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Leite MDL, Topocov TN, de Oliveira TL, Almeida DDS, Mota Ortiz SR, da Silva JC. Obstetric and neonatal outcomes, antiseizure medication profile, and seizure types in pregnant women in a vulnerability state from Brazil. PLoS One 2024; 19:e0291190. [PMID: 38558080 PMCID: PMC10984515 DOI: 10.1371/journal.pone.0291190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 08/24/2023] [Indexed: 04/04/2024] Open
Abstract
This retrospective cohort study described the obstetric and neonatal outcomes, antiseizure medication (ASM) use, and types of seizures in pregnant women with epilepsy (PWWE). Data collected from the medical records of 224 PWWE aged < 40 years with controlled or refractory seizures and 492 pregnant women without epilepsy (PWNE) control group from high-risk maternity hospitals in Alagoas between 2008 and 2021 were included in this study. The obstetric and neonatal outcomes observed in PWWE were pregnancy-related hypertension (PrH) (18.4%), oligohydramnios (10.3%), stillbirth (6.4%), vaginal bleeding (6%), preeclampsia (4.7%), and polyhydramnios (3%). There was a greater likelihood of PrH in PWWE with generalized tonic-clonic seizures (GTCS) and that of maternal intensive care unit (ICU) admissions in those with GTCS and status epilepticus, and phenytoin and lamotrigine use. PWWE with GTCS had a higher risk of stillbirth and premature delivery. PWWE with status epilepticus were treated with lamotrigine. Phenobarbital (PB) with diazepam were commonly used in GTCS and status epilepticus. Total 14% patients did not use ASM, while 50.2% used monotherapy and 35.8% used polytherapy. Total 60.9% of patients used PB and 25.2% used carbamazepine. This study described the association between the adverse obstetric and neonatal outcomes and severe seizure types in PWWE.
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Affiliation(s)
- Magnúcia de Lima Leite
- Universidade Estadual de Ciências da Saúde Alagoas (UNCISAL), Maceió, AL, Brazil
- Universidade de São Paulo (USP), São Paulo, SP, Brazil
| | | | | | | | - Sandra Regina Mota Ortiz
- Universidade Municipal de São Caetano do Sul (USCS), São Paulo, SP, Brazil
- Universidade São Judas Tadeu (USJT), São Paulo, SP, Brazil
| | - José Claudio da Silva
- Faculdade de Medicina do Centro Universitário(CESMAC), Maceió, AL, Brazil
- PPGSF/RENASF/FIOCRUZ/UNCISAL, Maceió, AL, Brazil
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Ershadi F, Mousavi Mirzaei SM, Tabrizi N, Roshanravan B, Sahebnasagh A, Avan R. Evaluation of family planning methods in married women with epilepsy. Epilepsy Behav 2022; 129:108618. [PMID: 35257991 DOI: 10.1016/j.yebeh.2022.108618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 01/13/2022] [Accepted: 02/05/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Epilepsy is one of the most common neurologic unit diseases that have different prevalence in different parts of the world. Antiepileptic drugs (AEDs) are associated with major fertility risks for women of childbearing age. Due to the fact that studies on family planning methods in married women with epilepsy (WWE) have not been conducted in Iran, the aim of this study was to evaluate the family planning methods in married WWE in Birjand, Iran. METHODS An analytical-descriptive study was performed on 126 married WWE hospitalized in the neurology ward or referred to Vali-e-Asr specialized and sub-specialized clinic in Birjand. Demographic information of patients as well as data on the type of used AED, and various methods of family planning were collected in a questionnaire. Data analysis was performed using Chi-square and Fisher tests. All of the above analyses were considered at a significance level of less than 5% by SPSS v.19 software. RESULTS The mean age of the patients was 33.41 ± 9.15 years. The mean age of experiencing the first seizure and the onset of menstruation were 24.82 and 13.79 years, respectively. Fifty (35.5%), 38 (27%), 15 (10.6%), 14 (9.9%), and 14 (9.9%) patients used sodium valproate, carbamazepine, phenytoin, levetiracetam, and lamotrigine, respectively. The results showed that 72 sexually active patients (70.6%) used family planning methods, of which 43 patients (59.7%) used withdrawal method, 20 patients (27.8%) used condoms, and 6 patients (8.3%) used oral contraceptive pills (OCP). Eight patients (9.6%) had a history of unintended pregnancy and 3 patients (3.6%) had a history of abortion. CONCLUSION It is recommended to apply effective family planning methods in married WWE to prevent unintended pregnancies and the subsequent adverse effects in the fetus, considering the fact that a significant percentage of WWE did not use effective family planning methods and 8 cases of unintended pregnancies were reported. Because of high consumption of valproate in women of childbearing age in our study and concerning issue about its fetal malformation, it is recommended to reduce the administration of valproate in this population. Moreover, regarding the low consumption of folic acid, especially for women of childbearing age and pregnant WWE who are taking AED, the necessary recommendations should be made by our physicians.
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Affiliation(s)
- Faranak Ershadi
- Medical Student, Birjand University of Medical Sciences, Birjand, Iran
| | | | - Nasim Tabrizi
- Department of Neurology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Babak Roshanravan
- Student Research Committee, Birjand University of Medical Sciences, Birjand, Iran
| | - Adeleh Sahebnasagh
- Clinical Research Center, Department of Internal Medicine, North Khorasan University of Medical Sciences, Bojnurd, Iran
| | - Razieh Avan
- Department of Clinical Pharmacy, School of Pharmacy, Medical Toxicology and Drug Abuse Research Center, Birjand University of Medical Sciences, Birjand, Iran.
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László K, Kiss O, Vörös D, Mintál K, Ollmann T, Péczely L, Kovács A, Zagoracz O, Kertes E, Kállai V, László B, Hormay E, Berta B, Tóth A, Karádi Z, Lénárd L. Intraamygdaloid Oxytocin Reduces Anxiety in the Valproate-Induced Autism Rat Model. Biomedicines 2022; 10:405. [PMID: 35203614 PMCID: PMC8962302 DOI: 10.3390/biomedicines10020405] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 01/26/2022] [Accepted: 01/31/2022] [Indexed: 12/10/2022] Open
Abstract
BACKGROUND Autism spectrum disorder (ASD) is a lifelong neurodevelopmental disorder affecting about 1.5% of children, and its prevalence is increasing. Anxiety is one of the most common comorbid signs of ASD. Despite the increasing prevalence, the pathophysiology of ASD is still poorly understood, and its proper treatment has not been defined yet. In order to develop new therapeutic approaches, the valproate- (VPA) induced rodent model of autism can be an appropriate tool. Oxytocin (OT), as a prosocial hormone, may ameliorate some symptoms of ASD. METHODS In the present study, we investigated the possible anxiolytic effect of intraamygdaloid OT on VPA-treated rats using the elevated plus maze test. RESULTS Our results show that male Wistar rats prenatally exposed to VPA spent significantly less time in the open arms of the elevated plus maze apparatus and performed significantly less head dips from the open arms. Bilateral OT microinjection into the central nucleus of the amygdala increased the time spent in the open arms and the number of head dips and reduced the anxiety to the healthy control level. An OT receptor antagonist blocked the anxiolytic effects of OT. The antagonist by itself did not influence the time rats spent in the open arms. CONCLUSIONS Our results show that intraamygdaloid OT has anxiolytic effects in autistic rats.
