic, and neuroimaging studies provide insights into pathophysiology, including overlaps and differences from focal epilepsies. IGE can begin in adulthood and patients have chronic and drug-resistant seizures. Neuromodulatory interventions for drug-resistant IGE are emerging. Rates of psychiatric and other comorbidities, including sudden unexpected death in epilepsy, parallel those in focal epilepsy. IGE is an understudied spectrum for which our diagnostic sensitivity and specificity, scientific understanding, and therapies remain inadequate.
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Affiliation(s)
- Orrin Devinsky
- From the Comprehensive Epilepsy Center (O.D., C.E.), New York University School of Medicine, New York, Department of Neuroscience (S.S.), Central Clinical School, Monash University, Melbourne, Department of Neurology (S.S.), Alfred Health, Melbourne; Departments of Medicine and Neurology, The Royal Melbourne Hospital (S.S.), Epilepsy Research Centre, Department of Medicine, Austin Health (I.E.S.), Murdoch Children's Research Institute (I.E.S.), and Department of Pediatrics (I.E.S.), Royal Children's Hospital, The University of Melbourne; The Florey Institute of Neuroscience and Mental Health (I.E.S.), Melbourne, Victoria, Australia; and Department of Clinical and Experimental Epilepsy (M.J.K.), University College London Institute of Neurology, United Kingdom
| | - Christopher Elder
- From the Comprehensive Epilepsy Center (O.D., C.E.), New York University School of Medicine, New York, Department of Neuroscience (S.S.), Central Clinical School, Monash University, Melbourne, Department of Neurology (S.S.), Alfred Health, Melbourne; Departments of Medicine and Neurology, The Royal Melbourne Hospital (S.S.), Epilepsy Research Centre, Department of Medicine, Austin Health (I.E.S.), Murdoch Children's Research Institute (I.E.S.), and Department of Pediatrics (I.E.S.), Royal Children's Hospital, The University of Melbourne; The Florey Institute of Neuroscience and Mental Health (I.E.S.), Melbourne, Victoria, Australia; and Department of Clinical and Experimental Epilepsy (M.J.K.), University College London Institute of Neurology, United Kingdom
| | - Shobi Sivathamboo
- From the Comprehensive Epilepsy Center (O.D., C.E.), New York University School of Medicine, New York, Department of Neuroscience (S.S.), Central Clinical School, Monash University, Melbourne, Department of Neurology (S.S.), Alfred Health, Melbourne; Departments of Medicine and Neurology, The Royal Melbourne Hospital (S.S.), Epilepsy Research Centre, Department of Medicine, Austin Health (I.E.S.), Murdoch Children's Research Institute (I.E.S.), and Department of Pediatrics (I.E.S.), Royal Children's Hospital, The University of Melbourne; The Florey Institute of Neuroscience and Mental Health (I.E.S.), Melbourne, Victoria, Australia; and Department of Clinical and Experimental Epilepsy (M.J.K.), University College London Institute of Neurology, United Kingdom
| | - Ingrid E Scheffer
- From the Comprehensive Epilepsy Center (O.D., C.E.), New York University School of Medicine, New York, Department of Neuroscience (S.S.), Central Clinical School, Monash University, Melbourne, Department of Neurology (S.S.), Alfred Health, Melbourne; Departments of Medicine and Neurology, The Royal Melbourne Hospital (S.S.), Epilepsy Research Centre, Department of Medicine, Austin Health (I.E.S.), Murdoch Children's Research Institute (I.E.S.), and Department of Pediatrics (I.E.S.), Royal Children's Hospital, The University of Melbourne; The Florey Institute of Neuroscience and Mental Health (I.E.S.), Melbourne, Victoria, Australia; and Department of Clinical and Experimental Epilepsy (M.J.K.), University College London Institute of Neurology, United Kingdom
| | - Matthias J Koepp
- From the Comprehensive Epilepsy Center (O.D., C.E.), New York University School of Medicine, New York, Department of Neuroscience (S.S.), Central Clinical School, Monash University, Melbourne, Department of Neurology (S.S.), Alfred Health, Melbourne; Departments of Medicine and Neurology, The Royal Melbourne Hospital (S.S.), Epilepsy Research Centre, Department of Medicine, Austin Health (I.E.S.), Murdoch Children's Research Institute (I.E.S.), and Department of Pediatrics (I.E.S.), Royal Children's Hospital, The University of Melbourne; The Florey Institute of Neuroscience and Mental Health (I.E.S.), Melbourne, Victoria, Australia; and Department of Clinical and Experimental Epilepsy (M.J.K.), University College London Institute of Neurology, United Kingdom
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15
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Thornton HF, Fantaneanu TA, Zhang T, Bercovici E, Hrazdil C, Ikeda KM, Kassiri J, Suller Marti A, Pana R, Rezazadeh A, Kobayashi E, Bui E. Real-world practices in reproductive health and counselling for women with epilepsy: A Canadian perspective. Epilepsy Behav 2024; 151:109623. [PMID: 38262329 DOI: 10.1016/j.yebeh.2024.109623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 12/27/2023] [Accepted: 01/02/2024] [Indexed: 01/25/2024]
Abstract
Canadian women of reproductive potential living with epilepsy present unique care challenges due to the complex interplay of hormones, seizures, and medications. This study explores reproductive health practices and counselling for women with epilepsy. Through a questionnaire developed by the Canadian League Against Epilepsy women with epilepsy (WWE) workgroup, we are the first to report demographic and real-world practice characteristics of Canadian healthcare professionals providing care for WWE with specific focus on family planning, birth plans, and postpartum care counselling. Among respondents, 76.9% routinely reviewed contraception with patients and an intrauterine device (IUD) was the most popular recommended method (85.3%). With regards to preconception planning, 50% of respondents routinely had a preconception drug level prior to pregnancy. A significant proportion, 44.9%, reported not communicating a neurology-informed birth plan to obstetrical health practitioners. The majority recommended breastfeeding for WWE on anti-seizure medications (92.3%) and regularly provided safety counselling for women in the postpartum period (84.6%). Overall, our study demonstrates that Canadian practice patterns conform reasonably well to existing evidence and guidelines, although important gaps in care exist.
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Affiliation(s)
- Hayley F Thornton
- Department of Neurosciences, University of Calgary, Calgary, Alberta, Canada.
| | - Tadeu A Fantaneanu
- Division of Neurology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, The Ottawa Hospital, Ontario, Canada.
| | - Tinghua Zhang
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ontario, Canada.
| | - Eduard Bercovici
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.
| | - Chantelle Hrazdil
- Division of Neurology, University of British Columbia, Vancouver Coastal Health, Vancouver, British Columbia, Canada.
| | - Kristin M Ikeda
- Division of Neurology, Department of Medicine, Dalhousie University, Nova Scotia Health, Canada.
| | - Janani Kassiri
- Division of Pediatric Neurology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.
| | - Ana Suller Marti
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; Department of Pediatrics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
| | - Raluca Pana
- Department of Neurology and Neurosurgery, McGill University, Montreal, Quebec, Canada.
| | - Arezoo Rezazadeh
- Department of Neurosciences, University of Calgary, Calgary, Alberta, Canada; Division of Neurology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
| | - Eliane Kobayashi
- Department of Neurology and Neurosurgery, McGill University, Montreal, Quebec, Canada.
| | - Esther Bui
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.
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16
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Lee SK. Issues of Women with Epilepsy and Suitable Antiseizure Drugs. J Epilepsy Res 2023; 13:23-35. [PMID: 38223363 PMCID: PMC10783964 DOI: 10.14581/jer.23005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 09/12/2023] [Accepted: 12/16/2023] [Indexed: 01/16/2024] Open
Abstract
Seizure aggravation in women with epilepsy (WWE) tends to occur at two specific times during the menstrual cycle: the perimenstrual phase and the ovulation period. Antiseizure drugs (ASDs), especially those that induce enzymes, can accelerate the metabolism of hormones in oral contraceptives, rendering them less effective. Estrogen in contraceptive pills increases the metabolism of lamotrigine. Physiological changes during pregnancy can significantly impact the pharmacokinetics of ASDs, potentially necessitating adjustments in dosage for women with epilepsy to maintain seizure control. The use of valproate in pregnant women is associated with the highest risk of major congenital malformations among ASDs. Risks of major congenital malformations associated with lamotrigine, levetiracetam, and oxcarbazepine were within the range reported in the general population. Exposure to valproate can lead to lower IQ in offspring. Reduced folic acid levels are linked to orofacial clefts, cardiovascular malformations, and urogenital and limb anomalies in WWE. Decreased folate levels are expected with the use of enzyme-inducing ASDs. However, a high dose of folate was associated with an increased risk of cancer in children of mothers with epilepsy. Most ASDs are generally considered safe for breastfeeding and should be encouraged. However, no single ASD is considered ideal for childbearing WWE. Lamotrigine and levetiracetam are relatively more suitable options for this situation.
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Affiliation(s)
- Sang Kun Lee
- Department of Neurology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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17
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Kuo C, Kuo C, See L, Chiou M, Hung P, Lin J, Lin K, Wang H, Chou I. The impact of epilepsy and antiseizure medications on pregnancy and neonatal outcomes: A nationwide cohort study. Brain Behav 2023; 13:e3287. [PMID: 37837631 PMCID: PMC10726760 DOI: 10.1002/brb3.3287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 09/26/2023] [Accepted: 09/28/2023] [Indexed: 10/16/2023] Open
Abstract
PURPOSE Our objective was to assess the adverse outcomes during pregnancy, as well as for the fetus and neonates, in women with epilepsy, both with and without the use of antiseizure medications (ASMs). METHODS A cohort of singleton pregnancies between January 1, 2004 and December 31, 2014 was identified using the Taiwan National Health Database. The pregnancies were categorized into ASM exposure, ASM nonexposure, and control (consisting of women without an epilepsy diagnosis) groups. We recorded adverse outcomes in neonates and documented pregnancy complications. The generalized estimating equation with logit link was used to estimate adjusted odds ratios. RESULTS There were 629 singleton pregnancies in the group exposed to ASMs, 771 in the epilepsy group without ASM exposure, and 2,004,479 in the control group. Women with epilepsy had a significantly higher risk of puerperal cerebrovascular diseases (adjusted odds ratios in the exposure and nonexposure groups = 54.46 and 20.37, respectively), respiratory distress syndrome (5.1 and 2.99), mortality (3.15 and 3.22), sepsis (2.67 and 2.54), pregnancy-related hypertension (1.71 and 1.8), preeclampsia (1.87 and 1.79), cesarean delivery (1.72 and 2.15), and preterm labor (1.38 and 1.56). The use of ASMs may increase the risk of eclampsia (adjusted odds ratio = 12.27). Compared to controls, fetuses/neonates born to women with epilepsy had a higher risk of unexplained stillbirth (adjusted odds ratios in the exposure and nonexposure groups = 2.51 and 2.37, respectively), congenital anomaly (1.37 and 1.33), central nervous system malformation (3.57 and 2.25), low birth weight (1.90 and 1.97), and a low Apgar score at 5 min (2.63 and 1.3). The use of ASMs may introduce an additional risk of small for gestational age; the adjusted odds ratio was 1.51. CONCLUSION Women with epilepsy, irrespective of their exposure to ASMs, had a slightly elevated risk of pregnancy and perinatal complications. Puerperal cerebrovascular diseases may be a hidden risk for women with epilepsy.
