Pregnancy outcomes of refractory epilepsy patients treated with Brain-responsive neurostimulation

Sexual and Reproductive Health in the Management of Epilepsy

OBJECTIVE

The management of epilepsy should be patient centered, and the treating team should carefully balance eliminating seizures while minimizing adverse effects associated with antiseizure medications. This article highlights important aspects of care related to sexual and reproductive health in people with epilepsy.

LATEST DEVELOPMENTS

Gender- and sex-based management in epilepsy can present unique challenges especially in people with epilepsy of childbearing potential. One of the most important considerations with the prescription of antiseizure medications to people of childbearing potential involves reproductive health. Folic acid supplementation is recommended to reduce the risk of congenital malformations, but there is no consensus on the optimal dose. The clinical management of pregnancy in the setting of epilepsy can be challenging. Significant knowledge gaps remain regarding the risks for most new antiseizure medications, neurostimulation therapy, and ketogenic diets during pregnancy. Ongoing multicenter pregnancy registries continue to inform practitioners on the medical treatment of people with epilepsy of childbearing potential. Data evaluating the effect of antiseizure medications on male patients with epilepsy, especially around conception, continue to be insufficient.

ESSENTIAL POINTS

The decision to prescribe an antiseizure medication depends on several considerations because of the potential for lifetime treatment with a daily medication. It is important to tailor management to the patient's specific circumstances. Seizures and antiseizure medications can both affect sexual and reproductive health. Furthermore, hormone fluctuations may affect seizure frequency, treatment, and contraception. All these factors should be considered when treating people with epilepsy during their reproductive years. In addition, it is important to foster a multidisciplinary approach for the treatment of people with epilepsy.

Happy Healthy Parents and Babies: Levetiracetam, Lacosamide and Epilepsy Pregnancy Registries

Fallik N, Trakhtenbroit I, Fahoum F, Goldstein L. Therapeutic drug monitoring in pregnancy: Levetiracetam. Epilepsia. 2024 May;65(5):1285-1293. Epub 2024 Feb 24. PMID: 38400747. doi:10.1111/epi.17925. Objective: Levetiracetam (LEV) is an antiseizure medication that is mainly excreted by the kidneys. Due to its low teratogenic risk, LEV is frequently prescribed for women with epilepsy (WWE). Physiological changes during gestation affect the pharmacokinetic characteristics of LEV. The goal of our study was to characterize the changes in LEV clearance during pregnancy and the postpartum period, to better plan an LEV dosing paradigm for pregnant women. Methods: This retrospective observational study incorporated a cohort of women who were followed up at the epilepsy in pregnancy clinic at Tel Aviv Sourasky Medical Center during the years 2020–2023. Individualized target concentrations of LEV and an empirical postpartum taper were used for seizure control and to reduce toxicity likelihood. Patient visits took place every 1–2 months and included a review of medication dosage, trough LEV blood levels, week of gestation and LEV dose at the time of level measurement, and seizure diaries. Total LEV concentration/dose was calculated based on LEV levels and dose as an estimation of LEV clearance. Results: A total of 263 samples were collected from 38 pregnant patients. We observed a decrease in LEV concentration/dose (C/D) as the pregnancy progressed, followed by an abrupt postpartum increase. Compared to the third trimester, the most significant C/D decrease was observed at the first trimester (slope = .85), with no significant change in the second trimester (slope = .11). A significant increase in C/D occurred postpartum (slope = 5.23). LEV dose was gradually increased by 75% during pregnancy compared to preconception. Average serum levels (μg/mL) decreased during pregnancy. During the postpartum period, serum levels increased, whereas the LEV dose was decreased by 24%, compared to the third trimester. Significance: LEV serum level monitoring is essential for WWE prior to and during pregnancy as well as postpartum. Our data contribute to determining a rational treatment and dosing paradigm for LEV use during both pregnancy and the postpartum period. Perucca P, Bourikas D, Voinescu PE, Vadlamudi L, Chellun D, Kumke T, Werhahn KJ, Schmitz B. Lacosamide and pregnancy: data from spontaneous and solicited reports. Epilepsia. 2024 May;65(5):1275-1284. Epub 2024 Feb 27. PMID: 38411300. doi:10.1111/epi.17924. Objective: In pregnancy, it is important to balance the risks of uncontrolled epileptic seizures to the mother and fetus against the potential teratogenic effects of antiseizure medications. Data are limited on pregnancy outcomes among patients taking lacosamide (LCM), particularly when taken as monotherapy. The objective of this analysis was to evaluate the pregnancy outcomes of LCM-exposed pregnancies. Methods: This analysis included all reports in the UCB Pharma pharmacovigilance database of exposure to LCM during pregnancy from spontaneous sources (routine clinical settings) or solicited reports from interventional clinical studies and noninterventional postmarketing studies. Prospective and retrospective reports were analyzed separately. Results: At the data cutoff (August 31, 2021), there were 202 prospective pregnancy cases with maternal exposure to LCM and known outcomes. Among these cases, 44 (21.8%) patients received LCM monotherapy and 158 (78.2%) received LCM polytherapy. Most patients received LCM during the first trimester (LCM monotherapy: 39 [88.6%]; LCM polytherapy: 143 [90.5%]). From the prospective pregnancy cases with maternal LCM exposure, there were 204 reported outcomes (two twin pregnancies occurred in the polytherapy group). The proportion of live births was 84.1% (37/44) in patients who received LCM as monotherapy, and 76.3% (122/160) for LCM polytherapy. The overall proportion of abortions (for any reason) was 15.9% (7/44) with LCM monotherapy, and 22.5% (36/160) with LCM polytherapy. Congenital malformations were reported in 2.3% (1/44) of known pregnancy outcomes with maternal exposure to LCM monotherapy, and 6.9% (11/160) with polytherapy. Significance: Our preliminary data do not raise major concerns on the use of LCM during pregnancy. Most pregnancies with LCM exposure resulted in healthy live births, and no new safety issues were identified. These findings should be interpreted with caution, as additional data are needed to fully evaluate the safety profile of LCM in pregnancy.

