Psychomotor development and general movements in offspring of women with epilepsy and anticonvulsant therapy

Neurodevelopmental outcome at two years of age and predictive value of General Movement Assessment in infants exposed to alcohol and/or drugs during pregnancy: a prospective cohort study

BACKGROUND

Exposure to alcohol and/or other addictive drugs in pregnancy is a documented risk factor for neurological impairment. We aimed to assess neurodevelopmental outcome at two years of age in infants exposed to prenatal alcohol and/or other addictive drugs and to examine the predictive value of early motor assessment.

METHODS

This was a follow-up at two years of age in the prospective cohort study Children Exposed to Alcohol and/or Drugs in Intrauterine Life (CEADIL). The exposed group comprised 73 infants recruited from primary health care and included in a hospital follow-up programme at St. Olavs Hospital, Trondheim University Hospital, Norway. The control group comprised 93 healthy, unexposed infants recruited from the maternity ward at the same hospital. All children had been assessed by physiotherapists using the General Movement Assessment (GMA) at three months of age. Presence of fidgety movements, movement character and the Motor Optimality Score - Revised (MOS-R) were used. At two years of age, the children were assessed by trained examiners using the Bayley Scales of Infant and Toddler Development - Third Edition (BSID-III), Ages & Stages Questionnaires: Social-Emotional (ASQ:SE) and the Hollingshead Two-Factor Index of Social Position (SES).

RESULTS

The cognitive, language and motor composite scores of BSID-III were considerably lower in the exposed group than in the control group. Mean differences adjusted for age and parental SES ranged from - 13.3 (95% confidence interval, CI: -18.6 to -8.0) to -17.7 (95% CI: -23.3 to -12.2). Suboptimal fidgety movements and monotonous movement character had high sensitivity (0.94 to 0.74), but low specificity (0.10 to 0.32), while sensitivity and specificity of the MOS-R was around 50 and 60%, respectively.

CONCLUSIONS

Neurodevelopmental outcome at two years of age was poorer in a group of children exposed to alcohol and/or drugs in pregnancy compared with a control group of healthy, unexposed children. Sensitivity of suboptimal fidgety movements and monotonous movement character at three months of age for later neurodevelopmental outcome was high to acceptable, but the MOS-R had limited sensitivity.

Treatment for epilepsy in pregnancy: neurodevelopmental outcomes in the child

BACKGROUND

Accumulating evidence suggests an association between prenatal exposure to antiepileptic drugs (AEDs) and increased risk of both physical anomalies and neurodevelopmental impairment. Neurodevelopmental impairment is characterised by either a specific deficit or a constellation of deficits across cognitive, motor and social skills and can be transient or continuous into adulthood. It is of paramount importance that these potential risks are identified, minimised and communicated clearly to women with epilepsy.

OBJECTIVES

To assess the effects of prenatal exposure to commonly prescribed AEDs on neurodevelopmental outcomes in the child and to assess the methodological quality of the evidence.

SEARCH METHODS

We searched the Cochrane Epilepsy Group Specialized Register (May 2014), Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (2014, Issue 4), MEDLINE (via Ovid) (1946 to May 2014), EMBASE (May 2014), Pharmline (May 2014) and Reprotox (May 2014). No language restrictions were imposed. Conference abstracts from the last five years were reviewed along with reference lists from the included studies.

SELECTION CRITERIA

Prospective cohort controlled studies, cohort studies set within pregnancy registers and randomised controlled trials were selected for inclusion. Participants were women with epilepsy taking AED treatment; the two control groups were women without epilepsy and women with epilepsy who were not taking AEDs during pregnancy.

DATA COLLECTION AND ANALYSIS

Three authors (RB, JW and JG) independently selected studies for inclusion. Data extraction and risk of bias assessments were completed by five authors (RB, JW, AS, NA, AJM). The primary outcome was global cognitive functioning. Secondary outcomes included deficits in specific cognitive domains or prevalence of neurodevelopmental disorders. Due to substantial variation in study design and outcome reporting only limited data synthesis was possible.