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Affiliation(s)
- Kristóf László
- Medical School, Institute of Physiology, University of Pécs, 7624 Pécs, Hungary; (O.K.); (D.V.); (K.M.); (T.O.); (L.P.); (A.K.); (O.Z.); (E.K.); (V.K.); (B.L.); (E.H.); (B.B.); (A.T.); (Z.K.); (L.L.)
- Neuroscience Center, University of Pécs, 7624 Pécs, Hungary
| | - Orsolya Kiss
- Medical School, Institute of Physiology, University of Pécs, 7624 Pécs, Hungary; (O.K.); (D.V.); (K.M.); (T.O.); (L.P.); (A.K.); (O.Z.); (E.K.); (V.K.); (B.L.); (E.H.); (B.B.); (A.T.); (Z.K.); (L.L.)
- Neuroscience Center, University of Pécs, 7624 Pécs, Hungary
| | - Dávid Vörös
- Medical School, Institute of Physiology, University of Pécs, 7624 Pécs, Hungary; (O.K.); (D.V.); (K.M.); (T.O.); (L.P.); (A.K.); (O.Z.); (E.K.); (V.K.); (B.L.); (E.H.); (B.B.); (A.T.); (Z.K.); (L.L.)
- Neuroscience Center, University of Pécs, 7624 Pécs, Hungary
| | - Kitti Mintál
- Medical School, Institute of Physiology, University of Pécs, 7624 Pécs, Hungary; (O.K.); (D.V.); (K.M.); (T.O.); (L.P.); (A.K.); (O.Z.); (E.K.); (V.K.); (B.L.); (E.H.); (B.B.); (A.T.); (Z.K.); (L.L.)
- Neuroscience Center, University of Pécs, 7624 Pécs, Hungary
| | - Tamás Ollmann
- Medical School, Institute of Physiology, University of Pécs, 7624 Pécs, Hungary; (O.K.); (D.V.); (K.M.); (T.O.); (L.P.); (A.K.); (O.Z.); (E.K.); (V.K.); (B.L.); (E.H.); (B.B.); (A.T.); (Z.K.); (L.L.)
- Neuroscience Center, University of Pécs, 7624 Pécs, Hungary
| | - László Péczely
- Medical School, Institute of Physiology, University of Pécs, 7624 Pécs, Hungary; (O.K.); (D.V.); (K.M.); (T.O.); (L.P.); (A.K.); (O.Z.); (E.K.); (V.K.); (B.L.); (E.H.); (B.B.); (A.T.); (Z.K.); (L.L.)
- Neuroscience Center, University of Pécs, 7624 Pécs, Hungary
| | - Anita Kovács
- Medical School, Institute of Physiology, University of Pécs, 7624 Pécs, Hungary; (O.K.); (D.V.); (K.M.); (T.O.); (L.P.); (A.K.); (O.Z.); (E.K.); (V.K.); (B.L.); (E.H.); (B.B.); (A.T.); (Z.K.); (L.L.)
- Neuroscience Center, University of Pécs, 7624 Pécs, Hungary
| | - Olga Zagoracz
- Medical School, Institute of Physiology, University of Pécs, 7624 Pécs, Hungary; (O.K.); (D.V.); (K.M.); (T.O.); (L.P.); (A.K.); (O.Z.); (E.K.); (V.K.); (B.L.); (E.H.); (B.B.); (A.T.); (Z.K.); (L.L.)
- Neuroscience Center, University of Pécs, 7624 Pécs, Hungary
| | - Erika Kertes
- Medical School, Institute of Physiology, University of Pécs, 7624 Pécs, Hungary; (O.K.); (D.V.); (K.M.); (T.O.); (L.P.); (A.K.); (O.Z.); (E.K.); (V.K.); (B.L.); (E.H.); (B.B.); (A.T.); (Z.K.); (L.L.)
- Neuroscience Center, University of Pécs, 7624 Pécs, Hungary
| | - Veronika Kállai
- Medical School, Institute of Physiology, University of Pécs, 7624 Pécs, Hungary; (O.K.); (D.V.); (K.M.); (T.O.); (L.P.); (A.K.); (O.Z.); (E.K.); (V.K.); (B.L.); (E.H.); (B.B.); (A.T.); (Z.K.); (L.L.)
- Neuroscience Center, University of Pécs, 7624 Pécs, Hungary
| | - Bettina László
- Medical School, Institute of Physiology, University of Pécs, 7624 Pécs, Hungary; (O.K.); (D.V.); (K.M.); (T.O.); (L.P.); (A.K.); (O.Z.); (E.K.); (V.K.); (B.L.); (E.H.); (B.B.); (A.T.); (Z.K.); (L.L.)
- Neuroscience Center, University of Pécs, 7624 Pécs, Hungary
| | - Edina Hormay
- Medical School, Institute of Physiology, University of Pécs, 7624 Pécs, Hungary; (O.K.); (D.V.); (K.M.); (T.O.); (L.P.); (A.K.); (O.Z.); (E.K.); (V.K.); (B.L.); (E.H.); (B.B.); (A.T.); (Z.K.); (L.L.)
- Neuroscience Center, University of Pécs, 7624 Pécs, Hungary
| | - Beáta Berta
- Medical School, Institute of Physiology, University of Pécs, 7624 Pécs, Hungary; (O.K.); (D.V.); (K.M.); (T.O.); (L.P.); (A.K.); (O.Z.); (E.K.); (V.K.); (B.L.); (E.H.); (B.B.); (A.T.); (Z.K.); (L.L.)
- Neuroscience Center, University of Pécs, 7624 Pécs, Hungary
| | - Attila Tóth
- Medical School, Institute of Physiology, University of Pécs, 7624 Pécs, Hungary; (O.K.); (D.V.); (K.M.); (T.O.); (L.P.); (A.K.); (O.Z.); (E.K.); (V.K.); (B.L.); (E.H.); (B.B.); (A.T.); (Z.K.); (L.L.)
- Neuroscience Center, University of Pécs, 7624 Pécs, Hungary
| | - Zoltán Karádi
- Medical School, Institute of Physiology, University of Pécs, 7624 Pécs, Hungary; (O.K.); (D.V.); (K.M.); (T.O.); (L.P.); (A.K.); (O.Z.); (E.K.); (V.K.); (B.L.); (E.H.); (B.B.); (A.T.); (Z.K.); (L.L.)
- Neuroscience Center, University of Pécs, 7624 Pécs, Hungary
- Szentágothai Center, Molecular Endocrinology and Neurophysiology Research Group, University of Pécs, 7624 Pécs, Hungary
| | - László Lénárd
- Medical School, Institute of Physiology, University of Pécs, 7624 Pécs, Hungary; (O.K.); (D.V.); (K.M.); (T.O.); (L.P.); (A.K.); (O.Z.); (E.K.); (V.K.); (B.L.); (E.H.); (B.B.); (A.T.); (Z.K.); (L.L.)
