Supplementation of vitamin K in pregnant women receiving anticonvulsant therapy prevents neonatal vitamin K deficiency

Role of vitamins in epilepsy

Epilepsy is a chronic neurological disorder that presents as recurrent, unprovoked seizures. Pharmacotherapy is the main treatment for epilepsy, but at least 30% of patients with epilepsy have pharmacoresistant epilepsy. Therefore, non-pharmacological treatments are still required. In addition to electrophysiological aberrations contributing to epileptogenesis and pathophysiology in epilepsy, neuroinflammation, oxidative stress, and metabolic derangement have been investigated as drug targets in the treatment of epilepsy. Vitamins have antioxidant, anti-inflammatory, and immunomodulatory effects, which can be beneficial for the treatment of epilepsy. Herein, we comprehensively review the role of vitamins in epilepsy. Certain epilepsies are vitamin-dependent or vitamin-responsive. Most studies on vitamins in epilepsy are of low evidence level or limited to animal studies. Nevertheless, vitamin supplementation should be considered in epilepsy therapy. Additionally, certain anti-seizure medications may alter the serum levels of certain vitamins. Monitoring the serum levels of vitamins and supplementing vitamins when needed are suggested during the follow-up of patients with epilepsy.

Amino Acid Composition of Amniotic Fluid during the Perinatal Period Reflects Mother's Fat and Carbohydrate Intake

Dietary content during pregnancy is important because it is necessary for the growth of the fetus. With the assumption that the nutritional status of the fetus can be monitored by measuring amino acid concentrations in the amniotic fluid, we investigated whether the habitual dietary intake of pregnant women affected the composition of the amniotic fluid and the significance of performing amniotic fluid analysis. The subjects were 34 mothers who delivered full-term babies by cesarean section. Three biological samples were collected from the mothers: blood, cord blood, and amniotic fluid. At the same time, the mothers' prenatal nutritional intake information was also recorded. When the amino acid contents of the samples were compared with the mothers' nutrient intake, many amino acids in the amniotic fluid were positively correlated with lipid intake, but not with protein intake. There was a negative correlation between lipid intake and carbohydrate intake, and the amino acid contents of the amniotic fluid were also negatively correlated with carbohydrate intake. The results of this study were consistent with those found in animal models, suggesting that the analysis of amniotic fluid may be a useful method to investigate the effects of habitual diet during human pregnancy on the fetus.

Vitamin K supplementation during pregnancy for improving outcomes: a systematic review and meta-analysis

To study supplementation effect of vitamin K (VK) alone or combined with other nutrients administered to pregnant women, we searched Cochrane Pregnancy and Childbirth Group's Trials Register (till 22 January 2016, updated on 28 February 2018) including other resources. Two review authors independently assessed randomised or quasi-randomised controlled trials for inclusion, data extraction, accuracy, and risk of bias. We included older trials from high-income countries (six; 21,493 women-newborns), judged mostly as high or unclear bias risk. We could not assess high-risk e.g. epileptic women, but healthy women (different gestational ages) received varying VK dosages and duration. We meta-analysed neonatal bleeding (RR 1.16, 95% CI 0.59 to 2.29; P = 0.67) and maternal plasma VK1 (MD 2.46, 95% CI 0.98 to 3.93; P = 0.001). We found many outcomes were un-assessed e.g. perinatal death, maternal bleeding, healthcare utilization. Mostly newborns were included where VK found significantly effective for e.g. serum VK (mother-newborn), maternal breast milk VK. Few trials reported neonatal adverse side effects. The GRADE evidence quality was very low i.e. neonatal bleeding, neonatal jaundice, maternal plasma VK1. The intervention was favourable for maternal sera VK1 but remained uncertain for neonatal bleeding and other outcomes. The existing literature gaps warrant future investigations on un-assessed or inadequately reported outcomes.

Which information on women's issues in epilepsy does a community pharmacist need to know? A Delphi consensus study

OBJECTIVE

The aim of this study was to develop and achieve consensus on a core list of important knowledge items that community pharmacists should know on women's issues in epilepsy.

METHODS

This was a consensual study using a modified Delphi technique. Knowledge items were collected from the literature and from nine key contacts who were interviewed on their views on what information community pharmacists should have on women's issues in epilepsy. More knowledge items were suggested by five researchers with interest in women's issues who were contacted to rate and comment on the knowledge items collected. Two iterative Delphi rounds were conducted among a panel of pharmacists (n=30) to achieve consensus on the knowledge items to be included in the core list. Ten panelists ranked the knowledge items by their importance using the Analytical Hierarchy Process (AHP).