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Affiliation(s)
- Cheng‐Yen Kuo
- Division of Pediatric NeurologyChang Gung Memorial HospitalTaoyuanTaiwan
| | - Chang‐Fu Kuo
- Division of Rheumatology, Allergy and ImmunologyChang Gung Memorial HospitalTaoyuanTaiwan
- Division of Rheumatology, Orthopaedics, and Dermatology, School of MedicineUniversity of NottinghamNottinghamUK
- Center for Artificial Intelligence in MedicineChang Gung Memorial HospitalTaoyuanTaiwan
| | - Lai‐Chu See
- Division of Rheumatology, Allergy and ImmunologyChang Gung Memorial HospitalTaoyuanTaiwan
- Department of Public HealthCollege of Medicine, Biostatistics Core Laboratory, Molecular Medicine Research CentreChang Gung UniversityTaoyuanTaiwan
| | - Meng‐Jiung Chiou
- Center for Artificial Intelligence in MedicineChang Gung Memorial HospitalTaoyuanTaiwan
| | - Po‐Cheng Hung
- Division of Pediatric NeurologyChang Gung Memorial HospitalTaoyuanTaiwan
| | - Jainn‐Jim Lin
- Division of Pediatric NeurologyChang Gung Memorial HospitalTaoyuanTaiwan
| | - Kuang‐Lin Lin
- Division of Pediatric NeurologyChang Gung Memorial HospitalTaoyuanTaiwan
| | - Huei‐Shyong Wang
- Division of Pediatric NeurologyChang Gung Memorial HospitalTaoyuanTaiwan
| | - I‐Jun Chou
- Division of Pediatric NeurologyChang Gung Memorial HospitalTaoyuanTaiwan
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18
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Aggarwal S, Barman M, Poudel B, Joshi K, Devi R, Singh P, Priyadarshi M, Chaurasia S, Basu S. Fetal Hydantoin Syndrome: A Case Report. Cureus 2023; 15:e49663. [PMID: 38161950 PMCID: PMC10756398 DOI: 10.7759/cureus.49663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2023] [Indexed: 01/03/2024] Open
Abstract
Epilepsy is not a common cause of morbidity in pregnancy. It has widespread effects on maternal and fetal health necessitating adequate control of seizures. Many anti-seizure medications (ASM) have teratogenic effects on the fetus. We report a case of severe fetal hydantoin syndrome resulting in life-threatening major congenital anomalies. The mother was on phenytoin for the last three years and the pregnancy was not registered. We discuss various features of fetal hydantoin syndrome and the ideal management of epilepsy in pregnancy in brief.
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Affiliation(s)
- Sanchit Aggarwal
- Paediatrics, All India Institute of Medical Sciences, Rishikesh, IND
| | - Manidipa Barman
- Paediatrics, All India Institute of Medical Sciences, Rishikesh, IND
| | - Binita Poudel
- Paediatrics, All India Institute of Medical Sciences, Rishikesh, IND
| | - Kamal Joshi
- Paediatrics, All India Institute of Medical Sciences, Rishikesh, IND
| | - Risha Devi
- Neonatology, All India Institute of Medical Sciences, Rishikesh, IND
| | - Poonam Singh
- Neonatology, All India Institute of Medical Sciences, Rishikesh, IND
| | | | - Suman Chaurasia
- Neonatology, All India Institute of Medical Sciences, Rishikesh, IND
| | - Sriparna Basu
- Neonatology, All India Institute of Medical Sciences, Rishikesh, IND
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19
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Válóczy R, Fekete I, Horváth L, Mészáros Z, Fekete K. Comparative analysis of three decades' experience in the management of pregnant women with epilepsy: a real-life scenario. Front Neurol 2023; 14:1254214. [PMID: 37771456 PMCID: PMC10525340 DOI: 10.3389/fneur.2023.1254214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 08/21/2023] [Indexed: 09/30/2023] Open
Abstract
Introduction People with epilepsy have to face many challenges, including regular follow-ups, the need to take antiseizure medications (ASMs), and the fear of seizures. Pregnant women with epilepsy (PWWE) are a special group with even more challenges because they are responsible for the fetus. We aimed to evaluate the change in the frequency of pregnancies over the years and the possible role of newer types of ASMs concerning this change, the shift in medication use over three decades, and their possible impact on the outcome of the observed pregnancies. Methods Data were retrieved from the prospective Epilepsy Database of the Outpatient Clinic at our tertiary center between 1 January 1992 and 31 December 2020. Groups were formed for comparison in time and depending on whether regular care consultation was our task. Statistical analysis was carried out using Microsoft Office Excel 2021. Basic statistics and categorical variables were assessed using Pearson's χ2 test with Yates' correction. Differences were considered significant if the p-value was <0.05. The odds ratio and 95% confidence intervals were calculated wherever needed. Results Altogether, 181 pregnancies were studied, mostly after 2002. The regular follow-up group consisted of 101 patients, with 44.5% presenting in the first trimester. The majority of seizures were either generalized or focal to bilateral tonic-clonic seizure types (85.6%). Pregnancies ended in live births in 91.7%, which gradually improved over time, while spontaneous abortion did not differ significantly in the time interval groups. Mostly, monotherapy was provided. PWWEs had higher chances for seizure freedom in the regular-care group I: OR = 2.9 (2.15-3.65) p < 0.0001. A shift toward newer-type ASMs was found as time passed. Levetiracetam and lamotrigine were more commonly used in the regular care group I than by those patients who were sent to consultation only and not treated at our center [OR = 3.18 (2.49-3.87)] p < 0.0001. Conclusion This is the first study in our region to evaluate experience in the treatment and outcome of PWWE. Having received reliable care and safer ASMs, the number of pregnancies among PWWEs grew. Data suggested that specialized centers' care offered cooperation with obstetricians is important. Moreover, professional care can also enable PWWEs to have uneventful pregnancies.
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Affiliation(s)
- Réka Válóczy
- Faculty of Medicine, Doctoral School of Neuroscience, University of Debrecen, Debrecen, Hungary
| | - István Fekete
- Department of Neurology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - László Horváth
- Department of Pharmaceutical Surveillance and Economy, Faculty of Pharmacy, University of Debrecen, Debrecen, Hungary
| | - Zsófia Mészáros
- Department of Neurology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Klára Fekete
- Department of Neurology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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20
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Perversi F, Costa C, Labate A, Lattanzi S, Liguori C, Maschio M, Meletti S, Nobili L, Operto FF, Romigi A, Russo E, Di Bonaventura C. The broad-spectrum activity of perampanel: state of the art and future perspective of AMPA antagonism beyond epilepsy. Front Neurol 2023; 14:1182304. [PMID: 37483446 PMCID: PMC10359664 DOI: 10.3389/fneur.2023.1182304] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 06/07/2023] [Indexed: 07/25/2023] Open
Abstract
Glutamate is the brain's main excitatory neurotransmitter. Glutamatergic neurons primarily compose basic neuronal networks, especially in the cortex. An imbalance of excitatory and inhibitory activities may result in epilepsy or other neurological and psychiatric conditions. Among glutamate receptors, AMPA receptors are the predominant mediator of glutamate-induced excitatory neurotransmission and dictate synaptic efficiency and plasticity by their numbers and/or properties. Therefore, they appear to be a major drug target for modulating several brain functions. Perampanel (PER) is a highly selective, noncompetitive AMPA antagonist approved in several countries worldwide for treating different types of seizures in various epileptic conditions. However, recent data show that PER can potentially address many other conditions within epilepsy and beyond. From this perspective, this review aims to examine the new preclinical and clinical studies-especially those produced from 2017 onwards-on AMPA antagonism and PER in conditions such as mesial temporal lobe epilepsy, idiopathic and genetic generalized epilepsy, brain tumor-related epilepsy, status epilepticus, rare epileptic syndromes, stroke, sleep, epilepsy-related migraine, cognitive impairment, autism, dementia, and other neurodegenerative diseases, as well as provide suggestions on future research agenda aimed at probing the possibility of treating these conditions with PER and/or other AMPA receptor antagonists.
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Affiliation(s)
| | - Cinzia Costa
- Section of Neurology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
- Neurological Clinic, S. Maria Della Misericordia Hospital, Perugia, Italy
| | - Angelo Labate
- Neurophysiopatology and Movement Disorders Clinic, University of Messina, Messina, Italy
| | - Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Claudio Liguori
- Department of Systems Medicine, University of Rome ‘Tor Vergata”, Rome, Italy
- Epilepsy Center, Neurology Unit, University Hospital “Tor Vergata”, Rome, Italy
| | - Marta Maschio
- Center for Tumor-Related Epilepsy, UOSD Neuro-Oncology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Stefano Meletti
- Neurology Department, University Hospital of Modena, Modena, Italy
- Department of Biomedical, Metabolic, and Neural Sciences, University of Modena and Reggio-Emilia, Modena, Italy
| | - Lino Nobili
- Child Neuropsychiatry Unit, IRCCS Istituto G. Gaslini, Genova, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Child and Maternal Health (DINOGMI), University of Genova, Genova, Italy
| | - Francesca Felicia Operto
- Child and Adolescent Neuropsychiatry Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, Salerno, Italy
- Department of Science of Health, School of Medicine, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Andrea Romigi
- Sleep Medicine Center, Neurological Mediterranean Institute IRCCS Neuromed, Pozzilli, Italy
- Psychology Faculty, International Telematic University Uninettuno, Rome, Italy
| | - Emilio Russo
- Department of Science of Health, School of Medicine, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Carlo Di Bonaventura
- Epilepsy Unit, Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
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Du Y, Fang W, Huang W, Xu Q, Gong J, Xia N, Zhu Z, Wang X, Zheng R, Xu H. Changes in seizure frequency and anti-seizure medication therapy during pregnancy and one year postpregnancy. Epilepsy Behav 2023; 144:109256. [PMID: 37244219 DOI: 10.1016/j.yebeh.2023.109256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 04/29/2023] [Accepted: 05/05/2023] [Indexed: 05/29/2023]
Abstract
Seizure control in women with epilepsy (WWE) during pregnancy is a vital concern. The aim of this study was to compare changes in seizure frequency and anti-seizure medication (ASM ) therapy in WWE in a real-world setting over three epochs (prepregnancy, pregnancy, and postpregnancy). We screened WWE who were pregnant between 1 January 2010 and 31 December 2020 from the epilepsy follow-up registry database of a tertiary hospital in China. We reviewed and collected follow-up data for the following time periods: 12 months before pregnancy (epoch 1), throughout pregnancy and the first 6 weeks postpartum (epoch 2), and from 6 weeks to 12 months postpartum (epoch 3). Seizures were classified into two categories: tonic‒clonic/focal to bilateral tonic‒clonic seizures and non-tonic‒clonic seizures. The main indicator was the seizure-free rate over the three epochs. Using epoch 1 as a reference, we also compared the percentage of women with an increased seizure frequency, as well as changes in ASM treatment, in epochs 2 and 3. Ultimately, 271 eligible pregnancies in 249 women were included. The seizure-free rates in epoch 1, epoch 2, and epoch 3 were 38.4%, 34.7%, and 43.9%, respectively (P = 0.09). The top three ASMs used in the three epochs were lamotrigine, levetiracetam, and oxcarbazepine. Using epoch 1 as a reference, the percentages of women with increased frequencies of tonic‒clonic/focal to bilateral tonic‒clonic seizures in epoch 2 and epoch 3 were 17.0% and 14.8%, respectively, while the percentages of women with an increased frequency of non-tonic‒clonic seizures in epoch 2 and epoch 3 were 31.0% and 21.8% (P = 0.02). The percentage of women whose ASM dosages were increased in epoch 2 was higher than that in epoch 3 (35.8% vs. 27.3%, P = 0.03). The seizure frequency during pregnancy may not differ significantly from that during prepregnancy and postpregnancy if WWE are treated according to the guidelines.
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Affiliation(s)
- Yanru Du
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, PR China.
| | - Wenqiang Fang
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, PR China.
| | - Wenting Huang
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, PR China.
| | - Qi Xu
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, PR China.
| | - Jiaoni Gong
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, PR China.
| | - Niange Xia
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, PR China.
| | - Zhenguo Zhu
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, PR China.
| | - Xinshi Wang
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, PR China.
| | - Rongyuan Zheng
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, PR China.
| | - Huiqin Xu
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, PR China.