- Neuroscience Center, University of Pécs, 7624 Pécs, Hungary
- Szentágothai Center, Molecular Endocrinology and Neurophysiology Research Group, University of Pécs, 7624 Pécs, Hungary
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Abstract
BACKGROUND Pregabalin is a gamma-aminobutyric acid analog that binds to the α2-δ subunits of the pre-synaptic voltage-dependent calcium channels of nerves with a high affinity and selectivity. In this study, the retinal teratogenic potential of pregabalin was investigated in a chick embryo model. MATERIALS AND METHODS Fertilised chicken eggs were divided into groups for administration with different doses of pregabalin. All eggs were opened on the 10th day of incubation. The embryos were dissected and the effects of pregabalin on the retina were investigated histopathologically, morphometrically, and immunohistochemically (Caspase-3). RESULTS There was no statistically significant difference between the low dose pregabalin, control, or vehicle control groups in terms of the number of retina layers and retinal thickness. Medium and high dose pregabalin caused a statistically significant decrease in the number of retina layers, as well as sensory retinal and pigment epithelium layer thicknesses. The outer nuclear and outer plexiform layer did not form in the group administered a medium dose. Similarly, the outer nuclear, outer plexiform, inner nuclear, and inner plexiform layer did not form in the high-dose group. No statistically significant difference was observed between the groups in terms of cellular damage and Caspase-3 expression. CONCLUSION The use of pregabalin during pregnancy compromises retinal development in a dose-dependent manner. The use of pregabalin in pregnancy causes the aforementioned defects in this system and it may have developmental effects that needs to be further evaluated.
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Affiliation(s)
- Ilke Evrim Secinti
- Department of Pathology, School of Medicine, Hatay Mustafa Kemal University, Hatay, Turkey
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Jeon JY, Bae JG, Kim KT, Cho YW. Pregnancy and Epilepsy: a Korean Tertiary Epilepsy Center Review. J Korean Med Sci 2020; 35:e119. [PMID: 32419394 PMCID: PMC7234856 DOI: 10.3346/jkms.2020.35.e119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 03/02/2020] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Pregnancy in women with epilepsy (WWE) is known to have a higher risk for fetal development complications, which may include congenital malformations. Unfortunately, information pertaining to pregnancy in WWE is difficult to obtain because there are considerable ethical issues preventing these studies from being conducted on pregnant women. Therefore, this study investigated the pregnancies of Korean WWE in a tertiary epilepsy center to observe data resulting from the outcome of the pregnancies. METHODS This was a retrospective study of 48 pregnant WWE who were treated at the regional tertiary epilepsy center. All records of hospital visits before and after the period of pregnancy were analyzed to obtain information about the seizures as well as pregnancy-related outcomes, including the status of the newborns' conditions. RESULTS The subject group consisted of 31 (63.3%) with partial epilepsy, 6 (12.5%) with generalized epilepsy, and 11 (22.9%) with unclassified epilepsy. There were 27 subjects who took one antiepileptic drug (AED), and 12 who took two AEDs. The most commonly used drug was lamotrigine (29.8%). Of the 48 WWE involved in the study, 31 underwent caesarian sections and 17 opted for natural birth. Thirty-nine (81.3%) delivered at full-term, but 9 (18.7%) delivered at preterm. Compared to full-term infants, pre-mature infants showed lower birth weight, smaller head circumference, shorter height, and lower 1-minute Apgar scores, but seizure frequencies of the mothers did not differ. CONCLUSION In WWE, epilepsy classification, number of AEDs taken, and frequency of seizures are not significantly correlated with delivery and fetal condition. This data could be used as a clinical reference for physicians to provide useful information to WWE if they are concerned about their pregnancies.
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Affiliation(s)
- Ji Ye Jeon
- Department of Neurology, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jin Gon Bae
- Department of Obstetrics and Gynecology, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Keun Tae Kim
- Department of Neurology, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Yong Won Cho
- Department of Neurology, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea.
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Prenatal valproate in rodents as a tool to understand the neural underpinnings of social dysfunctions in autism spectrum disorder. Neuropharmacology 2019; 159:107477. [DOI: 10.1016/j.neuropharm.2018.12.024] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 12/11/2018] [Accepted: 12/20/2018] [Indexed: 12/22/2022]
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Sarma AK, Khandker N, Kurczewski L, Brophy GM. Medical management of epileptic seizures: challenges and solutions. Neuropsychiatr Dis Treat 2016; 12:467-85. [PMID: 26966367 PMCID: PMC4771397 DOI: 10.2147/ndt.s80586] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Epilepsy is one of the most common neurologic illnesses. This condition afflicts 2.9 million adults and children in the US, leading to an economic impact amounting to $15.5 billion. Despite the significant burden epilepsy places on the population, it is not very well understood. As this understanding continues to evolve, it is important for clinicians to stay up to date with the latest advances to provide the best care for patients. In the last 20 years, the US Food and Drug Administration has approved 15 new antiepileptic drugs (AEDs), with many more currently in development. Other advances have been achieved in terms of diagnostic modalities like electroencephalography technology, treatment devices like vagal nerve and deep-brain stimulators, novel alternate routes of drug administration, and improvement in surgical techniques. Specific patient populations, such as the pregnant, elderly, those with HIV/AIDS, and those with psychiatric illness, present their own unique challenges, with AED side effects, drug interactions, and medical-psychiatric comorbidities adding to the conundrum. The purpose of this article is to review the latest literature guiding the management of acute epileptic seizures, focusing on the current challenges across different practice settings, and it discusses studies in various patient populations, including the pregnant, geriatric, those with HIV/AIDS, comatose, psychiatric, and "pseudoseizure" patients, and offers possible evidence-based solutions or the expert opinion of the authors. Also included is information on newer AEDs, routes of administration, and significant AED-related drug-interaction tables. This review has tried to address only some of these issues that any practitioner who deals with the acute management of seizures may encounter. The document also highlights the numerous avenues for new research that would help practitioners optimize epilepsy management.