RESULTS

Consensus was achieved to include 68 knowledge under 13 categories in the final core list. Items ranked by their importance were related to the following: teratogenicity (10.3%), effect of pregnancy on epilepsy (7.4%), preconception counseling (10.3%), bone health (5.9%), catamenial epilepsy (7.4%), menopause and hormonal replacement therapy (2.9%), contraception (14.7%), menstrual disorders and infertility (8.8%), eclampsia (2.9%), breastfeeding (4.4%), folic acid and vitamin K (5.9%), counseling on general issues (14.7%), and sexuality (4.4%).

CONCLUSION

Using consensual knowledge lists might promote congruence in educating and/or training community pharmacists on women's issues in epilepsy. Future studies are needed to investigate if such lists can improve health services provided to women with epilepsy (WWE).

Prevention of Vitamin K Deficiency Bleeding in Newborn Infants: A Position Paper by the ESPGHAN Committee on Nutrition

Vitamin K deficiency bleeding (VKDB) due to physiologically low vitamin K plasma concentrations is a serious risk for newborn and young infants and can be largely prevented by adequate vitamin K supplementation. The aim of this position paper is to define the condition, describe the prevalence, discuss current prophylaxis practices and outcomes, and to provide recommendations for the prevention of VKDB in healthy term newborns and infants. All newborn infants should receive vitamin K prophylaxis and the date, dose, and mode of administration should be documented. Parental refusal of vitamin K prophylaxis after adequate information is provided should be recorded especially because of the risk of late VKDB. Healthy newborn infants should either receive 1 mg of vitamin K1 by intramuscular injection at birth; or 3 × 2 mg vitamin K1 orally at birth, at 4 to 6 days and at 4 to 6 weeks; or 2 mg vitamin K1 orally at birth, and a weekly dose of 1 mg orally for 3 months. Intramuscular application is the preferred route for efficiency and reliability of administration. The success of an oral policy depends on compliance with the protocol and this may vary between populations and healthcare settings. If the infant vomits or regurgitates the formulation within 1 hour of administration, repeating the oral dose may be appropriate. The oral route is not appropriate for preterm infants and for newborns who have cholestasis or impaired intestinal absorption or are too unwell to take oral vitamin K1, or those whose mothers have taken medications that interfere with vitamin K metabolism. Parents who receive prenatal education about the importance of vitamin K prophylaxis may be more likely to comply with local procedures.

The Contact Activation System (CAS) in cord blood: Measurement of CAS components and comparison with mother's blood. A pilot study

INTRODUCTION

Classical reference data concerning the coagulation system and fibrinolysis in fetuses and newborns date back to the 1990 s. Since that time a number of methodological or other improvements have been implemented, which may cast some doubt on timeliness of the data. The study objective was to measure the levels of Contact Activation System (CAS) components by antigen, i.e. factors XII and XI (FXII, FXI), prekallikrein (PK) and high molecular weight kininogen (HMWK) in cord blood and maternal blood.

MATERIAL AND METHODS

The study group consisted of 35 healthy parturient women with an uneventful pregnancy and birth. The samples of cord blood and maternal blood were obtained immediately after delivery, before clumping the umbilical cord. The CAS components were measured by immunoenzymatic method (ELISA).

RESULTS

The median concentrations of CAS components in cord blood plasma and mother's plasma were as follow: FXII: 1.02 (0.60- 2.58) ng/mg protein vs. 0.94 (0.66-1.86) ng/mg protein (p>0.05); FXI: 2.71(0.03-8.0) ng/mg protein vs. 0.92 (0.03-10.44) ng/mg protein (p>0.05); PK: 168.78 (104.28-261.16) pg/mg protein vs. 113.44 (79.94-146.70) pg/mg protein (p>0.05); HMWK: 2169.45 (1530.64- 2539.83) ng/mg protein vs. 2857.96 (2541.52-3161.04) ng/mg protein (p<0.001).

CONCLUSIONS

1. The antigen levels of the three contact factors, i.e. FXII, FXI and PK in the cord blood of full-term and healthy fetuses were similar to those observed in mother's blood immediately after delivery. Only high molecular weight kininogen was found to be lower (accounting for 84% of the values noted in mothers). 2. Based on our measurements, we claim that the cited reference data concerning the contact factors in full-term and healthy newborns are underestimated; hence, new reference values need to be determined for each antigen and activity contact factor level.