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Mazzone PP, Hogg KM, Weir CJ, Stephen J, Bhattacharya S, Chin RFM. Comparison of Perinatal Outcomes for Women With and Without Epilepsy: A Systematic Review and Meta-analysis. JAMA Neurol 2023; 80:484-494. [PMID: 36912826 PMCID: PMC10012044 DOI: 10.1001/jamaneurol.2023.0148] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 01/12/2023] [Indexed: 03/14/2023]
Abstract
Importance Pregnant women who have epilepsy need adequate engagement, information, and pregnancy planning and management to improve pregnancy outcomes. Objective To investigate perinatal outcomes in women with epilepsy compared with women without epilepsy. Data Sources Ovid MEDLINE, Embase, CINAHL, and PsycINFO were searched with no language or date restrictions (database inception through December 6, 2022). Searches also included OpenGrey and Google Scholar and manual searching in journals and reference lists of included studies. Study Selection All observational studies comparing women with and without epilepsy were included. Data Extraction and Synthesis The PRISMA checklist was used for abstracting data and the Newcastle-Ottawa Scale for risk-of-bias assessment. Data extraction and risk-of-bias assessment were done independently by 2 authors with mediation conducted independently by a third author. Pooled unadjusted odds ratios (OR) or mean differences were reported with 95% CI from random-effects (I2 heterogeneity statistic >50%) or fixed-effects (I2 < 50%) meta-analyses. Main Outcomes and Measures Maternal, fetal, and neonatal complications. Results Of 8313 articles identified, 76 were included in the meta-analyses. Women with epilepsy had increased odds of miscarriage (12 articles, 25 478 pregnancies; OR, 1.62; 95% CI, 1.15-2.29), stillbirth (20 articles, 28 134 229 pregnancies; OR, 1.37; 95% CI, 1.29-1.47), preterm birth (37 articles, 29 268 866 pregnancies; OR, 1.41; 95% CI, 1.32-1.51) and maternal death (4 articles, 23 288 083 pregnancies; OR, 5.00; 95% CI, 1.38-18.04). Neonates born to women with epilepsy had increased odds of congenital conditions (29 articles, 24 238 334 pregnancies; OR, 1.88; 95% CI, 1.66-2.12), neonatal intensive care unit admission (8 articles, 1 204 428 pregnancies; OR, 1.99; 95% CI, 1.58-2.51), and neonatal or infant death (13 articles, 1 426 692 pregnancies; OR, 1.87; 95% CI, 1.56-2.24). The increased odds of poor outcomes was increased with greater use of antiseizure medication. Conclusions and Relevance This systematic review and meta-analysis found that women with epilepsy have worse perinatal outcomes compared with women without epilepsy. Women with epilepsy should receive pregnancy counseling from an epilepsy specialist who can also optimize their antiseizure medication regimen before and during pregnancy.
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Affiliation(s)
- Paolo Pierino Mazzone
- Muir Maxwell Epilepsy Centre, University of Edinburgh, Edinburgh, United Kingdom
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
- Child Life and Health, Centre for Inflammation Research, University of Edinburgh, Edinburgh, United Kingdom
| | | | - Christopher J. Weir
- Muir Maxwell Epilepsy Centre, University of Edinburgh, Edinburgh, United Kingdom
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Jacqueline Stephen
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, United Kingdom
| | - Sohinee Bhattacharya
- The Institute of Applied Health Sciences, Aberdeen Centre for Women’s Health Research, University of Aberdeen, Aberdeen, United Kingdom
| | - Richard F. M. Chin
- Muir Maxwell Epilepsy Centre, University of Edinburgh, Edinburgh, United Kingdom
- Royal Hospital for Children and Young People, Edinburgh, United Kingdom
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
- Child Life and Health, Centre for Inflammation Research, University of Edinburgh, Edinburgh, United Kingdom
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23
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Adams RS, Akobirshoev I, Brenner LA, Katon JG, Mitra M. Pregnancy, Fetal, and Neonatal Outcomes Among Women With Traumatic Brain Injury. J Head Trauma Rehabil 2023; 38:E167-E176. [PMID: 36731040 PMCID: PMC10102258 DOI: 10.1097/htr.0000000000000807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE There have been no systematic studies of pregnancy outcomes among women with traumatic brain injury (TBI), potentially limiting informed clinical care for women with such injuries. The purpose of this exploratory study was to evaluate pregnancy and fetal/neonatal outcomes among women with a TBI diagnosis recorded during their delivery hospitalization compared with women without TBI. SETTING In this cross-sectional study, we identified women with delivery hospitalizations using 2004-2014 data from the Nationwide Inpatient Sample of the Health Care and Cost Utilization Project. PARTICIPANTS We identified deliveries to women with a TBI diagnosis on hospital discharge records, which included all diagnoses recorded during the delivery, and compared them with deliveries of women without a TBI diagnosis. MAIN MEASURES Pregnancy outcomes included gestational diabetes; preeclampsia/eclampsia; placental abruption; cesarean delivery; and others. Fetal/neonatal outcomes included preterm birth; stillbirth; and small or large gestational age. DESIGN We modeled risk for each outcome among deliveries to women with TBI compared with women without TBI, using multivariate Poisson regression. Models included sociodemographic and hospital characteristics; secondary models added clinical characteristics (eg, psychiatric disorders) that may be influenced by TBI. RESULTS We identified 3 597 deliveries to women with a TBI diagnosis and 9 106 312 deliveries to women without TBI. Women with TBI were at an increased risk for placental abruption (relative risk [RR] = 2.73; 95% CI, 2.26-3.30) and associated sequelae (ie, antepartum hemorrhage, cesarean delivery). Women with TBI were at an increased risk for stillbirth (RR = 2.55; 95% CI, 1.97-3.29) and having a baby large for gestational age (RR = 1.30; 95% CI, 1.09-1.56). Findings persisted after controlling for clinical characteristics. CONCLUSIONS Risk for adverse pregnancy outcomes, including placental abruption and stillbirth, were increased among women with TBI. Future research is needed to examine the association between TBI and pregnancy outcomes using longitudinal and prospective data and to investigate potential mechanisms that may heighten risk for adverse outcomes.
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Affiliation(s)
- Rachel Sayko Adams
- Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts, USA
- VHA Rocky Mountain Mental Illness Research Education and Clinical Center, Aurora, Colorado, USA
| | - Ilhom Akobirshoev
- Lurie Institute for Disability Policy, The Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts, USA
| | - Lisa A. Brenner
- VHA Rocky Mountain Mental Illness Research Education and Clinical Center, Aurora, Colorado, USA
- University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Jodie G. Katon
- Health Services Research and Development, Center of Innovation for Veteran-Centered and Value-Driven Care, US Department of Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
- Department of Health Systems and Population Health, University of Washington, Seattle, WA, USA
| | - Monika Mitra
- Lurie Institute for Disability Policy, The Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts, USA
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Wahab A, Iqbal A. Black-Box Warnings of Antiseizure Medications: What is Inside the Box? Pharmaceut Med 2023; 37:233-250. [PMID: 37119452 DOI: 10.1007/s40290-023-00475-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2023] [Indexed: 05/01/2023]
Abstract
Antiseizure medications can cause serious adverse reactions and have deleterious drug interactions that often complicate the clinical management of patients. When the US Food and Drug Administration (FDA) wants to alert healthcare providers and patients about the risk of potentially serious or fatal drug reactions, the FDA requires the manufacturers of these medications to format these warnings within a "black-box" border, and prominently display this box on the first section of the package insert; such warnings are called "black-box warnings (BBWs)". The BBW is a way for the FDA to urge physicians to evaluate patients more rigorously and carefully weigh the risks and benefits, before prescribing medication that has the potential to cause serious adverse reactions, and to formulate a plan for close monitoring during therapy. The FDA BBW provides the extra layer of safety but many healthcare providers fail to comply with these warnings. Currently, there are 26 FDA-approved antiseizure medications in the US market, 38% of which have received BBWs, and most of the antiseizure medications with BBWs are older-generation drugs. Some antiseizure medications have multiple BBWs; for example, valproic acid has three BBWs including hepatotoxicity, fetal risk, and pancreatitis, carbamazepine has BBWs of serious skin and hematological reactions, and felbamate also has two BBWs including hepatic failure and aplastic anemia. The purpose of this review is to provide insight into each BBW received by antiseizure medications and discuss the FDA recommendations for evaluating the drug benefit/risk, and for monitoring parameters before the initiation of and during treatment.
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Affiliation(s)
- Abdul Wahab
- Department of Pharmacy, Emory Healthcare, Emory Decatur Hospital, Decatur, GA, 30033, USA.
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25
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McNulty ML. Gender Issues in Epileptic Patients. Neurol Clin 2023; 41:249-263. [PMID: 37030956 DOI: 10.1016/j.ncl.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Treatment approaches for epilepsy for both women and men are similar, however, there are special aspects that must be considered when caring for women with epilepsy. This includes how hormonal fluctuations may affect seizure frequency, contraception, and potential drug-drug interactions, and pregnancy planning to minimize and potentially mitigate any adverse neurodevelopmental outcomes and major congenital malformations. Adequate counseling for women across the lifespan can help prepare women for the future and optimize outcomes.
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Affiliation(s)
- Maggie L McNulty
- Department of Neurology, Rush University Medical Center, 1725 West Harrison Street Suite 885, Chicago, IL 60612, USA.
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26
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Morbidity and rehospitalization postpartum among women with epilepsy and their infants: A population-based study. Epilepsy Behav 2022; 136:108943. [PMID: 36252288 DOI: 10.1016/j.yebeh.2022.108943] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 09/15/2022] [Accepted: 09/29/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE We compared the relative occurrence of selected pregnancy outcomes and postpartum rehospitalizations among women with and without epilepsy and their infants. Using linked vital-hospital discharge records of women with deliveries in Washington State 1987-2014, comparisons were made overall, by epilepsy type, and by time periods related to antiepileptic drug (AED) marketing changes. METHODS This population-based retrospective cohort study identified women with, and without epilepsy per diagnosis codes in the hospital discharge record from among all deliveries during 1987-2014 to examine maternal and infant outcomes, rehospitalization and mortality <2 years postpartum. Relative risks (RRs) and 95 % confidence intervals (CI) overall, and by epilepsy type were calculated using Poisson regression. We assessed the validity of epilepsy identification based on diagnosis codes by conducting a medical chart review for a sample of women. RESULTS Women with epilepsy had increased risks of preeclampsia (RR 1.23; 95 % CI 1.08-1.41) and gestational diabetes (RR 1.18; 95 % CI 1.02-1.36). Their infants had increased malformation (RR 1.23; 95 % C: 1.08-1.42) and small for gestational age (SGA, RR 1.39; 95 % CI 1.25-1.54) risks, and were nearly three times as likely to not be breastfed. Affected mothers (RR 5.25; 95 % CI 2.46-11.23) and their infants (RR 1.64, 95 % CI 1.41-1.89) required more ICU admissions during the delivery hospitalizations, and more postpartum rehospitalization, with greatest risk in the first six months. Maternal mortality < 2 years after delivery was increased (RR 7.11; 95 % CI 2.47-20.49). Increased risks were observed for all epilepsy subtypes for nearly all outcomes examined. Risks of preterm delivery and low birthweight increased over time (p <.05). Suggestive, but not statistically significant temporal decreases in risks of gestational diabetes and malformations and increased risk of preterm labor were noted. We observed high sensitivity of diagnosis codes for identifying pregnant women with epilepsy. CONCLUSION These population-based results emphasize the need for frequent postpartum monitoring of women with epilepsy. Increases in risks of low birthweight and preterm delivery over time are of concern. Possible temporal changes in other outcomes warrant further investigation.