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Affiliation(s)
- Anand K Sarma
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
| | - Nabil Khandker
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
| | - Lisa Kurczewski
- Departments of Pharmacotherapy & Outcomes Science and Neurosurgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Gretchen M Brophy
- Departments of Pharmacotherapy & Outcomes Science and Neurosurgery, Virginia Commonwealth University, Richmond, VA, USA
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Laganà AS, Triolo O, D’Amico V, Cartella SM, Sofo V, Salmeri FM, Vrtačnik Bokal E, Spina E. Management of women with epilepsy: from preconception to post-partum. Arch Gynecol Obstet 2015; 293:493-503. [DOI: 10.1007/s00404-015-3968-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2015] [Accepted: 11/16/2015] [Indexed: 02/07/2023]
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Lassi ZS, Imam AM, Dean SV, Bhutta ZA. Preconception care: screening and management of chronic disease and promoting psychological health. Reprod Health 2014; 11 Suppl 3:S5. [PMID: 25415675 PMCID: PMC4196564 DOI: 10.1186/1742-4755-11-s3-s5] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION A large proportion of women around the world suffer from chronic diseases including mental health diseases. In the United States alone, over 12% of women of reproductive age suffer from a chronic medical condition, especially diabetes and hypertension. Chronic diseases significantly increase the odds for poor maternal and newborn outcomes in pregnant women. METHODS A systematic review and meta-analysis of the evidence was conducted to ascertain the possible impact of preconception care for preventing and managing chronic diseases and promoting psychological health on maternal, newborn and child health outcomes. A comprehensive strategy was used to search electronic reference libraries, and both observational and clinical controlled trials were included. Cross-referencing and a separate search strategy for each preconception risk and intervention ensured wider study capture. RESULTS Maternal prepregnancy diabetic care is a significant intervention that reduces the occurrence of congenital malformations by 70% (95% Confidence Interval (CI): 59-78%) and perinatal mortality by 69% (95% CI: 47-81%). Furthermore, preconception management of epilepsy and phenylketonuria are essential and can optimize maternal, fetal and neonatal outcomes if given before conception. Ideally changes in antiepileptic drug therapy should be made at least 6 months before planned conception. Interventions specifically targeting women of reproductive age suffering from a psychiatric condition show that group-counseling and interventions leading to empowerment of women have reported non-significant reduction in depression (economic skill building: Mean Difference (MD) -7.53; 95% CI: -17.24, 2.18; counseling: MD-2.92; 95% CI: -13.17, 7.33). CONCLUSION While prevention and management of the chronic diseases like diabetes and hypertension, through counseling, and other dietary and pharmacological intervention, is important, delivering solutions to prevent and respond to women's psychological health problems are urgently needed to combat this leading cause of morbidity.
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Affiliation(s)
- Zohra S Lassi
- Division of Women and Child Health, Aga Khan University Karachi, Pakistan
| | - Ayesha M Imam
- Division of Women and Child Health, Aga Khan University Karachi, Pakistan
| | - Sohni V Dean
- Division of Women and Child Health, Aga Khan University Karachi, Pakistan
| | - Zulfiqar A Bhutta
- Division of Women and Child Health, Aga Khan University Karachi, Pakistan
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Jose M, Banerjee M, Mathew A, Bharadwaj T, Vijayan N, Thomas SV. Pharmacogenetic evaluation of ABCB1, Cyp2C9, Cyp2C19 and methylene tetrahydrofolate reductase polymorphisms in teratogenicity of anti-epileptic drugs in women with epilepsy. Ann Indian Acad Neurol 2014; 17:259-66. [PMID: 25221392 PMCID: PMC4162009 DOI: 10.4103/0972-2327.138475] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Revised: 01/14/2014] [Accepted: 03/01/2014] [Indexed: 01/11/2023] Open
Abstract
Aim: Pregnancy in women with epilepsy (WWE) who are on anti-epileptic drugs (AEDs) has two- to three-fold increased risk of fetal malformations. AEDs are mostly metabolized by Cyp2C9, Cyp2C19 and Cyp3A4 and transported by ABCB1. Patients on AED therapy can have folate deficiency. We hypothesize that the polymorphisms in ABCB1, Cyp2C9, Cyp2C19 and methylene tetrahydrofolate reductase (MTHFR) might result in differential expression resulting in differential drug transport, drug metabolism and folate metabolism, which in turn may contribute to the teratogenic impact of AEDs. Materials and Methods: The ABCB1, Cyp2C9, Cyp2C19 and MTHFR polymorphisms were genotyped for their role in teratogenic potential and the nature of teratogenecity in response to AED treatment in WWE. The allelic, genotypic associations were tested in 266 WWE comprising of 143 WWE who had given birth to babies with WWE-malformation (WWE-M) and 123 WWE who had normal offsprings (WWE-N). Results: In WWE-M, CC genotype of Ex07 + 139C/T was overrepresented (P = 0.0032) whereas the poor metabolizer allele *2 and *2 *2 genotype of CYP2C219 was significantly higher in comparison to WWE-N group (P = 0.007 and P = 0.005, respectively). All these observations were independent of the nature of malformation (cardiac vs. non cardiac malformations). Conclusion: Our study indicates the possibility that ABCB1 and Cyp2C19 may play a pivotal role in the AED induced teratogenesis, which is independent of nature of malformation. This is one of the first reports indicating the pharmacogenetic role of Cyp2C19 and ABCB1 in teratogenesis of AED in pregnant WWE.
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Affiliation(s)
- Manna Jose
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India ; Human Molecular Genetics Laboratory, Rajiv Gandhi Centre for Biotechnology, Thiruvananthapuram, Kerala, India
| | - Moinak Banerjee
- Human Molecular Genetics Laboratory, Rajiv Gandhi Centre for Biotechnology, Thiruvananthapuram, Kerala, India
| | - Anila Mathew
- Human Molecular Genetics Laboratory, Rajiv Gandhi Centre for Biotechnology, Thiruvananthapuram, Kerala, India
| | - Tashi Bharadwaj
- Human Molecular Genetics Laboratory, Rajiv Gandhi Centre for Biotechnology, Thiruvananthapuram, Kerala, India
| | - Neetha Vijayan
- Human Molecular Genetics Laboratory, Rajiv Gandhi Centre for Biotechnology, Thiruvananthapuram, Kerala, India
| | - Sanjeev V Thomas
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
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Winterbottom JB, Smyth RMD, Jacoby A, Baker GA. WITHDRAWN: Preconception counselling for women with epilepsy to reduce adverse pregnancy outcome. Cochrane Database Syst Rev 2014; 2014:CD006645. [PMID: 24647831 PMCID: PMC10641638 DOI: 10.1002/14651858.cd006645.pub3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
This review has been replaced by the protocol 'Preconception counselling for women with epilepsy' (Winterbottom 2014). The full review is expected to be published by 1st July 2014. The editorial group responsible for this previously published document have withdrawn it from publication.
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Affiliation(s)
| | - Rebecca MD Smyth
- The University of ManchesterSchool of Nursing, Midwifery and Social WorkJean McFarlane BuildingOxford RoadManchesterUKM13 9PL
| | - Ann Jacoby
- The University of LiverpoolDivision of Public HealthWhelan BuildingThe Quadrangle, Brownlow HillLiverpoolUKL69 3GB
| | - Gus A Baker
- Clinical Sciences Centre for Research & EducationUniversity Department of Neurological ScienceLower LaneLiverpoolMerseysideUKL9 7LJ
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Winterbottom JB, Pulman J, Greenhalgh J, Smyth RMD, Marson AG. Preconception counselling for women with epilepsy. Hippokratia 2014. [DOI: 10.1002/14651858.cd011007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | - Jennifer Pulman
- Institute of Translational Medicine, University of Liverpool; Department of Molecular and Clinical Pharmacology; Clinical Sciences Centre for Research and Education, Lower Lane Fazakerley Liverpool Merseyside UK L9 7LJ
| | - Janette Greenhalgh
- University of Liverpool; Liverpool Reviews and Implementation Group; Sherrington Building Ashton Street Liverpool UK L69 3GE
| | - Rebecca MD Smyth
- The University of Manchester; School of Nursing, Midwifery and Social Work; Jean McFarlane Building Oxford Road Manchester UK M13 9PL
| | - Anthony G Marson
- Institute of Translational Medicine, University of Liverpool; Department of Molecular and Clinical Pharmacology; Clinical Sciences Centre for Research and Education, Lower Lane Fazakerley Liverpool Merseyside UK L9 7LJ
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13
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Preconception care in France. Int J Gynaecol Obstet 2014; 125:144-5. [DOI: 10.1016/j.ijgo.2013.10.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Revised: 10/02/2013] [Accepted: 01/17/2014] [Indexed: 11/22/2022]
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Abstract
Babies born to mothers exposed to antiepileptic drugs (AEDs) are at increased risk for major congenital malformations, cognitive impairment and fetal death. For the millions of women with epilepsy, maintaining the safest drug that will successfully prevent seizures during pregnancy remains a primary consideration. The recent development of collaborative international registries to examine the differential and dose-dependent effects of the expanding number of old and new AEDs, have shed light upon potential differences during pregnancy. Valproic acid appears to be associated with the highest risk of overall, as well as AED-specific, birth defects, becoming more evident as doses exceed 1000 mg/day. Lamotrigine may be less teratogenic to humans than other AEDs, although orofacial clefts have recently been reported. The effects of polytherapy appear to carry greater risks compared with monotherapy. Limited data exist for many of the newer AEDs. Furthermore, AED effects may persist during postnatal development. Although no class 1 outcome data are available, prepregnancy counseling to optimize patient-specific treatment is recommended for women of childbearing potential with epilepsy.