Oh baby! A review of mood stabilizers for bipolar disorder in the child-bearing woman

Background: Bipolar disorder is a brain disorder that can cause abnormal changes in a person's mood, cognitive function, and quality of life. Patients who are diagnosed with bipolar disorder often have intense emotional states that are characterized by either manic or depressive episodes. There is a strong correlation between women of child bearing age and the initial age of onset of the disease. Mood stabilizing drugs have been the mainstay of treatment for many decades; however, there is strong data supporting the teratogenic effects of these drugs on the fetus in pregnant and lactating women.

Methods: Review articles, clinical trials, and practice guidelines were located using online databases PubMed, CINAHL, IDIS, and Medline. Search terms included at least one of the following: “bipolar disorder”, “breast-feeding”, “carbamazepine”, “epilepsy”, “lactation”, “lamotrigine”, “lithium”, “mood stabilizers”, “pregnancy”, “valproate”, and “valproic acid”. Online clinical databases Clinical Pharmacology and Lexi-Comp were also used in the study.

Results: All mood stabilizer drugs are found to cause malformations in fetal development if given during the first trimester of pregnancy, thus use should be avoided if possible. Lamotrigine was found to cause lowest risk of adverse effects in both the mother and fetus during pregnancy; however, it should be avoided in breastfeeding women as it readily passes into breast milk. Lithium use during pregnancy and lactation has been associated with severe malformations and should only be used if maternal benefit outweighs fetal risk. Valproate is considered harmful to both the mother and fetus during pregnancy, but may be a compatible option for breastfeeding. Carbamazepine is found to cause serious malformations with the developing fetus as well as metabolic effects with the mother; however, it is found to cause little effects in breastfed infants as it does not readily pass through breast milk.

Conclusion: The use of medications in pregnant and breastfeeding women suffering from bipolar disorder must be carefully considered for impacts on fetal development as well as risks to the mother. Mood stabilizers are readily marketed as first line treatment options for bipolar disorder; however, their use in pregnant and lactating women may cause limitations as preferred therapy. Studies show that though lamotrigine has not been as well studied as the other agents, it may be the best recommendation during pregnancy, for both fetal and maternal health concerns. For breastfeeding women, carbamazepine has been shown to be the better option, as it carries the lowest risk of adverse events to the infant.

Pregnancy and epilepsy management and outcome: an update

Epilepsy affects one in 100 individuals. Although epilepsy is gender neutral, women face more challenges with regard to treatment than men. Treatment of women with epilepsy is a therapeutic challenge since they are unlikely to be medication free. An estimated 1 million women with epilepsy are of childbearing age. Each year, approximately 20,000 births occur in women with epilepsy. Despite these challenges, over 90% of women with epilepsy have normal healthy outcomes. Ensuring seizure control is of utmost importance to the health of the mother and fetus. Serum concentrations of antiepileptic drug (AED) decrease during pregnancy resulting in an increased risk of seizure activity, which may result in serious consequences such as maternal injury or fetal and/or maternal demise. Teratogenicity secondary to AED drug exposure has long been reported, especially with the older AEDs, and to some degree with newer agents. More recently, the discovery of long-term cognitive impairment has been reported in offspring exposed to valproate in utero. Choice of AED must balance seizure control with minimizing the risk of malformations and other health issues. Prenatal planning is warranted whenever possible in order to address these concerns. Supplementation with folic acid pregestationally may be helpful in preventing malformations such as spina bifida.

Procoagulants and anticoagulants in fetal blood. A literature survey

In intrauterine life, hemostasis is maintained by the same components as in extrauterine life (blood platelets, coagulation and fibrinolysis systems, involvement of the vascular wall); in the fetus, however, these components show significant differences of a quantitative/qualitative nature. In the present study, we surveyed the literature on the coagulation system in the fetus. We focused on the velocity of development of the coagulation system, being reflected in the increased concentration of all procoagulants and anticoagulants (a rise from approximately 20% in the middle of pregnancy to about 60% or more in the period of labor; exceptions: factors V, VIII and XIII which in the labor period reach the adult level) and screening test results (prothrombin time, aPTT - activated prothrombin time, and thrombin time). Reference values were given for the 19-38 weeks of pregnancy and the labor term. Biochemical features of fetal fibrinogen and PIVKA factors were also discussed. The role of activated protein C (APC) in the maintenance of balance between procoagulants and anticoagulants was postulated as well as the role of APC in the formation of thrombin activatable fibrinolysis inhibitor (TAFI).