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Tsai YC, Chang HC, Chiou MJ, Luo SF, Kuo CF. Fetal-neonatal and maternal pregnancy outcomes in women with rheumatoid arthritis: a population-based cohort study. BMJ Open 2022; 12:e059203. [PMID: 36288841 PMCID: PMC9615975 DOI: 10.1136/bmjopen-2021-059203] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Rheumatoid arthritis (RA) may adversely influence pregnancy and lead to adverse birth outcomes. This study estimated the risk of adverse fetal-neonatal and maternal pregnancy outcomes in women with RA. DESIGN This was a retrospective cohort study. SETTING We used both the National Health Insurance database and the Taiwan Birth Reporting System, between 2004 and 2014. PARTICIPANTS We identified 2 100 143 singleton pregnancies with 922 RA pregnancies, either live births or stillbirths, delivered by 1 468 318 women. OUTCOME MEASURES ORs with 95% CIs for fetal-neonatal and maternal outcomes were compared between pregnancies involving mothers with and without RA using an adjusted generalised estimating equation model. RESULTS Covariates including age, infant sex, Charlson Comorbidity Index, urbanisation, income, occupation, birth year and maternal nationality were adjusted. Compared with pregnancies in women without RA, pregnancies in women with RA showed that the fetuses/neonates had adjusted ORs (95% CI) of 2.03 (1.66 to 2.50) for low birth weight (n=123), 1.99 (1.64 to 2.40) for prematurity (n=141), 1.77 (1.46 to 2.15) for small for gestational age (n=144) and 1.35 (1.03 to 1.78) for fetal distress (n=60). Pregnancies in women with RA had adjusted ORs (95% CI) of 1.24 (1.00 to 1.52) for antepartum haemorrhage (n=106), 1.32 (1.15 to 1.51) for caesarean delivery (n=398), and 3.33 (1.07 to 10.34) for disseminated intravascular coagulation (n=3), compared with women without RA. Fetuses/neonates born to mothers with RA did not have a higher risk of being stillborn or having fetal abnormalities. Pregnant women with RA did not have increased risks of postpartum death, cardiovascular complications, surgical complications or systemic organ dysfunction. CONCLUSIONS Pregnancies in women with RA were associated with higher risks of multiple adverse fetal-neonatal and maternal outcomes; however, most pregnancies in these women were successful.
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Affiliation(s)
- Yun-Chen Tsai
- Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Hsiao-Chun Chang
- Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Zuellig Pharma Specialty Solutions Group Pte Ltd, Singapore
| | - Meng-Jiun Chiou
- Corporate Medical Affairs, Center for Artificial Intelligence in Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Shue-Fen Luo
- Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chang-Fu Kuo
- Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Division of Rheumatology, Orthopaedics and Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
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28
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Shi X, Wang Y, Zhang Y, Song C, Jiang Y, Zhao J, Xia L, Ma L, Jiang W. Effects of antiepileptic drugs polytherapy on pregnancy outcomes in women with epilepsy: An observation study in northwest China. Epilepsy Behav 2022; 135:108904. [PMID: 36095876 DOI: 10.1016/j.yebeh.2022.108904] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 08/01/2022] [Accepted: 08/26/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The management of pregnant women with epilepsy (WWE) treated with antiepileptic drugs (AEDs) polytherapy poses a great challenge. The purpose of this study was to evaluate the major congenital malformations (MCMs) associated with AED polytherapy, to assess the impacts of polytherapy regimens on seizure control and breastfeeding, and to determine the potential predictors for pregnancy outcomes. METHODS This study was based on prospectively acquired data from a registry enrolling WWE in early pregnancy from Feb 2010 to July 2019, in which 123 pregnancies in 110 WWE were exposed to 27 different AED combinations. RESULTS There were 123 pregnancies in 110 WWE analyzed in our study. The live birth rate was 86.2 % and the risk of MCMs was 10.4 %. Multivariate analysis indicated that prenatal exposure to phenobarbital (odds ratio [OR], 17.424; 95 %CI, 1.510-201.067; P = 0.022) and topiramate (OR, 9.469; 95 %CI, 1.149-62.402; P = 0.036) was associated with increased risk of MCMs. Valproate (OR, 4.441; 95 %CI, 1.165-16.934; P = 0.029), phenobarbital (OR, 13.636; 95 %CI, 2.146-86.660; P = 0.006) and topiramate (OR, 7.527; 95 %CI, 1.764-32.118; P = 0.006) were significantly correlated with adverse pregnancy outcomes. Among 67 pregnancies in four combinations over 10 patients, 15 (22.4 %) remained seizure free through pregnancy, seizure frequency increased in 17 (25.4 %), decreased in 24 (35.8 %) women, in 26 (38.8 %) remained unchanged. Only 23.6 % of mothers undertook exclusive breastfeeding. Planned pregnancy was the only independent factor significantly associated with decreased risk of adverse pregnancy outcomes (OR, 0.139; 95 % CI, 0.051-0.382; P < 0.001). Notably, no adverse pregnancy outcome was recorded in pregnancies exposed to the combination of lamotrigine plus levetiracetam. CONCLUSION Prenatal exposure to the combinations containing valproate, phenobarbital, or topiramate was associated with increased risk of adverse pregnant outcomes. AED-related teratogenicity may be reduced by planned pregnancy in WWE exposed to polytherapy. Our findings also suggest the combination of lamotrigine and levetiracetam seems to be most desirable to balance seizure control and fetal safety.
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Affiliation(s)
- Xiaojing Shi
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
| | - Yuanyuan Wang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
| | - Yaoyao Zhang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
| | - Changgeng Song
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
| | - Yongli Jiang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
| | - Jingjing Zhao
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
| | - Liang Xia
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
| | - Lei Ma
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
| | - Wen Jiang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
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29
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Epilepsy Complicating Pregnancy. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2022. [DOI: 10.1007/s13669-022-00344-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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30
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Jones-Muhammad M, Shao Q, Warrington JP. Increased seizure sensitivity in pregnant mice with genetic knockdown of acid sensing ion channel 2a is associated with impaired hippocampal inflammatory response. Front Physiol 2022; 13:983506. [PMID: 36187797 PMCID: PMC9515891 DOI: 10.3389/fphys.2022.983506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 08/30/2022] [Indexed: 11/17/2022] Open
Abstract
Acid sensing ion channels (ASICs) are mechano- and chemo-receptor channels that are activated by drops in extracellular pH as occurs after neurotransmission. In our previous study, we demonstrated that mice subjected to reduced utero-placental perfusion pressure during pregnancy, to mimic the pregnancy complication of preeclampsia, have reduced hippocampal expression of ASIC2a protein. We also showed that pregnant mice with heterozygous expression of ASIC2a (+/-) had increased sensitivity and severity to pentylenetetrazol-induced seizures; however, the mechanisms by which this occurs remain unclear. The purpose of this study was to investigate key molecular targets involving neurotransmission and inflammation that are differentially changed following seizure exposure in pregnant ASIC2a +/- mice. On gestational day 18.5, ASIC2a wild-type (+/+, n = 7) and +/- (n = 14) mice were injected with 40 mg/kg pentylenetetrazol and monitored for 30 min. Western blot and ELISA analysis revealed no difference in hippocampal synaptosome glutamate-related proteins but an increase in GABA concentration in pregnant +/- mice. Using ELISA and multiplex assays, we found a significant decrease in serum TNFα, and a decreased concentration of pro-inflammatory cytokines and chemokines in hippocampal cytosolic fraction. Significant reductions in IL-1β, IL-3, IL-12 (p70), eotaxin, interferon gamma, and macrophage inflammatory protein (MIP-1β), in the hippocampal cytosolic fractions of +/- mice were observed compared to +/+ mice. Additionally, there was no difference in hippocampal microglia density or activation in pregnant ASIC2a+/+ vs. +/- mice. These results support the hypothesis that pregnant mice with reduced ASIC2a may not be able to mount an inflammatory response following acute seizure exposure.
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Affiliation(s)
- Maria Jones-Muhammad
- Program in Neuroscience, University of Mississippi Medical Center, Jackson, MS, United States
| | - Qingmei Shao
- Department of Neurology, University of Mississippi Medical Center, Jackson, MS, United States
| | - Junie P. Warrington
- Department of Neurology, University of Mississippi Medical Center, Jackson, MS, United States
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Hophing L, Kyriakopoulos P, Bui E. Sex and gender differences in epilepsy. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2022; 164:235-276. [PMID: 36038205 DOI: 10.1016/bs.irn.2022.06.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Sex and gender differences in epilepsy are important influencing factors in epilepsy care. In epilepsy, the hormonal differences between the sexes are important as they impact specific treatment considerations for patients at various life stages particularly during early adulthood with establishment of the menstrual cycle, pregnancy, perimenopause and menopause. Choice of antiseizure medication may have direct consequences on hormonal cycles, hormonal contraception, pregnancy and fetal risk of major congenital malformation. Conversely hormones whether intrinsic or extrinsically administered may have direct impact on antiseizure medications and seizure control. This chapter explores these important influences on the management of persons with epilepsy.
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Affiliation(s)
- Lauren Hophing
- Krembil Brain Institute, University Health Network, University of Toronto, Toronto, Canada
| | | | - Esther Bui
- Krembil Brain Institute, University Health Network, University of Toronto, Toronto, Canada.
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Alvestad S, Husebye ESN, Christensen J, Dreier JW, Sun Y, Igland J, Leinonen MK, Gissler M, Gilhus NE, Tomson T, Bjørk M. Folic Acid and Risk of Preterm Birth, Preeclampsia, and Fetal Growth Restriction Among Women With Epilepsy: A Prospective Cohort Study. Neurology 2022; 99:e605-e615. [PMID: 35577577 PMCID: PMC9442624 DOI: 10.1212/wnl.0000000000200669] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 03/16/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Women with epilepsy treated with antiseizure medication (ASM) have increased risk of pregnancy complications including preterm birth, fetal growth restriction, and preeclampsia. We aimed to investigate whether folic acid supplementation is associated with these pregnancy complications in women with epilepsy using ASM. METHODS Singleton pregnancies in the prospective Norwegian Mother and Child Cohort Study (MoBa) (1999-2008) were included. Information on maternal epilepsy, ASM, folic acid supplementation, and pregnancy outcomes was obtained from the MoBa questionnaires and the Norwegian Medical Birth Registry. The main exposure, periconceptional folic acid supplementation, was defined as intake between 4 weeks before pregnancy and 12 weeks into pregnancy, retrospectively collected by recall of the mothers in weeks 17-19. The primary outcomes were preterm birth (gestational age <37 weeks at birth), small for gestational age (SGA), and preeclampsia. RESULTS The study included 100,105 pregnancies: 99,431 without maternal epilepsy, 316 with maternal epilepsy and ASM exposure in pregnancy, and 358 with untreated maternal epilepsy. Among ASM-treated women with epilepsy, the risk of preterm birth was higher in those who did not use periconceptional folic acid (n = 64) compared with those who did (n = 245, the reference) (adjusted odds ratio [aOR] 3.3, 95% CI 1.2-9.2), while the risk of preterm birth among the reference was similar to the risk among women without epilepsy using folic acid periconceptionally (aOR 0.9, 95% CI 0.5-1.6). ASM-treated women with epilepsy starting folic acid after the first trimester had a higher risk compared with women without epilepsy with similar timing of folic acid (aOR 2.6, 95% CI 1.1-6.5), and even higher if not using folic acid (aOR 9.4, 95% CI 2.6-34.8). Folic acid was not associated with risk of preterm birth among women with epilepsy without ASM or among women without epilepsy. Folic acid was not associated with risk of preeclampsia or SGA among women with epilepsy. DISCUSSION In women with epilepsy using ASM, periconceptional folic acid was associated with a lower risk of preterm birth. This finding supports the recommendation that ASM-treated women with epilepsy of childbearing potential should use folic acid supplementation on a regular basis. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that for women with epilepsy using ASM, periconceptional folic acid supplementation decreases the risk of preterm birth.