MAIN RESULTS

Twenty-two prospective cohort studies were included and six registry based studies. Study quality varied. More recent studies tended to be larger and to report individual AED outcomes from blinded assessments, which indicate improved methodological quality.The developmental quotient (DQ) was lower in children exposed to carbamazepine (CBZ) (n = 50) than in children born to women without epilepsy (n = 79); mean difference (MD) of -5.58 (95% confidence interval (CI) -10.83 to -0.34, P = 0.04). The DQ of children exposed to CBZ (n = 163) was also lower compared to children of women with untreated epilepsy (n = 58) (MD -7.22, 95% CI -12.76 to - 1.67, P = 0.01). Further analysis using a random-effects model indicated that these results were due to variability within the studies and that there was no significant association with CBZ. The intelligence quotient (IQ) of older children exposed to CBZ (n = 150) was not lower than that of children born to women without epilepsy (n = 552) (MD -0.03, 95% CI -3.08 to 3.01, P = 0.98). Similarly, children exposed to CBZ (n = 163) were not poorer in terms of IQ in comparison to the children of women with untreated epilepsy (n = 87) (MD 1.84, 95% CI -2.13 to 5.80, P = 0.36). The DQ in children exposed to sodium valproate (VPA) (n = 123) was lower than the DQ in children of women with untreated epilepsy (n = 58) (MD -8.72, 95% -14.31 to -3.14, P = 0.002). The IQ of children exposed to VPA (n = 76) was lower than for children born to women without epilepsy (n = 552) (MD -8.94, 95% CI -11.96 to -5.92, P < 0.00001). Children exposed to VPA (n = 89) also had lower IQ than children born to women with untreated epilepsy (n = 87) (MD -8.17, 95% CI -12.80 to -3.55, P = 0.0005).In terms of drug comparisons, in younger children there was no significant difference in the DQ of children exposed to CBZ (n = 210) versus VPA (n=160) (MD 4.16, 95% CI -0.21 to 8.54, P = 0.06). However, the IQ of children exposed to VPA (n = 112) was significantly lower than for those exposed to CBZ (n = 191) (MD 8.69, 95% CI 5.51 to 11.87, P < 0.00001). The IQ of children exposed to CBZ (n = 78) versus lamotrigine (LTG) (n = 84) was not significantly different (MD -1.62, 95% CI -5.44 to 2.21, P = 0.41). There was no significant difference in the DQ of children exposed to CBZ (n = 172) versus phenytoin (PHT) (n = 87) (MD 3.02, 95% CI -2.41 to 8.46, P = 0.28). The IQ abilities of children exposed to CBZ (n = 75) were not different from the abilities of children exposed to PHT (n = 45) (MD -3.30, 95% CI -7.91 to 1.30, P = 0.16). IQ was significantly lower for children exposed to VPA (n = 74) versus LTG (n = 84) (MD -10.80, 95% CI -14.42 to -7.17, P < 0.00001). DQ was higher in children exposed to PHT (n = 80) versus VPA (n = 108) (MD 7.04, 95% CI 0.44 to 13.65, P = 0.04). Similarly IQ was higher in children exposed to PHT (n = 45) versus VPA (n = 61) (MD 9.25, 95% CI 4.78 to 13.72, P < 0.0001). A dose effect for VPA was reported in six studies, with higher doses (800 to 1000 mg daily or above) associated with a poorer cognitive outcome in the child. We identified no convincing evidence of a dose effect for CBZ, PHT or LTG. Studies not included in the meta-analysis were reported narratively, the majority of which supported the findings of the meta-analyses.

AUTHORS' CONCLUSIONS

The most important finding is the reduction in IQ in the VPA exposed group, which are sufficient to affect education and occupational outcomes in later life. However, for some women VPA is the most effective drug at controlling seizures. Informed treatment decisions require detailed counselling about these risks at treatment initiation and at pre-conceptual counselling. We have insufficient data about newer AEDs, some of which are commonly prescribed, and further research is required. Most women with epilepsy should continue their medication during pregnancy as uncontrolled seizures also carries a maternal risk.

Fetal and infant spontaneous general movements as predictors of developmental disabilities

The challenge of identifying infants who are at risk for developmental delay and possible adverse neurodevelopmental outcome demands methods of evaluation that will lead to early intervention to minimize developmental disability and to maximize the infant's potential. A qualitative assessment of spontaneous general movements (GMs) in the preterm, term, and young infant at risk is a valid and reliable tool for evaluation (Prechtl [1990] Early Hum. Dev. 23:151-158). The aim of this review is to describe the theoretical and clinical bases for the assessment of GMs and its relationship to developmental delay and brain dysfunction. Thirty-seven studies related to the predictive validity of GMs were included in this review. Results suggested that consistent cramped synchronized GMs are highly predictive of later development of cerebral palsy. The fidgety movement quality that appears at the age of 2 to 3 months was found to be a most sensitive predictor of neurodevelopmental outcome in different populations of infants.