Intracranial hemorrhage in term newborns: management and outcomes

Child neurology is frequently a late player in the management of the term newborn with intracranial hemorrhage in the first neonatal week. It is crucial, however, that the child neurologist undertake a comprehensive evaluation by investigating etiology and management of the hemorrhage. Intracranial hemorrhage is usually associated with premature newborns. The literature on intracranial hemorrhage in term newborns is largely in the form of isolated case reports or a small series of cases, and mostly nonsystematic. Presented here is an evidence-based review of the incidence, risk factors, etiologies, and clinical management of intracranial hemorrhage in the first week after birth, with discussion of the role of neuroimaging and hematologic investigation. Consideration of these investigations along with documentation of every intervention or its explanation will reduce parental anxiety and will assure the best possible neurologic as well as legal outcomes of term newborns with intracranial hemorrhage.

In utero exposure to antiepileptic drugs: teratogenicity and neonatal morbidity

Clinical studies have extensively documented the various risks posed by in utero exposure to antiepileptic drugs (AEDs). However, it is difficult to sort out the extent to which any given AED is responsible for a particular outcome, given the disparities in patients taking the drugs, their type and severity of epilepsy, and the various possible AEDs, as well as the vast number of outcomes that could be assessed. This review focuses on AED exposure during pregnancy and how it affects the risks of neonatal morbidity and major congenital malformations.

Management of epilepsy in women of childbearing age: practical recommendations

Women with epilepsy should not be discouraged from becoming pregnant as the likelihood of having a healthy baby is very high. However, in such women, early and individualised counselling about pregnancy and contraception is essential. Ideally, pregnancies should be planned, folic acid (5 mg/day) given and antiepileptic drug (AED) treatment optimised well before conception to ensure that the lowest dosage that controls seizures is administered. When initiating AEDs in a woman of childbearing age, the most appropriate drug for the seizure type and syndrome should be chosen, although it is preferable to avoid valproate, because of a possible elevated risk of fetal malformations, when equi-effective agents are available for a given syndrome. In women who become pregnant while taking AEDs, fetal monitoring should include high-resolution ultrasonography before week 20 and measurement of serum alpha-fetoprotein levels. Amniocentesis is not routinely indicated. The measurement of blood concentrations of AEDs can be useful to ensure that the lowest possible maintenance dosage is being used, especially for those drugs whose pharmacokinetics are likely to change during pregnancy. Breastfeeding should be encouraged whatever the treatment administered.

Community-based, prospective, controlled study of obstetric and neonatal outcome of 179 pregnancies in women with epilepsy

PURPOSE

This study evaluated obstetric and neonatal outcome in a community-based cohort of women with active epilepsy (WWAE) compared with the general pregnant population receiving modern obstetric care.

METHODS

We reviewed the total population who gave birth between January 1989 and October 2000 at Kuopio University Hospital. Obstetric, demographic, and epilepsy data were collected prospectively from 179 singleton pregnancies of women with epilepsy and from 24,778 singleton pregnancies of unaffected controls. The obstetric data from the pregnancy register was supplemented with detailed neurologic data retrieved from the medical records. The data retrieved were comprehensive because of a follow-up strategy according to a predecided protocol.

RESULTS

During pregnancy, the seizure frequency was unchanged, or the change was for the better in the majority (83%) of the patients. We found no significant differences between WWAE and controls in the incidence of preeclampsia, preterm labor, or in the rates of caesarean sections, perinatal mortality, or low birth weight. However, the rate of small-for-gestational-age infants was significantly higher, and the head circumference was significantly smaller in WWAE. Apgar score at 1 min was lower in children of WWAE, and the need for care in the neonatal ward and neonatal intensive care were increased as compared with controls. The frequency of major malformations was 4.8% (-0.6-10.2%; 95% confidence interval) in the 127 children of WWAE.

CONCLUSIONS

Pregnancy course is uncomplicated and neonatal outcome is good in the majority of cases when a predecided protocol is used for the follow-up of WWAE in antenatal and neurologic care. Long-term follow-up of the neurologic and cognitive development of the children of WWAE is still needed.