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Affiliation(s)
- Silje Alvestad
- From the Department of Clinical Medicine (S.A., E.S.N.H., J.W.D., N.E.G., M.B.), University of Bergen; National Center for Epilepsy (S.A.), Oslo; Department of Neurology (E.S.N.H., N.E.G., M.B.), Haukeland University Hospital, Bergen, Norway; Department of Neurology (J.C., Y.S.), and National Centre for Register-Based Research (J.C., J.W.D., Y.S.), Aarhus University, Denmark; Core Facility for Biostatistics and Data Analysis (J.I.), Department of Global Public Health and Primary Care, University of Bergen, Norway; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare (THL), Helsinki, Finland; Departments of Molecular Medicine and Surgery (M.G.), Clinical Neuroscience (T.T.), and Department of Neurology (T.T.), Karolinska University Hospital, Stockholm, Sweden.
| | - Elisabeth Synnøve Nilsen Husebye
- From the Department of Clinical Medicine (S.A., E.S.N.H., J.W.D., N.E.G., M.B.), University of Bergen; National Center for Epilepsy (S.A.), Oslo; Department of Neurology (E.S.N.H., N.E.G., M.B.), Haukeland University Hospital, Bergen, Norway; Department of Neurology (J.C., Y.S.), and National Centre for Register-Based Research (J.C., J.W.D., Y.S.), Aarhus University, Denmark; Core Facility for Biostatistics and Data Analysis (J.I.), Department of Global Public Health and Primary Care, University of Bergen, Norway; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare (THL), Helsinki, Finland; Departments of Molecular Medicine and Surgery (M.G.), Clinical Neuroscience (T.T.), and Department of Neurology (T.T.), Karolinska University Hospital, Stockholm, Sweden
| | - Jakob Christensen
- From the Department of Clinical Medicine (S.A., E.S.N.H., J.W.D., N.E.G., M.B.), University of Bergen; National Center for Epilepsy (S.A.), Oslo; Department of Neurology (E.S.N.H., N.E.G., M.B.), Haukeland University Hospital, Bergen, Norway; Department of Neurology (J.C., Y.S.), and National Centre for Register-Based Research (J.C., J.W.D., Y.S.), Aarhus University, Denmark; Core Facility for Biostatistics and Data Analysis (J.I.), Department of Global Public Health and Primary Care, University of Bergen, Norway; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare (THL), Helsinki, Finland; Departments of Molecular Medicine and Surgery (M.G.), Clinical Neuroscience (T.T.), and Department of Neurology (T.T.), Karolinska University Hospital, Stockholm, Sweden
| | - Julie Werenberg Dreier
- From the Department of Clinical Medicine (S.A., E.S.N.H., J.W.D., N.E.G., M.B.), University of Bergen; National Center for Epilepsy (S.A.), Oslo; Department of Neurology (E.S.N.H., N.E.G., M.B.), Haukeland University Hospital, Bergen, Norway; Department of Neurology (J.C., Y.S.), and National Centre for Register-Based Research (J.C., J.W.D., Y.S.), Aarhus University, Denmark; Core Facility for Biostatistics and Data Analysis (J.I.), Department of Global Public Health and Primary Care, University of Bergen, Norway; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare (THL), Helsinki, Finland; Departments of Molecular Medicine and Surgery (M.G.), Clinical Neuroscience (T.T.), and Department of Neurology (T.T.), Karolinska University Hospital, Stockholm, Sweden
| | - Yuelian Sun
- From the Department of Clinical Medicine (S.A., E.S.N.H., J.W.D., N.E.G., M.B.), University of Bergen; National Center for Epilepsy (S.A.), Oslo; Department of Neurology (E.S.N.H., N.E.G., M.B.), Haukeland University Hospital, Bergen, Norway; Department of Neurology (J.C., Y.S.), and National Centre for Register-Based Research (J.C., J.W.D., Y.S.), Aarhus University, Denmark; Core Facility for Biostatistics and Data Analysis (J.I.), Department of Global Public Health and Primary Care, University of Bergen, Norway; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare (THL), Helsinki, Finland; Departments of Molecular Medicine and Surgery (M.G.), Clinical Neuroscience (T.T.), and Department of Neurology (T.T.), Karolinska University Hospital, Stockholm, Sweden
| | - Jannicke Igland
- From the Department of Clinical Medicine (S.A., E.S.N.H., J.W.D., N.E.G., M.B.), University of Bergen; National Center for Epilepsy (S.A.), Oslo; Department of Neurology (E.S.N.H., N.E.G., M.B.), Haukeland University Hospital, Bergen, Norway; Department of Neurology (J.C., Y.S.), and National Centre for Register-Based Research (J.C., J.W.D., Y.S.), Aarhus University, Denmark; Core Facility for Biostatistics and Data Analysis (J.I.), Department of Global Public Health and Primary Care, University of Bergen, Norway; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare (THL), Helsinki, Finland; Departments of Molecular Medicine and Surgery (M.G.), Clinical Neuroscience (T.T.), and Department of Neurology (T.T.), Karolinska University Hospital, Stockholm, Sweden
| | - Maarit K Leinonen
- From the Department of Clinical Medicine (S.A., E.S.N.H., J.W.D., N.E.G., M.B.), University of Bergen; National Center for Epilepsy (S.A.), Oslo; Department of Neurology (E.S.N.H., N.E.G., M.B.), Haukeland University Hospital, Bergen, Norway; Department of Neurology (J.C., Y.S.), and National Centre for Register-Based Research (J.C., J.W.D., Y.S.), Aarhus University, Denmark; Core Facility for Biostatistics and Data Analysis (J.I.), Department of Global Public Health and Primary Care, University of Bergen, Norway; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare (THL), Helsinki, Finland; Departments of Molecular Medicine and Surgery (M.G.), Clinical Neuroscience (T.T.), and Department of Neurology (T.T.), Karolinska University Hospital, Stockholm, Sweden
| | - Mika Gissler
- From the Department of Clinical Medicine (S.A., E.S.N.H., J.W.D., N.E.G., M.B.), University of Bergen; National Center for Epilepsy (S.A.), Oslo; Department of Neurology (E.S.N.H., N.E.G., M.B.), Haukeland University Hospital, Bergen, Norway; Department of Neurology (J.C., Y.S.), and National Centre for Register-Based Research (J.C., J.W.D., Y.S.), Aarhus University, Denmark; Core Facility for Biostatistics and Data Analysis (J.I.), Department of Global Public Health and Primary Care, University of Bergen, Norway; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare (THL), Helsinki, Finland; Departments of Molecular Medicine and Surgery (M.G.), Clinical Neuroscience (T.T.), and Department of Neurology (T.T.), Karolinska University Hospital, Stockholm, Sweden
| | - Nils Erik Gilhus
- From the Department of Clinical Medicine (S.A., E.S.N.H., J.W.D., N.E.G., M.B.), University of Bergen; National Center for Epilepsy (S.A.), Oslo; Department of Neurology (E.S.N.H., N.E.G., M.B.), Haukeland University Hospital, Bergen, Norway; Department of Neurology (J.C., Y.S.), and National Centre for Register-Based Research (J.C., J.W.D., Y.S.), Aarhus University, Denmark; Core Facility for Biostatistics and Data Analysis (J.I.), Department of Global Public Health and Primary Care, University of Bergen, Norway; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare (THL), Helsinki, Finland; Departments of Molecular Medicine and Surgery (M.G.), Clinical Neuroscience (T.T.), and Department of Neurology (T.T.), Karolinska University Hospital, Stockholm, Sweden
| | - Torbjörn Tomson
- From the Department of Clinical Medicine (S.A., E.S.N.H., J.W.D., N.E.G., M.B.), University of Bergen; National Center for Epilepsy (S.A.), Oslo; Department of Neurology (E.S.N.H., N.E.G., M.B.), Haukeland University Hospital, Bergen, Norway; Department of Neurology (J.C., Y.S.), and National Centre for Register-Based Research (J.C., J.W.D., Y.S.), Aarhus University, Denmark; Core Facility for Biostatistics and Data Analysis (J.I.), Department of Global Public Health and Primary Care, University of Bergen, Norway; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare (THL), Helsinki, Finland; Departments of Molecular Medicine and Surgery (M.G.), Clinical Neuroscience (T.T.), and Department of Neurology (T.T.), Karolinska University Hospital, Stockholm, Sweden
| | - Marte Bjørk
- From the Department of Clinical Medicine (S.A., E.S.N.H., J.W.D., N.E.G., M.B.), University of Bergen; National Center for Epilepsy (S.A.), Oslo; Department of Neurology (E.S.N.H., N.E.G., M.B.), Haukeland University Hospital, Bergen, Norway; Department of Neurology (J.C., Y.S.), and National Centre for Register-Based Research (J.C., J.W.D., Y.S.), Aarhus University, Denmark; Core Facility for Biostatistics and Data Analysis (J.I.), Department of Global Public Health and Primary Care, University of Bergen, Norway; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare (THL), Helsinki, Finland; Departments of Molecular Medicine and Surgery (M.G.), Clinical Neuroscience (T.T.), and Department of Neurology (T.T.), Karolinska University Hospital, Stockholm, Sweden
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de Lima Leite M, Toporcov TN, Pai JD, da Silva JC. Socio-demographic profiles and obstetrics outcomes of pregnant women with epilepsy in a vulnerability State, Brazil. PLoS One 2022; 17:e0271328. [PMID: 35857720 PMCID: PMC9299315 DOI: 10.1371/journal.pone.0271328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 06/28/2022] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION The socio-demographic profile of pregnant women in low- and middle- income countries is characterized by low educational attainment and unemployment, leading to social and economic morbidity. characterized by limited opportunities for education, employment, and marriage, which are strongly related to the stigmatization of the disease. The study of the socio- profile and obstetric outcomes of pregnant women with epilepsy in Alagoas, Brazil, may help understand this scenario and facilitate the development of public policy strategies to reduce local morbidity. OBJECTIVES We aimed to describe the sociodemographic profile of pregnant women with epilepsy and obstetric outcomes in Alagoas, Brazil. METHODS This cohort study was based on medical records of pregnant women with epilepsy in Brazilian high-risk maternity hospitals from 2008 to 2020. The following data were collected: age, race, education, marital status, occupation, number of pregnancies, delivery, and abortion. The inclusion criteria were pregnant women with and without epilepsy (control group) aged < 40 years. RESULTS The prevalence of PWWE was 0.49% (n = 224/44,917). Cesarean delivery was more frequent in PWWE than in pregnant women without epilepsy (adjusted odds ratio [OR] = 22.0; 95% confidence interval [CI] = 14.35-33.73; p<0,01). Abortion was associated with PWWE (OR adjusted = 1.72; 95% CI = 1.13-2.61; p = 0.01). Pregnant women in the countryside were more likely to develop epilepsy than those born in the capital (OR = 1.55; 95% CI = 1.12-2.14; p <0.01). CONCLUSION The PWWE socio-demographic profile of the Alagoas had a predominance of brown- colored skin, single status, homemakers, and illiteracy with a high proportion residing in the interior of the state. The obstetrics data show a higher incidence of cesarean deliveries and miscarriages.
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Affiliation(s)
- Magnúcia de Lima Leite
- Universidade Estadual de Ciências da Saúde Alagoas (UNCISAL), Maceió, AL, Brazil
- Universidade de São Paulo (USP), São Paulo, SP, Brazil
| | | | - Janise Dal Pai
- Universidade Pontifícia Católica do Rio Grande do Sul (PUCRS), Rio Grande do Sul, RS, Brazil
| | - José Claudio da Silva
- Universidade Estadual de Ciências da Saúde Alagoas (UNCISAL), Maceió, AL, Brazil
- Faculdade de Medicina do Centro Universitário (CESMAC), Maceió, AL, Brazil
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La Neve A, Falcicchio G, Trojano M, Boero G. Seizure medication and planned pregnancy: balancing the risks and outcomes. Expert Rev Neurother 2022; 22:527-539. [PMID: 35726788 DOI: 10.1080/14737175.2022.2093107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION The therapeutic management of women with epilepsy (WWE) of childbearing age can be complicated by the need to balance maternal/fetal risks related to seizure occurrence during gestation with the potential teratogenic risks related to the use of anti-seizure medications (ASMs). AREAS COVERED The authors review clinical evidence on seizure-related and ASM-related risks during pregnancy. Current regulatory indications are discussed, evaluating their impact on clinical practice, and ethical implications of pharmacological decisions are debated. EXPERT OPINION If properly informed about the maternal/fetal risks carried by different pharmacological choices, WWE can become the final decision makers regarding their care in every phase of their life. Over the coming years, analysis of aggregated pregnancy registry data on the structural impact, on the fetus, of low doses of valproate and of newer ASMs, together with analysis of the main population study data on functional (cognitive and behavioral) outcomes, could lead to huge advances, making choosing an ASM a less complex process for the clinician and a less painful decision for the woman. Future objectives should include identification of the potential role of the pharmacogenomic profile of WWE in determining the risk of fetal malformations.