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Affiliation(s)
- William O Tatum
- Tampa General Hospital and the University of South Florida, Department of Neurology, Tampa, c/o 13801 Bruce B. Downs Blvd, #401Tampa, FL, 33613 USA. www.wtatum.com
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Rihtman T, Parush S, Ornoy A. Developmental outcomes at preschool age after fetal exposure to valproic acid and lamotrigine: Cognitive, motor, sensory and behavioral function. Reprod Toxicol 2013; 41:115-25. [DOI: 10.1016/j.reprotox.2013.06.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2013] [Revised: 05/27/2013] [Accepted: 06/03/2013] [Indexed: 11/27/2022]
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16
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Impact of planning of pregnancy in women with epilepsy on seizure control during pregnancy and on maternal and neonatal outcomes. Seizure 2013; 23:112-6. [PMID: 24183922 DOI: 10.1016/j.seizure.2013.10.003] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Revised: 10/05/2013] [Accepted: 10/07/2013] [Indexed: 11/24/2022] Open
Abstract
PURPOSE To investigate whether planning of pregnancy in women with epilepsy affects seizure control during pregnancy and to compare the maternal and neonatal outcomes in planned and unplanned pregnancies. METHODS This was a retrospective cohort study of 153 pregnant women with epilepsy who were treated at the University of Tsukuba Hospital and Hokkaido University Hospital between 2003 and 2011. Twenty-one pregnancies were excluded due to insufficient data. Data of patients followed by neurologists during their planned pregnancies (planned-pregnancy group, n=51) were compared to those of patients referred to neurologists after conception for managing epilepsy during pregnancy (unplanned-pregnancy group, n=81). The treatment profile for epilepsy, seizure control, and maternal and neonatal outcomes in both groups were compared using Chi-square test or Fisher's exact test and Mann-Whitney U test. RESULTS Compared to the unplanned-pregnancy group, the planned-pregnancy group showed a significantly greater proportion of patients receiving monotherapy with antiepileptic drugs (80% vs. 61%: planned vs. unplanned, P=0.049) and those not requiring valproic acid (77% vs. 56%, P=0.031). Furthermore, the frequency of epileptic seizures (16% vs. 35%, P=0.018) and changes in antiepileptic drugs (24% vs. 41%, P=0.042) were significantly lower in the planned-pregnancy group than in the unplanned-pregnancy group. No significant intergroup differences were noted in the obstetric complications and neonatal outcomes, including congenital malformations. CONCLUSION For women with epilepsy, planning of pregnancy is associated with good seizure control during pregnancy and less fetal exposure to antiepileptic drugs.
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Abstract
Seizures and intracranial hemorrhage are possible medical diseases that any obstetrician may encounter. This article reviews the cause, treatment, and medical management in pregnancy for seizures and intracranial hemorrhage, and how the two can overlap into preeclampsia or eclampsia. This article also highlights some challenging management issues from the obstetrician's perspective.
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Rowe M, Gowda BA, Taylor D, Hannam S, Howard LM. Neonatal hypoglycaemia following maternal olanzapine therapy during pregnancy: a case report. Ther Adv Psychopharmacol 2012; 2:265-8. [PMID: 23983985 PMCID: PMC3736951 DOI: 10.1177/2045125312460395] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Melissa Rowe
- Section of Women's Mental Health, Institute of Psychiatry, King's College London, UK
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Gilboa SM, Broussard CS, Devine OJ, Duwe KN, Flak AL, Boulet SL, Moore CA, Werler MM, Honein MA. Influencing clinical practice regarding the use of antiepileptic medications during pregnancy: Modeling the potential impact on the prevalences of spina bifida and cleft palate in the United States. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2011; 157C:234-46. [DOI: 10.1002/ajmg.c.30306] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Fitzgerald KE. Use of Phenytoin in Pregnancy for Epileptic Seizure Prevention: A Case Report. J Midwifery Womens Health 2010; 49:145-7. [PMID: 15010668 DOI: 10.1016/j.jmwh.2003.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Epilepsy is the most common neurological disorder in women of reproductive age. Phenytoin is one of the most frequently prescribed antiepileptic drugs. Although the vast majority of women with epilepsy have normal pregnancy outcomes, certain fetal anomalies and pregnancy complications are associated with epilepsy and phenytoin use. Appropriate midwifery care of women with epilepsy includes consultation and co-management with an obstetrician and a neurologist. The clinical course of a woman with epilepsy taking phenytoin is presented.
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Abstract
Recent studies demonstrate an increased teratogenic risk for valproate and a probable increased risk for phenobarbital. Carbamazepine and lamotrigine appear relatively safe; however, results are inconclusive concerning a specific risk for cleft lip/palate for both drugs as well as a dose-dependent effect for malformations associated with lamotrigine. Data regarding teratogenic risks for other antiepileptic drugs are inadequate. Additional studies are needed to delineate further the risks for all antiepileptic drugs and determine the underlying mechanisms.
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Affiliation(s)
- Kimford J Meador
- Department of Neurology, University of Florida, McKnight Brain Institute Gainesville, Florida, USA.
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22
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Çoban D, Kurtoğlu S, Akın MA, Akçakuş M, Güneş T. Neonatal episodic hypoglycemia: a finding of valproic acid withdrawal. J Clin Res Pediatr Endocrinol 2010; 2:92-4. [PMID: 21274347 PMCID: PMC3005670 DOI: 10.4274/jcrpe.v2i2.92] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2010] [Accepted: 04/11/2010] [Indexed: 01/14/2023] Open
Abstract
The treatment of epilepsy during pregnancy is a worldwide problem. Drugs need to be used to control seizures in the mothers. In utero, exposure to valproic acid (VPA) and phenytoin (PH) may cause congenital malformations and also withdrawal symptoms such as irritability, jitteriness and symptoms of hypoglycemia. We present here a newborn with episodic hypoglycemia due to in utero exposure to VPA and PH. The mother was diagnosed as having complex partial epilepsy and was treated with PH (200 mg/day) and VPA (600 mg/day). The offspring developed jitteriness on the second day of life. The infant was hypoglycemic (32 mg/dl). These findings were accepted as withdrawal symptoms, since serum levels of VPA and PH were 37.8 μg/ml (50-100 μg/ml) and 6.37 μg/dl (10-20 μg/ml), respectively. Measurement of blood glucose is important and should be carefully monitored in infants exposed to antiepileptics in utero.