Pregnancy in women who have epilepsy

Ideal, comprehensive care of women who have epilepsy during the reproductive years must include effective preconceptional counseling and preparation. The importance of planned pregnancies with effective birth control should be emphasized, with consideration of the effects of the enzyme-inducing AEDs on lowering efficacy of hormonal contraceptive medications and the need for back-up barrier methods. Before pregnancy occurs, the patient's diagnosis and treatment regimen should be reassessed. Once the diagnosis of epilepsy is confirmed, it is important to verify if the individual patient continues to need medications and if she is taking the most appropriate AED to balance control of her seizures with teratogenic risks. For most women who have epilepsy, withdrawal of all AEDs before pregnancy is not a realistic option. A decision to undergo a trial while not taking AEDs before a planned pregnancy should be based on the same principles used for AED withdrawal in any person who has epilepsy. The taper should be completed at least 6 months before planned conception to provide some reassurance that seizures are not going to recur. If a woman who has epilepsy is in the more prevalent category of needing AEDs for seizure control, then monotherapy at the lowest effective dosage should be used. If large daily doses are needed, then frequent smaller doses or extended-release formulations may be helpful to avoid high peak levels. Some of the newest information about differential risks between AEDs also should be considered. The woman's AED regimen should be optimized and folate supplementation should begin before pregnancy. Given that 50% of pregnancies are unplanned in the United States, folate supplementation should be encouraged in all women of childbearing age who are taking any AED for any indication. Dosing recommendations vary from 0.4 mg/d to 5 mg/d. It is not uncommon for a physician to consider changing AED regimens when the patient first reports that she is pregnant. In many cases, she already is in or past the critical period of organogenesis (Table 3). If a woman who has epilepsy presents after conception and is taking a single AED that is effective, her medication usually should not be changed. Exposing the fetus to a second agent during a crossover period of AEDs only increases the teratogenic risk, and seizures are more likely to occur with any abrupt medication changes. If a woman is on polytherapy, it may be possible to switch to monotherapy safely. Seizure control remains an important goal during pregnancy. In particular, convulsive seizures place the mother and fetus at risk. Nonconvulsive seizures also may be harmful, especially if they involve falling or other forms of trauma. Monitoring serum AED levels during pregnancy can be helpful in optimizing seizure control. Prenatal screening can detect major malformations in the first and second trimesters. Vitamin K1 is given 10 mg/d orally during the last month of pregnancy followed by 1 mg intramuscularly or intravenously to the new-born. Although women who have epilepsy and women who are taking AEDs for other indications do have increased risks for maternal and fetal complications, these risks can be reduced considerably with effective preconceptional planning and careful management during pregnancy and the postpartum period.

Seizure disorders in pregnancy

This article discusses seizure disorders in pregnancy. Seizure disorder affects 1.1 million women of reproductive age in the United States. In 1995, the annual cost of treatment of patients who had epilepsy was estimated to be 12.5 billion dollars. Seizures are disorganized firing of neural cells. Epilepsy is the presence of two or more seizures in the absence of an identifiable cause for the seizures (ie, no intracranial or metabolic abnormality). Epilepsy has an impact on many aspects of women's health, particularly with respect to reproduction. The management of women who have epilepsy during pregnancy is the focus of this article.

Reproductive and metabolic disorders in women with epilepsy

Epilepsy is a common neurologic disorder affecting women during the reproductive years. Seizures and some antiepileptic drugs (AEDs) can compromise reproductive health, and some AEDs can adversely affect carbohydrate and bone metabolism. Women with epilepsy have lower birth rates and more frequent anovulatory menstrual cycles. This appears to be related to seizure- and AED-associated reproductive endocrine disturbances. Carbamazepine (CBZ), phenytoin (PHT), and phenobarbital (PB) induce hepatic cytochrome P450 enzymes and lower endogenous estrogens, adrenal and ovarian androgens, and contraceptive steroids. Valproate (VPA) inhibits steroid hormone metabolism, elevates androgens, and predisposes to phenotypic signs of hyperandrogenism-hirsutism, obesity, acne, and frequent anovulatory cycles. VPA is associated with weight gain, probably by altering insulin metabolism. CBZ, PHT, and VPA, but not lamotrigine (LTG), are associated with lower levels of calcium. PHT, but not VPA or LTG, appears to accelerate bone turnover. AED effects on bone mineral metabolism may explain the elevated risk of fracture described in women with epilepsy. Prospective pregnancy registries are beginning to provide information about AED-associated teratogenesis. The North American Antiepileptic Drug Pregnancy Registry reports a 12% rate of major malformations after first trimester exposure to PB and an 8.6% rate after first trimester exposure to VPA. A prospective LTG-specific registry reports a 1.8% chance of major malformations after the first trimester. The registries will continue to release information as data become significant. In the meantime, practitioners can be alert to signs and symptoms of reproductive or metabolic health disturbances and participate in pregnancy registry efforts.