Third generation antiseizure medications exposure during pregnancy and neonatal adverse birth outcomes: A systematic review

Background: Third generation antiseizure medications (ASMs) are currently used for seizure control as well as several other indications, including pain management and psychiatric disorders. As a result, maternal exposure to third generation ASMs during pregnancy has become increasingly prevalent. The current systematic review aimed to summarize the published evidence on third generation ASMs and their effect on preterm birth, cesarean section (c-section) and fetal loss. Methods: The following databases were searched: Medline, Embase, International Pharmaceutical Abstracts, Cochrane Library and Scopus until September 2022. Results: We screened 2987 studies, and identified 32 studies or case reports for inclusion, however only one study utilized a control group. Narrative systematic evidence synthesis was conducted for brivaracetam, eslicarbazepine, fosphenytoin, lacosamide and perampanel. Conclusion: Due to the scarcity and quality of published studies, drawing clear-cut conclusions regarding third generation ASMs and the outcomes of interest is challenging. More comparative safety studies focusing on neonatal safety of third generation ASMs in pregnancy are essential.

Management of epilepsy during pregnancy and lactation

Epilepsy is a group of neurological diseases characterized by susceptibility to recurrent seizures. Antiseizure medications (ASMs) are the mainstay of treatment, but many antiseizure medications with variable safety profiles have been approved for use. For women with epilepsy in their childbearing years, the safety profile is important for them and their unborn children, because treatment is often required to protect them from seizures during pregnancy and lactation. Since no large randomized controlled trials have investigated safety in this subgroup of people with epilepsy, pregnancy registries, cohort and case-control studies from population registries, and a few large prospective cohort studies have played an important role. Valproate, in monotherapy and polytherapy, has been associated with elevated risk of major congenital malformations and neurodevelopmental disorders in children born to mothers who took it. Topiramate and phenobarbital are also associated with elevated risks of congenital malformations and neurodevelopmental disorders, though the risks are lower than those of valproate. Lamotrigine and levetiracetam are relatively safe. Insufficient data exist to reach strong conclusions about the newest antiseizure medications such as eslicarbazepine, perampanel, brivaracetam, cannabidiol, and cenobamate. Besides antiseizure medications, other treatments such as vagal nerve stimulation, responsive neurostimulation, and deep brain stimulation are likely safe. In general, breastfeeding does not appear to add any additional long term risks to the child. Creative ways of optimizing registry enrollment and data collection are needed to enhance patient safety.

Neurostimulation for Chronic Low Back Pain during Pregnancy: Implications for Child and Mother Safety

Pain therapy for low back pain in pregnancy is a very topical issue. In fact, it is necessary to balance the patient's needs to control pain with the need to manage a pregnancy without negative effects on the fetus. We report a case of a 37-year-old woman with low back pain treated with neurostimulation before pregnancy. She described severe chronic low back pain unresponsive to pharmacologic treatments. We first implanted a subcutaneous stimulator into the patient, and then a definitive stimulator resulting in excellent pain control. The improvement in her quality of life allowed the woman to become pregnant. We decided to stop neurostimulation with the patient during pregnancy. The patient completed her pregnancy without complications and the baby was born healthy. During the pregnancy, the woman took only paracetamol when needed. However, this painful symptomatology, completely anecdotal, is not attributable solely to the previous spine problem but probably also to the changes occurring during pregnancy. At the end of pregnancy, the neurostimulator was reactivated without any discomfort for the patient, who is now pain free. This case report provides a first line of evidence of a possible treatment of low back pain in women intending to become pregnant, with risk-free management for both the patient and the child.

Sex and gender differences in epilepsy

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.

Epilepsy and Pregnancy

PURPOSE OF REVIEW

Seizure disorders are the most frequent major neurologic complication in pregnancy, affecting 0.3% to 0.8% of all gestations. Women of childbearing age with epilepsy require special care related to pregnancy. This article provides up-to-date information to guide practitioners in the management of epilepsy in pregnancy.

RECENT FINDINGS

Ongoing multicenter pregnancy registries and studies continue to provide important information on issues related to pregnancy in women with epilepsy. Valproate poses a special risk for malformations and cognitive/behavioral impairments. A few antiseizure medications pose low risks (eg, lamotrigine, levetiracetam), but the risks for many antiseizure medications remain uncertain. Although pregnancy rates differ, a prospective study found no difference in fertility rates between women with epilepsy who were attempting to get pregnant and healthy controls. During pregnancy, folic acid supplementation is important, and a dose greater than 400 mcg/d during early pregnancy (ie, first 12 weeks) is associated with better neurodevelopmental outcome in children of women with epilepsy. Breastfeeding is not harmful and should be encouraged in women with epilepsy even when they are on antiseizure medication treatment.

SUMMARY

Women with epilepsy should be counseled early and regularly about reproductive health. Practitioners should discuss the risks of various obstetric complications; potential anatomic teratogenicity and neurodevelopmental dysfunction related to fetal antiseizure medication exposure; and a plan of care during pregnancy, delivery, and postpartum. Women with epilepsy should also be reassured that the majority of pregnancies are uneventful.