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Affiliation(s)
- Dilek Çoban
- Erciyes University Faculty of Medicine, Department of Pediatrics, Division of Neonatology, 38039 Kayseri, Turkey.
| | - Selim Kurtoğlu
- Erciyes University Faculty of Medicine, Department of Pediatrics, Division of Neonatology, Kayseri, Turkey
| | - Mustafa Ali Akın
- Erciyes University Faculty of Medicine, Department of Pediatrics, Division of Neonatology, Kayseri, Turkey
| | - Mustafa Akçakuş
- Erciyes University Faculty of Medicine, Department of Pediatrics, Division of Neonatology, Kayseri, Turkey
| | - Tamer Güneş
- Erciyes University Faculty of Medicine, Department of Pediatrics, Division of Neonatology, Kayseri, Turkey
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23
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Verrotti A, D'Egidio C, Coppola G, Parisi P, Chiarelli F. Epilepsy, sex hormones and antiepileptic drugs in female patients. Expert Rev Neurother 2010; 9:1803-14. [PMID: 19951139 DOI: 10.1586/ern.09.112] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Women with epilepsy have a higher incidence of reproductive endocrine disorders than the general female population. These alterations include polycystic ovary syndrome, hyperandrogenemia, infertility, hypothalamic amenorrhea and hyperprolactinemia. Reproductive dysfunction is attributed both to epilepsy itself and to antiepileptic drugs (AEDs). Focal epileptic discharges from the temporal lobe may have a direct influence on the function of the hypothalamic-pituitary axis, thus altering the release of sex steroid hormones, including the production of luteinizing hormone, follicle-stimulating hormone, gonadotropin-releasing hormone and prolactin. AEDs may modulate hormone release from the hypothalamic-pituitary-gonadal axis and they may alter the metabolism of sex hormones and their binding proteins. Hepatic enzyme-inducing AEDs, such as carbamazepine and phenytoin, may be most clearly linked to altered metabolism of sex steroid hormones, but valproic acid, an enzyme inhibitor, has also been associated with a frequent occurrence of polycystic ovary syndrome and hyperandrogenism in women with epilepsy. Therefore, treatment of epilepsy and selection of AEDs are important for reproductive health in female patients. The aim of the present review is to critically evaluate the recently published data concerning the interactions between sex hormones, epilepsy and AEDs.
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Affiliation(s)
- Alberto Verrotti
- Department of Pediatrics, University of Chieti, Via dei Vestini 5, 66100 Chieti, Italy.
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24
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Santoli F, Crespel A. Recherche étiologique lors d’un état de mal épileptique. Rev Neurol (Paris) 2009; 165:338-43. [DOI: 10.1016/j.neurol.2008.11.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2008] [Accepted: 11/25/2008] [Indexed: 10/21/2022]
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Winterbottom J, Smyth R, Jacoby A, Baker G. The effectiveness of preconception counseling to reduce adverse pregnancy outcome in women with epilepsy: what's the evidence? Epilepsy Behav 2009; 14:273-9. [PMID: 19100341 DOI: 10.1016/j.yebeh.2008.11.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2008] [Revised: 10/16/2008] [Accepted: 11/14/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The purpose of this Cochrane review was to determine the effectiveness of delivering preconception counseling interventions to women with epilepsy (WWE) as a means of reducing adverse pregnancy outcomes, increasing knowledge, and increasing intentions to plan pregnancy. METHODS Two hundred twenty-five citations were retrieved from a systematic search of the Cochrane Library and electronic databases: Medline (OVID), Scopus, CINAHL, PsychINFO, and ASSIA, and hand searches of relevant epilepsy and obstetric journals. RESULTS The search strategy identified 11 studies for consideration for inclusion. However, none met the required criteria for inclusion. CONCLUSIONS There is no robust evidence to inform the content, methods of delivery, or likely effectiveness of preconception counseling to improve pregnancy outcomes for WWE and their offspring. The value of counseling WWE prior to conception remains uncertain and requires evaluation in well-designed studies, appropriately powered to detect changes likely associated with both maternal and infant outcomes.
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Affiliation(s)
- Janine Winterbottom
- Epilepsy Department, The Walton Centre for Neurology and Neurosurgery NHS Trust, Lower Lane, Fazakerley, Liverpool, UK.
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26
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Aguglia U, Barboni G, Battino D, Battista Cavazzuti G, Citernesi A, Corosu R, Maria Guzzetta F, Iannetti P, Mamoli D, Patella A, Pavone L, Perucca E, Primiero F, Pruna D, Savasta S, Specchio LM, Verrotti A. Italian Consensus Conference on Epilepsy and Pregnancy, Labor and Puerperium. Epilepsia 2009; 50 Suppl 1:7-23. [DOI: 10.1111/j.1528-1167.2008.01964.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Risk of major congenital malformations in the offsprings of women with epilepsy is not related to family history. Epilepsy Res 2009; 83:52-7. [DOI: 10.1016/j.eplepsyres.2008.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2008] [Revised: 08/10/2008] [Accepted: 09/14/2008] [Indexed: 11/23/2022]
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Abstract
Most infants born to women with epilepsy are healthy, but there are increased risks related to in utero antiepileptic drug (AED) exposure and seizures. Emerging data from pregnancy registries and other studies allow us to better balance the anatomic teratogenic and neurodevelopmental effects of AEDs against the need to maintain maternal seizure control. Several large prospective pregnancy registries demonstrate a consistent pattern of increased risk for major congenital malformations (MCMs) with valproate (VPA) use as monotherapy, compared to nonexposed populations and to other AEDs used in monotherapy. AED polytherapy likely increases risk for MCMs, but the risk is more pronounced if VPA is included. Reduced cognitive outcomes have been reported with AED polytherapy, and with use of VPA, phenobarbital (PB), and PHT as monotherapy. Dose-dependent risk has been demonstrated with VPA for MCMs and cognitive consequences. CBZ groups show normal neurodevelopment. Increased clearance of most of the AEDs occurs during pregnancy. Use of therapeutic drug monitoring during pregnancy with LTG reduces the risk for seizure worsening. The consistent findings of increased teratogenic risk for VPA should discourage use of this medication as first-line treatment in women of childbearing age.
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Affiliation(s)
- Page B Pennell
- Department of Nuerology, Emory Epilepsy Program, Emory University School of Medicine, Atlanta, Georgia 30322, USA.