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Affiliation(s)
- Angela La Neve
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari, Bari, Italy
| | - Giovanni Falcicchio
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari, Bari, Italy
| | - Maria Trojano
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari, Bari, Italy
| | - Giovanni Boero
- Complex Structure of Neurology, SS Annunziata Hospital, Taranto, Italy
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The Rate of and Factors Associated with Delivery by Caesarean Section among Women with Epilepsy: Time Trend in a Single-Centre Cohort in Mazovia, Poland. J Clin Med 2022; 11:jcm11092622. [PMID: 35566748 PMCID: PMC9104823 DOI: 10.3390/jcm11092622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 04/27/2022] [Accepted: 05/04/2022] [Indexed: 02/04/2023] Open
Abstract
Data from literature suggest that the rate of caesarean section (CS) in women with epilepsy (WWE) is higher than in the general population. In Poland, there is neither a national registry nor another data set to access the outcome of pregnancy in WWE. Therefore, we address this gap by prospectively studying CS rates among 1021 WWE pregnancies at a single centre, their trends over time, and factors increasing the likelihood of the CS. To determine whether the diagnosis of epilepsy itself increased this likelihood, mixed models were used to analyse the contributions of specific variables, including the presence of seizures at different pregnancy-related timepoints. Over 20 years, the mean rate of CS in WWE was progressively growing and was higher than in the general population in Mazovia (47% vs. 32%). Generalized seizures in the third trimester increased the likelihood of CS with the highest odds (OR 4.4). The most frequent indication for a CS was obstetric (58.1%), followed by epilepsy-related (25.2%). Almost half of women who indicated epilepsy as the sole reason for CS had no seizure during pregnancy, and nearly 70% did not have generalized seizures. This suggests the overuse of epilepsy as an indication of CS and encourages defining more strict criteria.
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Decker BM, Thibault D, Davis KA, Willis AW. Population-Based Study of Nonelective Postpartum Readmissions in Women With Stroke, Migraine, Multiple Sclerosis, and Myasthenia Gravis. Neurology 2022; 98:e1545-e1554. [PMID: 35169012 PMCID: PMC9012272 DOI: 10.1212/wnl.0000000000200007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 01/03/2022] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To compare maternal obstetric complications and nonelective readmissions in women with common neurologic comorbidities (WWN) vs women without neurologic disorders. METHODS We performed a retrospective cohort study of index characteristics and acute postpartum, nonelective rehospitalizations from the 2015-2017 National Readmissions Database using ICD-10 codes. Wald χ2 testing compared baseline demographic, hospital, and clinical characteristics and postpartum complications between WWN (including previous stroke, migraine, multiple sclerosis [MS], and myasthenia gravis [MG]) and controls. Multivariable logistic regression models examined odds of postpartum complications and nonelective readmissions within 30 and 90 days for each neurologic comorbidity compared to controls (α = 0.05). RESULTS A total of 7,612 women with previous stroke, 83,430 women with migraine, 6,760 women with MS, 843 women with MG, and 8,136,335 controls met the criteria for index admission after viable infant delivery. WWN were more likely than controls to have inpatient diagnoses of edema, proteinuria, or hypertensive disorders and to have received maternal care for poor fetal growth. The adjusted odds of a Centers for Disease Control and Prevention severe maternal morbidity indicator were greater for women with previous stroke (adjusted odds ratio [AOR] 8.53, 95% CI 7.24-10.06), migraine (AOR 2.04, 95% CI 1.85-2.26), and MG (AOR 4.45, 95% CI 2.45-8.08) (all p < 0.0001). Readmission rates at 30 and 90 days for WWN were higher than for controls (30 days: previous stroke 2.9%, migraine 1.7%, MS 1.8%, MG 4.3%, controls 1.1%; 90 days: previous stroke 3.7%, migraine 2.5%, MS 5.1%, MG 6.0%, controls 1.6%). Women with MG had the highest adjusted odds of readmission (30 days: AOR 3.96, 95% CI 2.37-6.65, p < 0.0001; 90 days: AOR 3.30, 95% CI 1.88-5.78, p < 0.0001). DISCUSSION WWN may be at higher risk of severe maternal morbidity at the time of index delivery and postpartum readmission. More real-world evidence is needed to develop research infrastructure and create efficacious interventions to optimize maternal-fetal outcomes in WWN, especially for women with previous stroke or MG.
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Affiliation(s)
- Barbara M Decker
- From the Department of Neurology (B.M.D., K.A.D., A.W.W.), Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics (B.M.D., D.T., A.W.W.), Department of Neurology, Translational Center of Excellence for Neuroepidemiology and Neurology Outcomes Research, School of Medicine (B.M.D., D.T., A.W.W.), and Leonard Davis Institute of Health Economics (B.M.D., A.W.W.), University of Pennsylvania, Philadelphia; and Department of Neurological Sciences (B.M.D.), University of Vermont Medical Center, Burlington
| | - Dylan Thibault
- From the Department of Neurology (B.M.D., K.A.D., A.W.W.), Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics (B.M.D., D.T., A.W.W.), Department of Neurology, Translational Center of Excellence for Neuroepidemiology and Neurology Outcomes Research, School of Medicine (B.M.D., D.T., A.W.W.), and Leonard Davis Institute of Health Economics (B.M.D., A.W.W.), University of Pennsylvania, Philadelphia; and Department of Neurological Sciences (B.M.D.), University of Vermont Medical Center, Burlington
| | - Kathryn A Davis
- From the Department of Neurology (B.M.D., K.A.D., A.W.W.), Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics (B.M.D., D.T., A.W.W.), Department of Neurology, Translational Center of Excellence for Neuroepidemiology and Neurology Outcomes Research, School of Medicine (B.M.D., D.T., A.W.W.), and Leonard Davis Institute of Health Economics (B.M.D., A.W.W.), University of Pennsylvania, Philadelphia; and Department of Neurological Sciences (B.M.D.), University of Vermont Medical Center, Burlington
| | - Allison W Willis
- From the Department of Neurology (B.M.D., K.A.D., A.W.W.), Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics (B.M.D., D.T., A.W.W.), Department of Neurology, Translational Center of Excellence for Neuroepidemiology and Neurology Outcomes Research, School of Medicine (B.M.D., D.T., A.W.W.), and Leonard Davis Institute of Health Economics (B.M.D., A.W.W.), University of Pennsylvania, Philadelphia; and Department of Neurological Sciences (B.M.D.), University of Vermont Medical Center, Burlington
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Kohn E, Dinavitser N, Berlin M, Brandriss N, Bar-Chaim A, Gueta I, Keidar R, Livne A, Stepensky D, Berkovitch M, Masarwi M. Magnitude of Lamotrigine Exposure Through Breastfeeding. Breastfeed Med 2022; 17:341-348. [PMID: 35049332 DOI: 10.1089/bfm.2021.0304] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Importance: Lamotrigine use during breastfeeding has significantly increased in the recent years, whereas breast milk lamotrigine pharmacokinetics data are still sparse. Objectives: To assess lamotrigine exposure in breastfed infants by monitoring maternal serum and breast milk concentrations. Methods: Breastfeeding women treated with lamotrigine were recruited to this study. Maternal trough breast milk and serum samples were collected, and additional breast milk samples were collected 1, 3, 6, 9, 12 hours after lamotrigine consumption. Trough breast milk/serum ratios (M/S ratio) and breast milk area under the curve (AUC) values were calculated. Results: Twenty-one breastfeeding women were recruited to this study, and the final dataset was based on the samples collected from 17 women. Lamotrigine trough serum and mother's milk concentrations were 5.1 ± 3.3 mg/L and 3.1 ± 1.9 mg/L, respectively (mean ± standard deviation). The trough M/S ratio of lamotrigine was 0.66 ± 0.22. The lamotrigine breast milk average AUC was 41.7 ± 24.6 mg·h/L. The estimated infant dose of lamotrigine was 0.52 ± 0.31 mg/kg/day and 0.26 ± 0.15 mg/kg/day for fully and partially breastfed infants, respectively. Significant correlation was found between the maternal lamotrigine serum trough concentrations and the breast milk parameters: trough breast milk concentrations (Spearman's rho = 0.986, p < 0.0001) and breast milk AUC values (Spearman's rho = 0.941, p < 0.0001). No significant correlation was found between the maternal lamotrigine daily dose and serum trough concentrations, breast milk trough concentrations, and breast milk AUC values (Spearman's rho = 0.294, 0.285, and 0.438, p = 0.252, 0.396, and 0.078, respectively). Conclusion and Relevance: High correlation between the maternal lamotrigine trough serum concentrations and the breast milk AUC values was found, implying that monitoring the maternal lamotrigine serum concentrations can be useful for prediction of exposure of infants to lamotrigine through the breast milk. The trial was registered in the Israeli trials registry MOH_2021-09-05_010243 at September 5, 2021 Retrospectively registered https://my.health.gov.il/CliniTrials.
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Affiliation(s)
- Elkana Kohn
- Clinical Pharmacology and Toxicology Unit, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
| | - Natalie Dinavitser
- Clinical Pharmacology and Toxicology Unit, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
| | - Maya Berlin
- Clinical Pharmacology and Toxicology Unit, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
| | - Nurit Brandriss
- Biochemistry Laboratory, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
| | - Adina Bar-Chaim
- Biochemistry Laboratory, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
| | - Itai Gueta
- Institute of Clinical Pharmacology and Toxicology, Sheba Medical Center, Tel Hashomer, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Medicine A, Sheba Medical Center, Tel Hashomer, Israel
| | - Rimona Keidar
- Neonatal Intensive Care Unit, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
| | - Ayelet Livne
- Neonatal Intensive Care Unit, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
| | - David Stepensky
- Department of Clinical Biochemistry and Pharmacology, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Matitiahu Berkovitch
- Clinical Pharmacology and Toxicology Unit, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Majdi Masarwi
- Pharmacy Department, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
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Abstract
PURPOSE OF REVIEW Issues pertaining to women with epilepsy have advanced with a better understanding of multidirectional influences among hormones, seizures, and antiseizure medications, as well as pregnancy-related concerns around fertility, seizure destabilization, and antiseizure medication-associated teratogenicity. This article highlights important developments in this field and reviews best practices in the management of women with epilepsy. RECENT FINDINGS Important external hormonal influences may impact women with epilepsy particularly in the context of gender-affirming medications, hormonal replacement therapy, and fertility therapies. Fertility for women with epilepsy is influenced by multiple variables; however, in the absence of preexisting fertility issues, epilepsy per se is not associated with significantly impaired fertility. Once women with epilepsy are pregnant, the majority have a stable course. Antiseizure medication use in pregnancy is associated with major congenital malformations 2 to 5 times that of the general population and is highest with high-dose (≥1500 mg or greater total daily) valproate. Carefully considered changes in drug choice and dose may mitigate these risks. Therapeutic drug monitoring plays an important role in pregnancy care, and under expert supervision, women with epilepsy in pregnancy have similar seizure risks as women with epilepsy who are not pregnant. As women with epilepsy age, bone health and menopause may further be impacted by seizures and antiseizure medications. SUMMARY The care of women with epilepsy is a multifaceted discipline that recognizes the life-long impact of sex and gender influences on epilepsy care.