Neurobehavioral consequences of prenatal antiepileptic drug exposure

Despite elevated rates of birth defects associated with prenatal antiepileptic drug exposure, pharmacotherapy is typically continued throughout pregnancy because of the risks posed to mother and child by recurrent seizures. Emerging data suggest that prenatal exposure to valproate or polytherapy may also be associated with increased risk of cognitive impairment. However, our understanding of the longer-term sequelae of prenatal antiepileptic drug exposure remains incomplete. Improved understanding of the neurobehavioral consequences of prenatal antiepileptic drug exposure is essential to ensure accurate information is available for women with epilepsy planning a pregnancy, and to achieve optimal outcomes for mothers and children.

Neonatal exposure to antiepileptic drugs disrupts striatal synaptic development

OBJECTIVE

Drug exposure during critical periods of brain development may adversely affect nervous system function, posing a challenge for treating infants. This is of particular concern for treating neonatal seizures, as early life exposure to drugs such as phenobarbital is associated with adverse neurological outcomes in patients and induction of neuronal apoptosis in animal models. The functional significance of the preclinical neurotoxicity has been questioned due to the absence of evidence for functional impairment associated with drug-induced developmental apoptosis.

METHODS

We used patch-clamp recordings to examine functional synaptic maturation in striatal medium spiny neurons from neonatal rats exposed to antiepileptic drugs with proapoptotic action (phenobarbital, phenytoin, lamotrigine) and without proapoptotic action (levetiracetam). Phenobarbital-exposed rats were also assessed for reversal learning at weaning.

RESULTS

Recordings from control animals revealed increased inhibitory and excitatory synaptic connectivity between postnatal day (P)10 and P18. This maturation was absent in rats exposed at P7 to a single dose of phenobarbital, phenytoin, or lamotrigine. Additionally, phenobarbital exposure impaired striatal-mediated behavior on P25. Neuroprotective pretreatment with melatonin, which prevents drug-induced neurodevelopmental apoptosis, prevented the drug-induced disruption in maturation. Levetiracetam was found not to disrupt synaptic development.

INTERPRETATION

Our results provide the first evidence that exposure to antiepileptic drugs during a sensitive postnatal period impairs physiological maturation of synapses in neurons that survive the initial drug insult. These findings suggest a mechanism by which early life exposure to antiepileptic drugs can impact cognitive and behavioral outcomes, underscoring the need to identify therapies that control seizures without compromising synaptic maturation.

The potential of 4D sonography in the assessment of fetal neurobehavior--multicentric study in high-risk pregnancies

OBJECTIVE

An evolving challenge for obstetrician is to better define normal and abnormal fetal neurological function in utero in order to better predict antenatally which fetuses are at risk for adverse neurological outcome.

PATIENTS AND METHODS

Prenatal neurological assessment in high-risk fetuses using four-dimensional ultrasound applying the recently developed Kurjak antenatal neurodevelopmental test (KANET). Postnatal neurological assessment was performed using Amiel Tison's neurological assessment at term (ATNAT) for all live-borns and general movement (GM) assessment for those with borderline and abnormal ATNAT.

RESULTS

Inclusion criteria were met by 288 pregnant women in four centers of whom 266 gave birth to a live-born baby. It was revealed that 234 fetuses were neurologically normal, 7 abnormal and 25 borderline. Out of 7 abnormal fetuses ATNAT was borderline in 5 and abnormal in 2, whereas GM assessment was abnormal in 5 and definitely abnormal in 2. Out of 25 KANET borderline fetuses, ATNAT was normal in 7, borderline in 17 and abnormal in 1, whereas the GM assessment was as follows: normal optimal in 4, normal suboptimal in 20, and abnormal in 1. In summary, out of 32 borderline and abnormal fetuses ATNAT was normal in 7, borderline in 22 and abnormal in 3; GM assessment was normal optimal in 4, normal suboptimal in 20, abnormal in 6 and definitely abnormal in 2.

CONCLUSION

The sonographic test requires further studies before being recommended for wider clinical practice.

Cognitive abilities and behaviour of children exposed to antiepileptic drugs in utero

PURPOSE OF REVIEW

The last two decades have witnessed a growing concern over the treatment of epilepsy in women of childbearing age, with an increased risk of major congenital malformations and possible cognitive difficulties associated with certain antiepileptic drugs. The aim here is to review the literature regarding the possible cognitive and behavioural impact of exposure to antiepileptic drugs in utero.

RECENT FINDINGS

Recent evidence from large prospective cohorts indicates that there is a longer term risk to the cognitive and behavioural development of the child exposed in utero to sodium valproate. Information on other antiepileptic agents is conflicting or nonexistent and more research in this area is urgently required.

SUMMARY

Despite the methodological shortfalls of some of the research in this area, there is an accumulation of evidence highlighting an increased risk for cognitive and behavioural difficulties in children exposed to sodium valproate in utero. Although less certain, there may also be risks associated with phenobarbital and phenytoin exposure. Information regarding these risks should be communicated to the potential mother who has epilepsy.