Effects of menatetrenone on the bone and serum levels of vitamin K2 (menaquinone derivatives) in osteopenia induced by phenytoin in growing rats

OBJECTIVE

We investigated the effects of phenytoin, an antiepileptic drug, and vitamin K2 (menatetrenone) on bone mineral density and the changes in the levels of menaquinone derivatives (MK-1 approximately MK-14) in the sera and femurs of growing male rats.

METHODS

Levels of menaquinone derivatives were measured with high-performance liquid chromatography with an electrochemical detector.

RESULTS

Bone mineral density values decreased significantly in all parts of the femoral bones measured (diaphysis and metaphysis) in the phenytoin-treated group. When the serum and bone levels of menatetrenone and MK-6 decreased due to phenytoin administration, we observed bone loss in rats. Conversely, when bone loss was prevented by the combined administration of phenytoin and menatetrenone, serum and bone levels of menatetrenone and MK-6 increased to the levels of vehicle-treated rats.

CONCLUSIONS

Long-term phenytoin exposure may inhibit bone formation concomitantly with insufficient vitamin K, which, at least in part, contributes to bone loss in rats.

Anti-epileptic drugs in pregnancy: current safety and other issues

Women with epilepsy of child-bearing years have their own considerations, which must be taken into account if management of their epilepsy is to be optimised. The main issues to consider include the effects of: female hormones on seizure control, anti-epileptic drugs (AEDs) on hormonal methods of contraception, epilepsy and AEDs on fertility, epilepsy and AEDs on pregnancy itself, pregnancy on AEDs and seizure control and epilepsy, seizures and AEDs on the developing embryo/fetus. Whereas previous studies have concentrated on the increased risk of major congenital malformations from prenatal AED exposure, the effects on cognitive and behavioural development are increasingly being explored. This article looks at the evidence currently available for all of the above issues, taking into account the increased number of AEDs which are now available.

Chondrodysplasia punctata (CDP) with features of the tibia-metacarpal type and maternal phenytoin treatment during pregnancy

We describe a 2-year-old boy with chondrodysplasia punctata (CDP). The boy was exposed to phenytoin, in combination with carbamazepine, during pregnancy. There has been previous evidence for a connection between phenytoin exposure during pregnancy and chondrodysplasia punctata. The boy had clinical and some radiological characteristic features of CDP, of the tibia-metacarpal type. We know of no other report on a child exposed to phenytoin during pregnancy who developed CDP of this type.

Drugs in pregnancy. Anticonvulsants and drugs for neurological disease

The use of anticonvulsant drugs in pregnancy presents unique challenges to clinicians and their patients. The need for control of maternal epilepsy must be balanced with the fetal and neonatal risks associated with anticonvulsant drugs. Anticonvulsant drugs may have potential effects on embryogenesis, neurological development, growth and subsequent paediatric progress. Drug selection and dose adjustment must be appropriate and based on a combination of known maternal and fetal risks as well as the clinical status of the patient. Overall, no one drug can be specifically recommended but monotherapy with most of the recognized first-line drugs will result in a satisfactory outcome. Polytherapy is associated with an increase in congenital malformations and should be avoided if possible. It is possible that newer second-line agents, for example, gabapentin, may be safer as add-on therapy. Neurological disorders such as migraine, and the less common conditions of myasthenia gravis and multiple sclerosis, may require the use of drugs which have not been well studied in pregnancy. Information is provided about the use of drugs to control symptoms and prevent disease progression in these disorders during pregnancy.

Seizure disorders in pregnancy

Epilepsy is the presence of two or more seizures in the absence of an identifiable cause for the seizures; that is, no intracranial or metabolic abnormality. Epilepsy affects approximately 1% of the US population, which represents an estimated 1.1 million women of reproductive age. The management of women with epilepsy during pregnancy is the focus of this article.