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Dickmark M, Ågren J, Hellström-Westas L, Jonsson M. Risk factors for seizures in the vigorous term neonate: A population-based register study of singleton births in Sweden. PLoS One 2022; 17:e0264117. [PMID: 35176121 PMCID: PMC8853521 DOI: 10.1371/journal.pone.0264117] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 02/03/2022] [Indexed: 11/24/2022] Open
Abstract
Background Neonatal seizures have been associated with increased mortality and impaired neurodevelopment and, knowledge about risk factors may be useful for prevention. Clear associations have been established between labor-related risk factors and seizures in asphyxiated neonates. However, there is limited information about why some vigorous term-born infants experience seizures. Objectives Our aim was to assess antepartum and intrapartum risk factors for seizures in vigorous term-born neonates. Methods This was a national cohort study of singleton infants born at term in Sweden from 2009–2015. Vigorous was defined as an Apgar score of at least 7 at 5 and 10 minutes. Data on the mothers and infants were obtained from the Swedish Medical Birth Register and the Swedish Neonatal Quality Register. A diagnosis of neonatal seizures was the main outcome measure and the exposures were pregnancy and labor variables. Logistic regression analysis was used and the results are expressed as adjusted odds ratios (aOR) with 95% confidence intervals (CI). Results The incidence of neonatal seizures was 0.81/1,000 for 656 088 births. Seizures were strongly associated with obstetric emergencies (aOR 4.0, 95% CI 2.2–7.4), intrapartum fever and/or chorioamnionitis (aOR 3.4, 95% CI 2.1–5.3), and intrapartum fetal distress (aOR 3.0, 95% CI 2.4–3.7). Other associated intrapartum factors were: labor dystocia, occiput posterior position, operative vaginal delivery, and Cesarean delivery. Some maternal factors more than doubled the risk: a body mass of more than 40 (aOR 2.6, 95% CI 1.4–4.8), hypertensive disorders (aOR 2.3, 95% CI 1.7–3.1) and diabetes mellitus (aOR 2.6, 95% CI 1.7–4.1). Conclusion A number of intrapartum factors were associated with an increased risk of seizures in vigorous term-born neonates. Obstetric emergencies, intrapartum fever and/or chorioamnionitis and fetal distress were the strongest associated risks. The presence of such factors, despite a reassuring Apgar score could prompt close surveillance.
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Affiliation(s)
- Malin Dickmark
- Department of Obstetrics and Gynecology, Uppsala University Hospital, Uppsala, Sweden
| | - Johan Ågren
- Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
| | | | - Maria Jonsson
- Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
- * E-mail:
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Christensen J, Antonsen S, Sun Y, Dreier JW. Maternal Epilepsy and Long-term Offspring Mortality - a Nationwide Cohort Study. Ann Neurol 2022; 91:455-465. [PMID: 35148430 PMCID: PMC9315000 DOI: 10.1002/ana.26315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 01/27/2022] [Accepted: 01/29/2022] [Indexed: 11/13/2022]
Abstract
Objective We examined how maternal epilepsy and use of antiseizure medications in pregnancy was associated with offspring mortality. Methods This population‐based cohort study included all live‐ and stillborn singletons in Denmark between 1981 and 2016. We used nation‐wide registers to retrieve information on pregnancy characteristics, epilepsy diagnoses, use of antiseizure medications, and mortality. Adjusted mortality rate ratios (MRR) were estimated using log‐linear Poisson regression. Results The cohort consisted of 1,862,474 children. In total, 12,026 live‐born children died during follow‐up, of whom 170 (1.4%) were offspring of mothers with epilepsy. Overall mortality was increased in offspring of mothers with epilepsy compared to offspring of mothers without epilepsy (MRR = 1.46, 95% CI: 1.23–1.71), driven by an excess mortality only in the first year of life. Mortality was increased for natural deaths (MRR = 1.50, 95% CI: 1.25–1.78) but not from unnatural deaths (MRR = 1.38, 95% CI: 0.84–2.14), and only in offspring of women with epilepsy who used antiseizure medications during pregnancy (MRR = 1.51, 95% CI: 1.00–2.17), but not in offspring of women with epilepsy who did not use antiseizure medications while pregnant (MRR = 0.97, 95% CI: 0.69–1.31). When analyses were restricted to children born from 2000 and onwards, the excess mortality that was observed in the first year of life among children of mothers with epilepsy, was no longer evident. Interpretation During the 1981 to 1999 epoch, offspring of women with epilepsy were at increased risk of dying in the first year of life. However, this risk did not extend to children born after 2000. Future retrospective studies of the effects of maternal epilepsy on the health of the offspring should take this difference into account. ANN NEUROL 2022;91:455–465
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Affiliation(s)
- Jakob Christensen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark.,National Center for Register-Based Research, Aarhus University, Denmark
| | - Sussie Antonsen
- National Center for Register-Based Research, Aarhus University, Denmark
| | - Yuelian Sun
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark.,National Center for Register-Based Research, Aarhus University, Denmark
| | - Julie W Dreier
- National Center for Register-Based Research, Aarhus University, Denmark.,Centre for Integrated Register-based Research, CIRRAU, Aarhus University, Aarhus, Denmark
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Epilepsy in Pregnancy—Management Principles and Focus on Valproate. Int J Mol Sci 2022; 23:ijms23031369. [PMID: 35163292 PMCID: PMC8836209 DOI: 10.3390/ijms23031369] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 01/18/2022] [Accepted: 01/22/2022] [Indexed: 02/06/2023] Open
Abstract
An estimated 60 million people worldwide suffer from epilepsy, half of whom are women. About one-third of women with epilepsy are of childbearing age. The childbirth rate in women with epilepsy is about 20–40% lower compared to that of the general population, which may be partly due to a lower number of these women being in relationships. Lower fertility in women with epilepsy may be linked to the disease itself, but it is mainly a result of the treatment provided. Valproate, as an antiepileptic drug inhibiting histone deacetylases, may affect the expression of genes associated with cell cycle control and cellular differentiation. Evidently, this drug is associated with the risk of malformations although other antiepileptic drugs (AEDs) may also trigger birth defects, however, to a lower degree. Valproate (and to a certain degree other AEDs) may induce autism spectrum disorders and attention deficit hyperactivity disorder. The main mechanism responsible for all negative effects of prenatal exposure to valproate seems inhibition of histone deacetylases. Animal studies show a reduction in the expression of genes involved in social behavior and an increase in hippocampal cytokines. Valproate-induced oxidative stress may also contribute to neural tube defects. Interestingly, paternal exposure to this AED in mice may trigger neurodevelopmental disorders as well although a population-based cohort study does not confirm this effect. To lower the risk of congenital malformations and neurodevelopmental disorders, a single AED at the optimal dose and supplementation with folic acid is recommended. VPA should be avoided in women of childbearing age and especially during pregnancy.
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Craig JJ, Scott S, Leach JP. Epilepsy and pregnancy: identifying risks. Pract Neurol 2021; 22:98-106. [PMID: 34887343 DOI: 10.1136/practneurol-2019-002304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2021] [Indexed: 11/04/2022]
Abstract
Pregnancy is a time of physical, physiological and psychological challenge. For women with epilepsy, as well as its potential for joy and fulfilment, pregnancy may bring additional risks and difficulties. Clinicians must anticipate and prevent these complications, ensuring that pregnancy, delivery and motherhood proceed without obstetric or medical complications, using available evidence to balance individual risks of undertreatment and overtreatment. Here we review epilepsy management in pregnancy, identifying some of the known effects of epilepsy and its treatment on gestation, fetal malformation, delivery, and neurocognitive and behavioural development. We outline strategies to reduce obstetric and fetal complications in women with epilepsy, while recognising the sometimes competing need to maintain or improve seizure control. We reinforce the importance of identifying those at highest risk, who may require additional measures or safeguards.
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Affiliation(s)
- John J Craig
- Neurology, Belfast Health and Social Care Trust, Belfast, UK
| | - Shona Scott
- Department of Clinical Neurosciences, University of Edinburgh Division of Medical and Radiological Sciences, Edinburgh, UK
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Panelli DM, Leonard SA, Kan P, Meador KJ, McElrath TF, Darmawan KF, Carmichael SL, Lyell DJ, El-Sayed YY, Druzin ML, Herrero TC. Association of Epilepsy and Severe Maternal Morbidity. Obstet Gynecol 2021; 138:747-754. [PMID: 34619720 PMCID: PMC8542621 DOI: 10.1097/aog.0000000000004562] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 07/29/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate severe maternal morbidity (SMM) among patients with epilepsy and patients without epilepsy. METHODS We retrospectively examined SMM using linked birth certificate and maternal hospital discharge records in California between 2007 and 2012. Epilepsy present at delivery admission was the exposure and was subtyped into generalized, focal and other less specified, or unspecified. The outcomes were SMM and nontransfusion SMM from delivery up to 42 days' postpartum, identified using Centers for Disease Control and Prevention indicators. Multivariable logistic regression models were used to adjust for confounders, which were selected a priori. We also estimated the association between epilepsy and SMM independent of comorbidities by using a validated obstetric comorbidity score. Severe maternal morbidity indicators were then compared using the same multivariable logistic regression models. RESULTS Of 2,668,442 births, 8,145 (0.3%) were to patients with epilepsy; 637 (7.8%) had generalized, 6,250 (76.7%) had focal or other less specified, and 1,258 (15.4%) had unspecified subtypes. Compared with patients without epilepsy, patients with epilepsy had greater odds of SMM (4.3% vs 1.4%, adjusted odds ratio [aOR] 2.91, 95% CI 2.61-3.24) and nontransfusion SMM (2.9% vs 0.7%, aOR 4.16, 95% CI 3.65-4.75). Epilepsy remained significantly associated with increased SMM and nontransfusion SMM after additional adjustment for the obstetric comorbidity score, though the effects were attenuated. When grouped by organ system, all SMM indicators were significantly more common among patients with epilepsy-most notably those related to hemorrhage and transfusion. CONCLUSION Severe maternal morbidity was significantly increased in patients with epilepsy, and SMM indicators across all organ systems contributed to this.
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Affiliation(s)
- Danielle M. Panelli
- Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - Stephanie A. Leonard
- Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - Peiyi Kan
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Kimford J. Meador
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Thomas F. McElrath
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Kelly F. Darmawan
- Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - Suzan L. Carmichael
- Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Deirdre J. Lyell
- Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - Yasser Y. El-Sayed
- Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - Maurice L. Druzin
- Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - Tiffany C. Herrero
- Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
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Sharma A, Sah N, Kannan S, Kannan RM. Targeted drug delivery for maternal and perinatal health: Challenges and opportunities. Adv Drug Deliv Rev 2021; 177:113950. [PMID: 34454979 PMCID: PMC8544131 DOI: 10.1016/j.addr.2021.113950] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 08/06/2021] [Accepted: 08/24/2021] [Indexed: 12/18/2022]
Abstract
Pre-existing conditions at reproductive age, and complications arising during pregnancy can be detrimental to maternal and fetal health. Current therapies to combat obstetric disorders are limited due to the inherent complexity of pregnancy, and can have harmful effects on developing fetus. Emerging research shows intricate signaling between the cells from mother and fetus at maternal-fetal interface, providing unique opportunities for interventions specifically targeted to the mother, fetus, or placenta. Advancements in nanotechnology, stem-cell biology and gene therapy have resulted in target-specific treatments with promising results in pre-clinical maternal and fetal disorder models. Comprehensive understanding of the effect of physicochemical properties of delivery systems on their uptake, retention and accumulation across placenta will help in the better diagnosis and treatment of perinatal disorders. This review describes the factors leading to obstetric complications along with their effect on pregnancy outcomes, and discusses key targeted therapeutic strategies for addressing conditions related to maternal and fetal health.