Neurodevelopmental delay in children exposed to antiepileptic drugs in utero: a critical review directed at structural study-bias

INTRODUCTION

The general issue whether in utero exposure to antiepileptic drugs (AEDs) causes congenital malformations (teratogenicity) was raised as early as 1968. The 'congenital hydantoin syndrome' after intrauterine exposure to phenytoin (PHT) was first described in 1975. In 1984, DiLiberti proposed the label 'Fetal Valproate Syndrome' (FVS) for children with a cluster of minor congenital anomalies in the form of dysmorphic facial appearances with or without major abnormalities after intra-uterine exposure to valproate (VPA). Later, also the presence of central nervous system (CNS) dysfunction became part of the description. The question whether developmental delay, educational impairment, or behavioural disorders are also a characteristic of intrauterine exposure to AEDs and especially VPA, is of major importance to many women with epilepsy, parents and physicians involved.

METHODS

Literature was searched using MEDLINE and other relevant databases: 56 studies were identified and interpreted.

RESULTS

The identified studies do not allow definite conclusions. The possibility of neurodevelopmental delay, behavioural disorders, or learning disabilities as an outcome of in utero exposure to AEDs and especially VPA, needs to be considered seriously. The literature however does not provide evidence for a valid risk estimate. Moreover the evidence found for a specific increased risk for VPA could be structurally biased.

DISCUSSION

The major problem in this field is the methodology and in particular the existence of important confounding factors that complicate any attempt to correlate intra-uterine exposure to AEDs with neurodevelopmental delay. We propose a number of guidelines for studies on behavioural teratogenicity.

Continuity between Fetal and Neonatal Neurobehavior

As the development of the brain is unique and continuing process throughout the gestation and after birth, it is expected that there is also continuity of fetal and neonatal movements which are the best functional indicator of developmental processes of the brain. Understanding the relation between fetal and infant behavior and developmental processes of the brain in different periods of gestation may make achievable the distinction between normal and abnormal brain development. Epidemiological studies revealed that many neurologically impaired infants belong to low risk population, which means that they seemed to be developmentally normal as fetuses and as infants, while later childhood neurological disability was diagnosed. Which methods of neurological assessment are available for that purpose? Prenatally we have not many possibilities for neurological assessment, while postnatally the repertoire of diagnostic possibilities is increasing. Among the postnatally available methods for neurological assessment, the most important are: clinical neurological assessment, neuroimaging methods, assessment of general movements (GMs) and combinations. Postnatal neurological assessment is probably easier to perform than prenatal, by using a simple and suitable for everyday work screening clinical test with good reliability, specificity and sensitivity.

There is a possibility for the early and simple neurological assessment of the term and preterm newborns with the aim to detect associated risks and anticipate long-term outcome of the infant, and to establish a possible causative link between pregnancy course and neurodevelopmental outcome. The evaluation of infant's developmental optimality should be assessed in order to investigate whether the infant is neurologically normal or damaged. Neurological assessment at term by Amiel-Tison (ATNAT) is taking into account neurological maturation exploring so called lower subcortical system developing earlier from the reticular formation, vestibular nuclei and tectum, and upper cortical system developing from the corticospinal pathways.

Conventional acquisition neuroimaging techniques together with modern diffusion neuroimaging techniques can identify typical patterns of brain injury, even in the early course of the disease. However, even though highly suggestive, these patterns cannot be considered as pathognomonic. Nevertheless neuroimaging methods alone are not sufficient to predict the neurological outcome in neonates from highrisk population.

Prechtl stated that spontaneous motility, as the expression of spontaneous neural activity, is a marker of brain proper or disturbed function. The observation of unstimulated fetus or infant which is the result of spontaneous behavior without sensory stimulation is the best method to assess its central nervous system capacity. All endogenously generated movement patterns from un-stimulated central nervous system could be observed as early as from the 7-8 weeks of postmenstrual age, with developing a reach repertoire of movements within the next two or three weeks, continuing to be present for 5 to 6 months postnatally. This remarkable fact of the continuity of endogenously generated activity from prenatal to postnatal life is the great opportunity to find out those high-risk fetuses and infants in whom development of neurological impairment is emerging. The most important among those movements are GMs involving the whole body in a variable sequence of arm, leg, neck and trunk movements, with gradual beginning and the end. They wax and wane in intensity, force and speed being fluent and elegant with the impression of complexity and variability. Assessment of GMs in high-risk newborns has significantly higher predictive value for later neurological development than neurological examination. Kurjak and co-workers conducted a study by 4D ultrasound and confirmed earlier findings made by 2D ultrasonography, that there is behavioral pattern continuity from prenatal to postnatal life. Assessment of neonatal behavior is a better method for early detection of cerebral palsy than neurological examination alone.