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Dunlop AL, Jack BW, Bottalico JN, Lu MC, James A, Shellhaas CS, Hallstrom LHK, Solomon BD, Feero WG, Menard MK, Prasad MR. The clinical content of preconception care: women with chronic medical conditions. Am J Obstet Gynecol 2008; 199:S310-27. [PMID: 19081425 DOI: 10.1016/j.ajog.2008.08.031] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2008] [Accepted: 08/08/2008] [Indexed: 11/29/2022]
Abstract
This article reviews the medical conditions that are associated with adverse pregnancy outcomes for women and their offspring. We also present the degree to which specific preconception interventions and treatments can impact the effects of the condition on birth outcomes. Because avoiding, delaying, or achieving optimal timing of a pregnancy is often an important component of the preconception care of women with medical conditions, contraceptive considerations particular to the medical conditions are also presented.
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Affiliation(s)
- Anne L Dunlop
- Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, GA 30322, USA.
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Abstract
Antiepileptic drugs (AEDs) are frequently used to treat several conditions that are common in women of childbearing age, including epilepsy, headaches, and mood disorders. Moreover, as in the case of epilepsy and severe psychiatric disease, clinicians frequently do not have the option of stopping these medications or switching to another class of drugs. Overall, AEDs have been associated with an increased risk of major congenital malformations, minor anomalies, specific congenital syndromes, and developmental disorders seen in childhood. However, the differential effects of individual AEDs remain uncertain. Data are accumulating which strongly suggest that these risks are highest in patients receiving polypharmacy and valproate. There is also modest evidence to suggest an increased risk for phenobarbital. While other older AEDs appear to carry some teratogenic risk, there is not adequate evidence to further stratify their risk. Clinical and basic science research regarding newer AEDs suggests equivalent, if not safer, profiles compared with older AEDs, but these data are inconclusive. Management of women with epilepsy should include a discussion of these risks, prophylactic treatment with folic acid, and the minimal use of polypharmacy and valproate needed to maintain optimum seizure control.
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Affiliation(s)
- Benzi M Kluger
- Department of Neurology, University of Florida, Gainesville, Florida 32610, USA
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31
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Winterbottom JB, Smyth RM, Jacoby A, Baker GA. Preconception counselling for women with epilepsy to reduce adverse pregnancy outcome. Cochrane Database Syst Rev 2008:CD006645. [PMID: 18646164 DOI: 10.1002/14651858.cd006645.pub2] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The provision of preconception counselling to women with epilepsy (WWE) has become established as recommended practice and includes a review of drug treatment and the provision of information and advice on both seizure and treatment-related risks to both mother and child. In this review we assess the evidence regarding the effectiveness of preconception counselling for WWE. OBJECTIVES To determine the effectiveness of preconception counselling for WWE, measured by a reduction in adverse pregnancy outcome in both mother and child; increased knowledge of preconception issues in WWE and increasing intention to plan pregnancy. SEARCH STRATEGY We searched the Epilepsy Group's Specialized Register (30/01/2008), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 4), and electronic databases: MEDLINE (OVID) (1950-February 2008); SCOPUS (1966-March 2008); CINAHL (1982-March 2008); PsyclNFO (1806-March 2008); ASSIA (1987-March 2008). SELECTION CRITERIA Randomised control trials; including cluster and quasi-randomised trials, prospective cohorts, controlled before and after studies, and interrupted time series that compared the outcomes in mothers with epilepsy and infants of mothers with epilepsy who received preconception counselling, to the outcomes of mothers with epilepsy and their infants who received standard care or no intervention. DATA COLLECTION AND ANALYSIS The methodological quality of potentially relevant studies were assessed to determine appropriate inclusion. Where necessary, study authors were contacted for additional information. No studies met the review inclusion criteria. MAIN RESULTS The search strategy identified 11 studies for consideration of inclusion. However, none met the required criteria for inclusion. AUTHORS' CONCLUSIONS There is no evidence to inform the content, methods of delivery or effectiveness of preconception counselling to improve pregnancy outcomes for WWE and their offspring. The value of counselling delivered to WWE prior to conception, with the intention of reducing the risks of adverse outcome in mother and child, requires evaluation in well-designed studies, appropriately powered to detect changes in both maternal and infant outcome.
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Affiliation(s)
- Jacqueline A French
- Department of Neurology, New York University School of Medicine, New York, USA.
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Turner K, Piazzini A, Franza A, Canger R, Canevini MP, Marconi AM. Do women with epilepsy have more fear of childbirth during pregnancy compared with women without epilepsy? A case-control study. Birth 2008; 35:147-52. [PMID: 18507586 DOI: 10.1111/j.1523-536x.2008.00228.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Although anxiety and depression in populations with epilepsy have been studied, no research on fear of childbirth in women with epilepsy have been conducted. The purposes of this study were to examine whether a significant difference occurred in fear of childbirth between pregnant women with epilepsy and pregnant healthy controls and to evaluate the most common fears. METHODS Fifty pregnant women with epilepsy and 50 pregnant women without epilepsy were assessed at a gestational age between 32 and 36 weeks of pregnancy, using two questionnaires for the measurement of fear of childbirth, an open question, and a clinical interview. RESULTS We found that during pregnancy, women with epilepsy experienced a significantly higher rate of fear of childbirth when compared with healthy controls, whereas after delivery, the experiences and feelings about childbirth are almost the same as those of women without epilepsy. CONCLUSIONS Our findings signify the importance of the assessment of the fear of childbirth, especially in women with epilepsy, and the need to offer professional and ad hoc support to those who suffer from it.
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Affiliation(s)
- Katherine Turner
- Epilepsy Center, St. Paolo Hospital, University of Milan, Milan, Italy
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Neurodevelopmental delay in children exposed to antiepileptic drugs in utero: a critical review directed at structural study-bias. J Neurol Sci 2008; 271:1-14. [PMID: 18479711 DOI: 10.1016/j.jns.2008.03.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2007] [Revised: 03/13/2008] [Accepted: 03/18/2008] [Indexed: 11/20/2022]
Abstract
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.
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Abstract
The majority of epileptic disorders are not self-limiting over time, and therefore require a long-lasting and often even lifelong antiepileptic drug (AED) treatment, in Wi/omen with epilepsy, the influence of their disease on the possibility and course of pregnancies, as well as the potential impact of the AED treatment on mother and child, are crucial questions. This review addresses the clinically relevant knovledge concerning the impact of the disease itself and the AED treatment on fertility, pregnancy, delivery, the postpartum period, and teratogenicity. Some of the new AEDs appear to have a favorable profile due to a lack of clinically relevant interactions and promising teratogenic profiles. However, the finding of decreases in lamotrigine serum concentrations during hormonal contraception and pregnancy is an instructive example, shovt/ing that ongoing studies are urgently needed to further investigate stillunanswered questions. Several prospective multinational surveys are currently being performed, and should add essential information in this context.
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Common problems in critically ill obstetric patients, with an emphasis on pharmacotherapy. Am J Med Sci 2008; 335:65-70. [PMID: 18195587 DOI: 10.1097/maj.0b013e31815f1e14] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Pharmacological treatment of critically ill obstetric patients can be especially challenging due to the complexity of caring for 2 patients, with a paucity of research to support practice. This review will provide practitioners with primary recommendations for management of the critical illnesses most commonly encountered in pregnancy and will discuss the scientific and clinical merit of these recommendations.