The use of anticonvulsants during pregnancy

Antiepilepsy (AED) medications have revolutionized the treatment of epilepsy, transforming it from a chronic progressive disease with inevitable cognitive and motor decline to a disorder in which most effected persons operate largely in a normal fashion. As with all medications adverse experiences can occur. However, it has been clear that the alternative of uncontrolled seizures are more hazardous than pharmacological therapies. However, physicians are faced with a dilemma when treating fertile or pregnant women with epilepsy. Many AED impair the effectiveness of oral contraceptives. There is evidence that some AED may effect fertility. AED metabolism changes in pregnancy, making management of women with epilepsy more difficult. AED exposure in early pregnancy increases the risk of congenital malformations, and exposure during other phases may increase the risk of developmental delay and neonatal hemorrhage. AED can be secreted in breast milk, thus extending the exposure into infancy. The exclusion of women of childbearing age from clinical trials limits our ability to collect information on the pharmacokinetics and potential adverse experiences of AED in pregnancy. Thus, when new medications are marketed, clinicians and their patients have no information on how to best manage conception, pregnancy, and lactation. This article discusses these issues in detail and describes our current understanding of the use of AED in women of childbearing age.

Vitamin K in neonates: how to administer, when and to whom

Vitamin K-dependent factors are lower in neonates than in adults, and these anomalies are more prevalent in preterm neonates and in breast-fed infants. Vitamin K deficiency can account for vitamin K deficiency bleeding (VKDB) which occurs in 3 forms--early, classic and late. Vitamin K should be administered to all neonates at birth or immediately afterwards. However, the protocols for administration (route of administration, dosage, number of doses) remain a subject of discussion. Oral administration of a single dose of vitamin K protects against classical and early VKDB, but is less effective than intramuscular (IM) prophylaxis for the prevention of late VKDB. Although an increased risk of solid tumour, associated vitamin K administration, can be definitively excluded, a low potential risk of lymphoblastic leukaemia in childhood can not be ruled out. For formula-fed neonates without risk of haemorrhage, a 2 mg oral dose of vitamin K at birth, followed by a second 2 mg oral dose between day 2 and 7, is probably sufficient to prevent VKDB. For infants who are exclusively or nearly exclusively breast-fed, weekly oral administration of 2mg (or 25 microg/day) vitamin K after the initial 2 oral doses is justified at completion of breast-feeding. For neonates at high risk of haemorrhage (premature, neonatal disease, birth asphyxia, difficult delivery, any illness which will delay feeding, known hepatic disease, maternal drugs inhibiting vitamin K activity), the first dose must be administered by the IM or slow intravenous route. Doses should be repeated, particularly in premature infants, by a route of administration decided for each dose according to the clinical state of the infant. For infants of mothers treated with drugs inhibiting vitamin K activity, antenatal maternal prophylaxis (10 to 20 mg/day orally for 15 to 30 days before delivery) prevents early VKDB. After neonatal prophylaxis, as for infants at high risk of haemorrhage, doses need to be repeated at a rate and route of administration decided for each dose, according to the clotting factor profile specific for each infant.

Effect of maternal anticonvulsant treatment on neonatal blood coagulation

AIMS

To investigate the impact of maternal anticonvulsant use on the ability of cord blood to coagulate.

METHODS

Cord blood prothrombin times were measured, over 15 years in a consecutive series of 137 term babies born to women taking phenobarbitone, phenytoin, and/or carbamazepine while pregnant. The response to parenteral vitamin K was measured in 83 neonates.

RESULTS

Only 14 of the 105 babies born to the mothers who had therapeutic anticonvulsant blood concentrations at birth had a prolonged prothrombin time (outside the 95% reference range). None had an overt bleeding tendency. The abnormality was corrected within 2 hours by 1 mg of parenteral vitamin K, but rapid intravenous prophylaxis produced complications in three infants.

CONCLUSIONS

A policy of giving vitamin K throughout the last third of pregnancy to all women being treated with anticonvulsants, as recently recommended, is not justified by the available evidence. The belief that there is a distinct, early form of neonatal vitamin K deficiency that is different from, and more dangerous than, the classic form of the disease, is not supported by a review of the published evidence.

Prothrombin and PIVKA-II levels in cord blood from newborn exposed to anticonvulsants during pregnancy

PURPOSE

To determine whether anticonvulsant exposure during human pregnancy caused an increase of the abnormal form of prothrombin, known as PIVKA-II (prothrombin induced by vitamin K absence for factor II), and a decrease in total prothrombin, in the blood of the newborn.

METHODS

Cord blood was collected from the placenta at the time of parturition from 12 women who had received anticonvulsant therapy during pregnancy and from 11 control women.