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Affiliation(s)
- Anjali Sharma
- Center for Nanomedicine, Department of Ophthalmology, Wilmer Eye Institute Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA
| | - Nirnath Sah
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Sujatha Kannan
- Center for Nanomedicine, Department of Ophthalmology, Wilmer Eye Institute Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA; Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; Hugo W. Moser Research Institute at Kennedy Krieger, Inc., Baltimore MD, 21205, USA
| | - Rangaramanujam M Kannan
- Center for Nanomedicine, Department of Ophthalmology, Wilmer Eye Institute Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA; Hugo W. Moser Research Institute at Kennedy Krieger, Inc., Baltimore MD, 21205, USA; Department of Chemical and Biomolecular Engineering, Johns Hopkins University, Baltimore MD, 21218, USA.
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Levetiracetam, lamotrigine and carbamazepine: which monotherapy during pregnancy? Neurol Sci 2021; 43:1993-2001. [PMID: 34468899 PMCID: PMC8860795 DOI: 10.1007/s10072-021-05542-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 07/31/2021] [Indexed: 10/31/2022]
Abstract
OBJECTIVE Epilepsy treatment during pregnancy is still challenging. The study is aimed at comparing the efficacy and safety of carbamazepine (CBZ), lamotrigine (LTG) and levetiracetam (LEV) monotherapies during pregnancy in women with focal (FE) or generalized (GE) epilepsy. METHODS A multicentre retrospective study was conducted to evaluate seizures frequency and seizure freedom (SF) rate during 3 months before pregnancy, each trimester of gestation and post-partum period in women on monotherapy with CBZ, LTG and LEV. RESULTS Fifty-seven pregnancies (45 FE, 12 GE) on monotherapy (29 CBZ, 11 LTG, 17 LEV) were included. A significant reduction of seizure frequency was found in the first trimester of pregnancy as compared with that one before pregnancy (p = 0.004), more evident in GE (p = 0.003) and in LEV group (p = 0.004). The SF rate significantly increased in the first trimester in comparison to that one before pregnancy and persisted in the post-partum period in the whole sample (p < 0.001) and in women on LEV (p = 0.004). Besides, 88.57% of SF women before pregnancy remained unchanged during gestation and the post-partum period. One major heart malformation in CBZ and no major malformations in LTG and LEV groups were found. CONCLUSIONS A better clinical outcome during pregnancy emerged since the first trimester in comparison to the before-pregnancy period, mostly evident in women with GE and LEV therapy, reinforcing the hypothesis of a protective role of pregnancy versus seizures. SF before pregnancy represents a significant predictive factor of good clinical outcome during gestation and the post-partum period. Compared to CBZ, LTG and LEV showed a better safety profile.
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Hallab A, Sen A. Epilepsy and psychogenic non-epileptic seizures in forcibly displaced people: A scoping review. Seizure 2021; 92:128-148. [PMID: 34509907 DOI: 10.1016/j.seizure.2021.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Revised: 08/09/2021] [Accepted: 08/11/2021] [Indexed: 01/24/2023] Open
Abstract
With a growing number of forcibly displaced people (FDP) globally, the focus on their medical needs has necessarily increased. Studies about the prevalence and incidence of epilepsy and psychogenic non-epileptic seizures (PNES) in this population are, though, sparse. This Review highlights the importance of exploring and managing both conditions in these vulnerable people to promote global health. We performed an exhaustive review of 10 databases, as well as a manual search of relevant websites related to global health and refugee-related organizations. We analyzed data related to the prevalence and incidence of epilepsy and PNES; health visits; costs of medical care and challenges faced by healthcare workers in relation to FDP with these conditions. Fifty six papers met our inclusion criteria. Of these, 53 reported directly or indirectly on the prevalence of epilepsy and its costs in FDP. Two articles reported on the prevalence of PNES in forcibly displaced people. The reported prevalence of epilepsy in FDP varied from 0.2% to 39.13%, being highest in people with pre-existing neurological or psychiatric comorbidities. Only one study reported on the incidence of epilepsy in internally displaced children. Data from the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) have identified a tendency to higher incidence of epilepsy in children following wars. While within displaced women without a history of sexual violence the rate of PNES was 16.7%, in FDP women with such a history the rate of PNES was 43.7% (p=0.02). The healthcare costs for epilepsy can be high, with recurrent health visits related to seizures being the most common cause of health encounters in refugee camps. Increasing awareness and further studies of multicultural aspects to improve shared understanding of seizure phenomenon in vulnerable displaced populations would seem crucial.
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Affiliation(s)
- Asma Hallab
- Department of Psychiatry and Psychotherapy, Section for personality disorder and posttraumatic stress disorder, Campus Benjamin Franklin, Charité-Universitätsmedizin, Berlin, Hindenburgdamm 30, Berlin 12203, Germany; Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health. Department of Psychiatry and Psychotherapy, Campus Benjamin Franklin, Berlin, Germany.
| | - Arjune Sen
- Oxford Epilepsy Research Group, NIHR Oxford Biomedical Research Centre, Nuffield Department of Clinical Neuroscience, John Radcliffe Hospital, Oxford OX3 9DU, United Kingdom.
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Neuro-anesthesiology in pregnancy. HANDBOOK OF CLINICAL NEUROLOGY 2021. [PMID: 32736750 DOI: 10.1016/b978-0-444-64239-4.00010-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/08/2023]
Abstract
Management of the pregnant patient requiring neurosurgery poses multiple challenges, juxtaposing pregnancy-specific considerations with that accompanying the safe provision of intracranial or spine surgery. There are no specific evidence-based recommendations, and case-by-case interdisciplinary discussions will guide informed decision-making about the timing of delivery vis-à-vis neurosurgery, the performance of cesarean delivery immediately before neurosurgery, consequences of neurosurgery on subsequent delivery, or even the optimal anesthetic modality for neurosurgery and/or cesarean delivery. In general, identifying whether increased intracranial pressure poses a risk for herniation is crucial before allowing neuraxial procedures. Modified rapid sequence induction with advanced airway approaches (videolaryngoscopic or fiberoptic) allows improved airway manipulation with reduced risks associated with endotracheal intubation of the obstetric airway. Currently, very few anesthetic drugs are avoided in the neurosurgical pregnant patient; however, ensuring access to critical care units for prolonged monitoring and assistance of the respiratory-compromised patient is necessary to ensure safe outcomes.
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Smok D, Prager KM. The ethics of neurologically complicated pregnancies. HANDBOOK OF CLINICAL NEUROLOGY 2021; 171:227-242. [PMID: 32736753 DOI: 10.1016/b978-0-444-64239-4.00013-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
Bioethical conflicts in pregnancy are distinguished from those in other areas of medicine due to competing interests between mother and fetus because of their shared biology. Historically, prior to the advent of fetal therapy and advances in medical technology, the maternal-fetal complex was considered to be a single entity. With advances in medicine, treatment options can now be directed at both the mother and the fetus, and a duality has evolved in the maternal-fetal unit. Thus at some point during pregnancy, two individuals rather than just one are the responsibility of the physician. In determining how to properly care for the pregnant woman with a neurologic condition, therapeutic choices must take into consideration the impact a treatment will have on both the mother and the fetus. Since what benefits one may harm the other, tension results from the need to choose. This chapter will highlight ethical conflicts arising at the interface of obstetrics and neurology. We will delve into situations where difficult reproductive and therapeutic decisions must be made in pregnant women with intellectual disabilities, stroke, brain tumors, and epilepsy. The complexity of brain death in pregnancy will be analyzed, acknowledging the influence of politics, law, and religion that bears on ethical decision-making. In approaching ethical dilemmas encountered in pregnancies complicated by neurologic conditions, frameworks based on principles, virtues, care, and feminist ethics, and case precedents will be applied to facilitate ethically appropriate shared decision-making. We hope that this chapter will provide valuable guidance for providers caring for this complex obstetric population.
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Affiliation(s)
- Dorothy Smok
- Department of Obstetrics Gynecology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States.
| | - Kenneth M Prager
- Department of Medicine, Columbia University Irving Medical Center, New York, NY, United States
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Gyamfi-Bannerman C, Huang Y, Bateman BT, Benson RJ, Pack AM, Wright JD, D'Alton ME, Friedman AM. Maternal morbidity and mortality associated with epilepsy. J Matern Fetal Neonatal Med 2021; 35:7917-7923. [PMID: 34154486 DOI: 10.1080/14767058.2021.1938528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Prior research demonstrated large increased risk for maternal mortality among women with epilepsy. The objective of this study was to estimate risk for adverse maternal outcomes during delivery hospitalizations among women with epilepsy. METHODS Truven Health MarketScan databases were used to compare risk for adverse maternal outcomes during delivery hospitalizations based upon whether there was diagnosis of epilepsy and receipt of anti-epileptic drugs prior to delivery. Outcomes included: (i) death during delivery hospitalization, (ii) severe maternal morbidity, (iii) cesarean delivery, (iv) postpartum hemorrhage, (v) placental abruption, (vi) preeclampsia, (vii) preterm delivery, (viii) premature rupture of membranes, and (ix) stillbirth. Adjusted models including hospital and demographic factors were performed with adjusted risk ratios (aRR) with 95% CIs as measures of effect. RESULTS Women with epilepsy prior to delivery who received antiepileptic drugs (n = 6019) during pregnancy were not at increased risk for mortality with no deaths occurring in this group (p = .27). Risk for severe maternal morbidity in this group was approximately double (aRR 2.16, 95% CI 1.86-2.51) with risks for other outcomes including placental abruption (aRR 1.29, 95% CI 1.04-1.60), cesarean delivery (aRR 1.14, 95% CI 1.10-1.18), and preterm delivery (aRR 1.25, 95% CI 1.15-1.35) slightly increased compared to women without seizures. CONCLUSION No significant difference in mortality risk was found for women with epilepsy. Increased risk for other adverse maternal outcomes for women with epilepsy on antiepileptics was modest.
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Affiliation(s)
- Cynthia Gyamfi-Bannerman
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Yongmei Huang
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Brian T Bateman
- Department of Medicine, Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.,Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Rachael J Benson
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
| | - Alison M Pack
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
| | - Jason D Wright
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Mary E D'Alton
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Alexander M Friedman
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Columbia University Irving Medical Center, New York, NY, USA
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Maternal epilepsy- perinatal outcome and long-term neurological morbidity of the offspring: a population-based cohort study. Arch Gynecol Obstet 2021; 305:55-62. [PMID: 34100131 DOI: 10.1007/s00404-021-06114-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 06/02/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE The current study was aimed to assess whether maternal epilepsy is linked to long-term neurological morbidity of the offspring, and to examine whether maternal epilepsy is associated with adverse pregnancy outcomes. METHODS A population-based cohort study was conducted comparing perinatal outcomes of women with and without epilepsy, including long-term neurological morbidity of the offspring. Both the exposed and unexposed groups were followed up to 18 years of age for neurological-related morbidity. To assess perinatal outcomes of women with epilepsy, generalized estimation equation (GEE) models were used to control for confounders. To compare the cumulative incidence of long-term neurological morbidity a Kaplan-Meier survival curve was used. A Cox proportional hazards model was built to control for confounders. RESULTS During the study period, 243,682 deliveries met the inclusion criteria; 711 (0.29%) were of mothers with epilepsy. Maternal epilepsy was noted as an independent risk factor for preterm delivery, cesarean delivery, and low birth weight using GEE models controlling for maternal age and parity. Offspring born to mothers with epilepsy had higher rates of long-term neurological morbidity (Kaplan-Meier log-rank test, p < 0.001). A Cox proportional hazards model, controlled for maternal age, hypertensive disorders, gestational age, and diabetes mellitus, demonstrated that being born to a mother with epilepsy was an independent risk factor for long-term neurological morbidity of the offspring (adjusted HR 2.7, 95% CI 2.12-3.56, p < 0.001). CONCLUSIONS The pregnancy of epileptic women is independently associated with the adverse perinatal outcome as well as a higher risk for long-term neurological morbidity of the offspring.
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