Are we approaching the era when there will be applicable neurological test for fetus and assessment of neonate will be just the continuation? This is still not easy question to answer, because even postnatally there are several neurological methods of evaluation, while in utero we are dealing with more complicated situation and less mature brain. Could neonatal assessment of neurologically impaired fetuses bring some new insights into their prenatal neurological status is still unclear and to be investigated. New scoring system for prenatal neurological assessment of the fetus proposed by Kurjak et al will give some new possibilities to detect fetuses at high neurological risk, although it is obvious that dynamic and complicated process of functional CNS development is not easy to investigate.

The aim of this review is to present continuity of the functional central nervous system assessment from prenatal to postnatal life.

Teratogenicity of antiepileptic drugs: state of the art: review

PURPOSE OF REVIEW

Information on the risks associated with antiepileptic drug (AED) use in pregnancy is necessary for a rational approach to the management of women of childbearing potential who have epilepsy. This reviews addresses recent reports on the risk for birth defects and impaired postnatal development attributable to prenatal exposure to AEDs.

RECENT FINDINGS

Some studies have indicated greater risk for birth defects as well as for lower verbal IQ in association with exposure to valproic acid, as compared with some other AEDs. The risk appears to be greater at doses above 800-1000 mg/day; lower doses may not carry higher risks than those associated with other AEDs. This observation is a cause of concern but more data are needed from prospective studies to assess the possible impact of confounding factors in order to clarify whether there is a causal relationship. Large-scale pregnancy registries have been launched and are expected to provide more conclusive comparative data on the most frequently used AEDs in the near future.

SUMMARY

Although further studies are needed, it appears reasonable to use valproic acid with caution in women with epilepsy who are planning to become pregnant, and to consider prescribing other equally effective and safer AEDs if they are available. The importance of seizure control during pregnancy must not be neglected, and any attempt to change treatment should be done before conception. Drug withdrawal during pregnancy should be avoided, and patients should be made aware that definitive evidence on the relative safety of AEDs is lacking.

Common antiepileptic drugs in pregnancy in women with epilepsy

BACKGROUND

The potential adverse effects of antiepileptic drug (AED) exposure in pregnancy have been well recognised but the relative risks of specific antiepileptic drug exposures remain poorly understood.

OBJECTIVES

To assess the adverse effects of commonly used antiepileptic drugs on maternal and fetal outcomes in pregnancy in women with epilepsy. Comparison of outcomes following specific antiepileptic drug exposures in utero to unexposed pregnancies in the general population or women with epilepsy are described. The current manuscript reports the first phase of this review which focuses upon neurodevelopmental outcomes in children exposed to antiepileptic drugs in utero.

SEARCH STRATEGY

We searched MEDLINE, Pharmline, EMBASE, Reprotox and TERIS from 1966 to December 2003. Review articles and conference abstracts were also hand searched.

SELECTION CRITERIA

All randomized controlled trials, prospective cohorts of children of pregnant women with and without epilepsy and case control studies (cases: developmental delay or impaired cognitive outcome, control: normal development) were included.

DATA COLLECTION AND ANALYSIS

Methodological quality was assessed using an adapted version of the Newcastle-Ottawa Scale. The wide variety of outcome measures and methodological approaches made meta-analysis difficult and a descriptive analysis of the results is presented.

MAIN RESULTS

PART A 1b - DEVELOPMENTAL OUTCOMES: The majority of studies were of limited quality. There was little evidence about which specific drugs carry more risk than others to the development of children exposed in utero. The results between studies are conflicting and while most failed to find a significant detrimental outcome with in utero exposure to monotherapy with carbamazepine, phenytoin or phenobarbitone, this should be interpreted cautiously. There were very few studies of exposure to sodium valproate. Polytherapy exposure in utero was more commonly associated with poorer outcomes, as was exposure to any AEDs when analysis did not take into account type of AED. The latter may reflect the large proportion of children included in these studies who were in fact exposed to polytherapy.

REVIEWERS' CONCLUSIONS

PART A 1b - DEVELOPMENTAL OUTCOMES: Based on the best current available evidence it would seem advisable for women to continue medication during pregnancy using monotherapy at the lowest dose required to achieve seizure control. Polytherapy would seem best avoided where possible. More population based studies adequately powered to examine the effects of in utero exposure to specific monotherapies which are used in everyday practice are required.