Neonatal outcome in infants of epileptic mothers

Comparison of Perinatal Outcomes for Women With and Without Epilepsy: A Systematic Review and Meta-analysis

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.

Pregnancy in epilepsy: issues of concern

Every pregnancy, even under the best of circumstances, carries risks with it. Having epilepsy and taking medications to treat seizures further increase these risks and not all patients are willing to accept risks. The issues related to pregnancy, epilepsy, and antiepileptic drugs and pregnancy are fraught with confusion and misperceptions. Lay publications may misinform the public by assigning risks to drugs not known to be teratogenic in humans. Women report that their physicians have encouraged them to terminate otherwise wanted pregnancies "just to be on the safe side" which is clearly an excess of caution. In this chapter, we review the most common risk factors and divide them in two broad categories: (a) avoidable or modifiable risk factors and (b) unavoidable or non modifiable risk factors. Physicians counseling women with epilepsy who are pregnant or are planning a pregnancy should make every effort to understand the nature and magnitude of the risks associated with epilepsy and antiepileptic drugs in order to ensure the best possible outcomes in these cases. We discuss preventive measures that, when properly followed, can minimize risks and allow the vast majority of women with epilepsy to give birth to normal children.

CPD-Education and self-assessment: Epilepsy and pregnancy

Pregnancies in women with epilepsy are high risk and need careful management by both the medical and obstetric teams due to the increased incidence of complications and adverse outcomes of pregnancy. By the time a pregnant woman with epilepsy presents, the foetus is virtually fully formed and the opportunity for altering drug treatment has passed. Women need to be counselled and told to seek advice about their anticonvulsant therapy should they wish to become pregnant. All major anticonvulsant drugs are teratogenic but the main risk to the developing foetus appears to be when the mother is on polytherapy especially if sodium valproate forms part of the combination. Folate supplements (5 mg) before conception are advisable. There appears to be a minor but significant increased risk of maternal complications in women with epilepsy such as hyperemesis gravidarum, pre-eclampsia and eclampsia, vaginal bleeding and premature labour. In the majority of women seizure control will not alter during pregnancy. Oral vitamin K should be given to the mother receiving enzyme-inducing antiepileptic drugs. Post-natal infant development: there is an increased risk of prematurity (9-11%), stillbirth, neonatal and perinatal death, haemorrhagic disease of the newborn, low Apgar scores and low birth weight (7-10%). Breast feeding: virtually all the anticonvulsant drugs are excreted in breast milk in low concentrations. Feeding difficulties, irritability and lethargy can occur. However, the benefits of breast feeding usually far outweigh any minor risks to the baby.

Pregnancy and epilepsy

Pregnant women with epilepsy are at risk for a variety of complications. This article reviews the extensive literature on pregnancy and epilepsy with special emphasis on the management of pregnancy. Information is presented concerning seizure frequency in pregnancy, effects of epileptic seizures on the fetus, occurrence of complications during pregnancy and delivery, the incidence of fetal congenital malformations, and infant development. Recommendations are given concerning prenatal counseling, antiepileptic drug management, breast feeding, vitamin K supplementation and folic acid supplementation.

Pregnancy and epilepsy

Women with epilepsy account for approximately 0.5% of all pregnancies. Their pregnancies are high risk because of an increased frequency of maternal seizures, complications of pregnancy, and adverse pregnancy outcomes. The increase in seizure frequency is associated with a progressive decline in antiepileptic drug (AED) levels during pregnancy even with constant dosing. Fetal deaths after a generalized seizure, although rare, have been reported, and a marked decline in fetal heart rate has been demonstrated after such seizures during delivery. AEDs have been implicated in causing a twofold increase in the rate of congenital malformations, a variety of minor physical anomalies, mostly involving the midface, and a neonatal hemorrhagic disorder. The clinician caring for a pregnant woman with epilepsy is therefore faced with a dilemma and must carefully chart a middle ground providing effective seizure control while minimizing fetal exposure to AEDs.

Antiepileptic medication in pregnancy: late effects on the children's central nervous system development

In a follow-up study long-term effects of antenatal exposure to two anticonvulsant drugs, phenobarbital and carbamazepine on central nervous system development were evaluated. Children aged 6 to 13 years of epileptic mothers who used phenobarbital (n = 13), carbamazepine (n = 12), phenobarbital plus carbamazepine (n = 12), or no medication (n = 24) during pregnancy were studied. None of the mothers had seizures during pregnancy. A control group carefully matched for confounding variables was selected of children of nonepileptic mothers (n = 61). Minor and major congenital anomalies appeared to be more related to mother's epilepsy than to maternal medication. There were no neurologic differences between the groups. Exposure to phenobarbital was associated with smaller head circumference. An accompanying negative effect of phenobarbital on cognitive development was suggested. Further research on this intriguing phenomenon seems warranted.

Parental epilepsy, anticonvulsant drugs, and reproductive outcome: epidemiologic and experimental findings spanning three decades; 2: Human studies

Evidence accumulated over the past three decades has established AEDs as human teratogens. Important developments in the delineation of these compounds as human teratogens include: the demonstration of a consistent association between in utero exposure to AEDs and an increased occurrence of single major malformations, the description of AED-induced dysmorphogenic syndromes; demonstration of a dose-response relationship, both in terms of the number and dosage of AEDs; and evidence that pharmacogenetic differences in the metabolism of AEDs are strongly correlated with the occurrence of congenital malformations. Furthermore, the experimental animal findings, having accumulated in parallel to those of human studies, strongly support the teratogenic role of AEDs. Areas that require further amplification and clarification in future studies are the relative contribution of AEDs and other factors, such as genetic predisposition and maternal seizures, particularly with respect to the occurrence of minor anomalies, growth retardation, and developmental outcome; the relative teratogenicity of specific monotherapies and polytherapies; the predictive role of pharmacogenetic differences in the metabolism of AEDs in the occurrence of structural and functional abnormalities; and characterization of the precise nature of the pharmacogenetic defect underlying the aforementioned differences in AED metabolism. Attempts should also be made in future prospective studies to monitor metabolite levels of AEDs, particularly the oxidative metabolites, in order to further elucidate the relative contribution of individual differences in metabolism in the determination of adverse fetal outcome. Similarly, further efforts should be made to assess the clinical significance of decreased growth parameters in terms of mental and neurologic development, and to ascertain whether there is any risk for such abnormalities in children who do not display overt or persistent reductions in physical growth parameters. This is critically important in light of the animal studies that have shown functional abnormalities at doses that do not necessarily produce structural defects. Future investigations would be conducted through collaborative studies that would encompass sufficiently large numbers of women to provide adequate power to the statistical analyses of the data obtained. Care would have to be exercised to establish a uniform protocol for the collaborating centers. Regionally based investigations would be preferable to studies based at special centers, in order to assess the relative role of risk factors associated with abnormal pregnancy outcomes in the epileptic population at large.(ABSTRACT TRUNCATED AT 400 WORDS)

Current controversies in pregnancy and epilepsy: a unique challenge to nursing

Approximately 11,550 women with epilepsy give birth annually, yet maternity nurses receive little information on how to care for these patients. Children of epileptic mothers are born with an increased incidence of birth defects, and have a higher perinatal mortality rate. Complications such as bleeding during pregnancy, and interventions such as cesarean births and labor inductions are more common among epileptic women, and seizures tend to increase during pregnancy in more than one-third of epileptic women. Informed nursing care is essential to ensure the best possible outcome of these pregnancies.