RESULTS

PIVKA-II was present in cord blood from control mothers at low or nondetectable levels. In the same samples, total prothrombin concentrations were approximately 50% of adult levels, but there was wide variation between individuals. Exposure to carbamazepine (CBZ) alone during pregnancy was associated with markedly increased PIVKA-II levels in four of six samples and decreased total prothrombin levels for the whole group. High PIVKA-II levels also were recorded in one cord blood sample from a mother who received phenytoin (PHT) and vigabatrin (VGB). Two cases of PHT alone and one of valproic acid (VPA) alone were not associated with increased PIVKA-II levels.

CONCLUSIONS

These results are consistent with the hypothesis that some anticonvulsants (particularly CBZ) interfere with vitamin K metabolism during pregnancy and may result in hematologic signs of vitamin K deficiency in the newborn.

Neurologic care of pregnant women with epilepsy

Epilepsy is a common neurologic condition in women of reproductive age. Although their risks are greater than those for women in the general population, the majority of women with epilepsy have a good pregnancy outcome. An understanding of the risks and appropriate management of both the pregnancy and epilepsy in these patients is essential for their physicians. Health-care providers should discuss contraception and reproductive issues with all of their female patients with epilepsy as they enter reproductive age. Optimal care requires prepregnancy counseling, including information about contraception, dietary folate supplementation, and the risks related to pregnancy. Although antiepileptic drugs (AEDs) have been implicated as the major cause of teratogenesis in infants born to mothers with epilepsy, uncontrolled epilepsy is also associated with maternal and fetal risk. Therefore, optimal seizure control during pregnancy remains an important goal for women with epilepsy. Women with epilepsy should be counseled about breast-feeding their infants and supported in their decision. The recommendations in this article reflect those of a Practice Parameter developed by the American Academy of Neurology Quality Standards Subcommittee.

Obstetric and gynecologic care of women with epilepsy

Optimal gynecologic and obstetric care for women with epilepsy requires a multidisciplinary approach throughout the various life stages. Epilepsy has important effects on puberty, contraceptive efficacy, pregnancy and fetal development, and menopause. This article discusses these effects and makes recommendations for gynecologic and obstetric care of patients with epilepsy, with particular focus on pregnancy. Despite very real risks to both the developing fetus and the mother, the majority of women with epilepsy--with appropriate pregnancy planning and management--have good pregnancy outcomes.

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.

Epilepsy in women

Physicians should be aware of certain gender-related issues in the treatment of women with epilepsy. Although in the past reproduction was discouraged in women with epilepsy, more than 90% of the pregnancies in such patients currently have an uneventful outcome with appropriate management. Oral contraceptive agents are not contraindicated in women with epilepsy; however, the contraceptive failure rate increases fourfold if patients are being treated concurrently with enzyme-inducing antiepileptic drugs. In pregnant patients, free drug levels of carbamazepine, phenobarbital, phenytoin, and valproate may change because of alterations in protein binding, clearance, and possible absorption. The dosage should be adjusted if the patient's seizures are increasing. Women with epilepsy may have disease-related or treatment-related menstrual dysfunction, complications of pregnancy (slightly increased risk of toxemia and fetal loss), endocrine dysfunction, appearance changes (a general coarsening of facial features with long-term administration of antiepileptic agents), and psychosocial maladjustment. Some effects are drug specific. Although control of seizures remains the primary goal of treating women with epilepsy, the widening choice of antiepileptic drugs may facilitate optimal management of secondary and gender-specific complications.

Prenatal exposure to phenytoin, facial development, and a possible role for vitamin K

Ten patients with maxillonasal hypoplasia (Binder "syndrome"), who were prenatally exposed to phenytoin (usually in combination with other anticonvulsants), were identified retrospectively. In addition to their facial anomalies, 6 of the patients were radiographed neonatally and showed punctate calcification, characteristic of chondrodysplasia punctata. Evidence is presented that the facial abnormalities seen in these children are due to anticonvulsant-induced vitamin K deficiency, causing abnormal development of the cartilaginous nasal septum. We propose that early vitamin K supplementation of at-risk pregnancies may prevent the development of maxillonasal hypoplasia, which in some patients is severely disfiguring and causes great emotional distress. Correction of this facial defect requires surgical and dental treatment over a long period of time.

Maternal nutrition and obstetric outcome

In general, maternal nutritional status in civilized countries is not at risk. However, even a marginal malnutritional state for some (micro)nutrients for the pregnant women can adversely affect obstetrical outcome. From the data available so far, only folic acid supplementation is advised. However, the importance of an adequate iron and zinc status has to be stressed. In addition, women should be warned preconceptionally about excessive intake of vitamins, especially of those products containing large amounts of vitamin A.