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Quenby SM, Anin S, Bates MD, Chadwick D, Vince GS, Neilson JP. Phenytoin but not valproate directly affected in vitro trophoblast differentiation. Eur J Obstet Gynecol Reprod Biol 2008; 137:31-6. [PMID: 17543440 DOI: 10.1016/j.ejogrb.2007.04.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2006] [Revised: 03/05/2007] [Accepted: 04/16/2007] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Epilepsy has been associated with poor obstetric outcomes that could be the result of the epilepsy itself or a direct effect of anti-epileptic medication on placentation. The aim of this study was to investigate any direct effect of anti-epileptic drugs on an established, in vitro bioassay of trophoblast differentiation. STUDY DESIGN Primary extravillous trophoblast cells were cultured in the presence of phenytoin and sodium valproate at a range of concentrations with appropriate solvent controls. The formation of multinuclear giant cells was used as a marker of trophoblast differentiation. RESULTS Phenytoin inhibited giant multinuclear cell formation in a dose-dependent manner; in contrast sodium valproate had no effect (p=0.011). CONCLUSIONS This study found that two anti-epileptic medications induced different effects on an in vitro trophoblast bioassay, suggesting that further research should be aimed at elucidating which anti-epileptic medication is most suitable for pregnant women.
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Affiliation(s)
- Siobhan M Quenby
- School of Reproductive and Developmental Medicine, University of Liverpool, UK.
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Beach RL, Kaplan PW. Chapter 15 Seizures in Pregnancy. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2008; 83:259-71. [DOI: 10.1016/s0074-7742(08)00015-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Hamed SA. Neuronal plasticity: implications in epilepsy progression and management. Drug Dev Res 2008. [DOI: 10.1002/ddr.20217] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Tomson T, Battino D, French J, Harden C, Holmes L, Morrow J, Robert-Gnansia E, Scheuerle A, Vajda F, Wide K, Gordon J. Antiepileptic drug exposure and major congenital malformations: the role of pregnancy registries. Epilepsy Behav 2007; 11:277-82. [PMID: 17996635 DOI: 10.1016/j.yebeh.2007.08.015] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2007] [Accepted: 08/14/2007] [Indexed: 10/22/2022]
Abstract
The use of antiepileptic drugs (AEDs) in pregnancy is associated with an increased risk of fetal malformations. Although it is known that AEDs may differ with respect to the type of malformations they can induce, earlier studies have generally lacked the power to demonstrate differences between AEDs in their overall teratogenic potential. Furthermore, there is an urgent need to assess the clinical teratogenic potential of the newer-generation AEDs. Epilepsy and pregnancy registries have been established to provide such information, which is essential for the rational management of women with epilepsy with childbearing potential. The registries also provide opportunities for additional studies of seizures observed during pregnancy and labor and, with the enrolled woman's consent, for separate studies on cognitive outcomes and pharmacogenetics. Although most are prospective, the existing registries vary somewhat in design, which needs to be considered when their results are compared. Some registries are driven by pharmaceutical companies (often compelled by national or international drug licensing agencies) and provide data on pregnancy outcome related to the sponsor's own product. Others are organized by independent research groups and are potentially more useful in that they publish comparative data. This review provides a critical discussion and comparison of important methodological aspects of AED and pregnancy registries along with a summary of results published so far.
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Affiliation(s)
- Torbjörn Tomson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
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Jenkins KJ, Correa A, Feinstein JA, Botto L, Britt AE, Daniels SR, Elixson M, Warnes CA, Webb CL. Noninherited risk factors and congenital cardiovascular defects: current knowledge: a scientific statement from the American Heart Association Council on Cardiovascular Disease in the Young: endorsed by the American Academy of Pediatrics. Circulation 2007; 115:2995-3014. [PMID: 17519397 DOI: 10.1161/circulationaha.106.183216] [Citation(s) in RCA: 544] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Prevention of congenital cardiovascular defects has been hampered by a lack of information about modifiable risk factors for abnormalities in cardiac development. Over the past decade, there have been major breakthroughs in the understanding of inherited causes of congenital heart disease, including the identification of specific genetic abnormalities for some types of malformations. Although relatively less information has been available on noninherited modifiable factors that may have an adverse effect on the fetal heart, there is a growing body of epidemiological literature on this topic. This statement summarizes the currently available literature on potential fetal exposures that might alter risk for cardiovascular defects. Information is summarized for periconceptional multivitamin or folic acid intake, which may reduce the risk of cardiac disease in the fetus, and for additional types of potential exposures that may increase the risk, including maternal illnesses, maternal therapeutic and nontherapeutic drug exposures, environmental exposures, and paternal exposures. Information is highlighted regarding definitive risk factors such as maternal rubella; phenylketonuria; pregestational diabetes; exposure to thalidomide, vitamin A cogeners, or retinoids; and indomethacin tocolysis. Caveats regarding interpretation of possible exposure-outcome relationships from case-control studies are given because this type of study has provided most of the available information. Guidelines for prospective parents that could reduce the likelihood that their child will have a major cardiac malformation are given. Issues related to pregnancy monitoring are discussed. Knowledge gaps and future sources of new information on risk factors are described.
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Manent JB, Jorquera I, Mazzucchelli I, Depaulis A, Perucca E, Ben-Ari Y, Represa A. Fetal Exposure to GABA-Acting Antiepileptic Drugs Generates Hippocampal and Cortical Dysplasias. Epilepsia 2007; 48:684-93. [PMID: 17437411 DOI: 10.1111/j.1528-1167.2007.01056.x] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE The management of epilepsy during pregnancy entails a number of concerns. While seizures may affect adversely maternal and fetal outcome, antiepileptic drugs (AEDs) may increase the incidence of congenital abnormalities and possibly affect postnatal cognitive development in the offspring. Experimental animal studies can aid in assessing teratogenic features associated with individual AEDs and/or with seizures, and to identify the mechanisms involved. The purpose of this study was to investigate the consequences of prenatal exposure to (a) different AEDs and (b) maternal seizures on brain maturational processes in rats. METHODS Pregnant rats received from embryonic days 14 to 19 intraperitoneal injections of carbamazepine (20 mg/kg/day), vigabatrin (200 mgkg/day), and valproate (100 mg/kg/day) at doses not widely different from those used clinically. Pups exposed to AEDs in utero were analyzed postnatally. Animals born to "kindled" pregnant animals that had experienced one generalized convulsive seizure per day during the same gestational period were analyzed in parallel. RESULTS Prenatal exposure to vigabatrin and valproate, which act on GABA signaling, induced hippocampal and cortical dysplasias, which were likely to result from a neuronal migration defect and neuronal death. By contrast, offspring of rats exposed to carbamazepine (which at the dose used produced low plasma concentrations) or to generalized convulsive seizures showed no clear-cut evidence of dysplasias. CONCLUSIONS We suggest that AEDs that increase the extracellular concentration of GABA might induce severe neuronal migration disorders. Drugs acting through other molecular targets would also perturb cortical maturation. The potential clinical relevance of these results should be a subject of future research.
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Affiliation(s)
- Jean-Bernard Manent
- INMED, INSERM U29, Université de la Méditerranée, Campus de Luminy, Marseille, France
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Atrash HK, Johnson K, Adams M, Cordero JF, Howse J. Preconception care for improving perinatal outcomes: the time to act. Matern Child Health J 2006; 10:S3-11. [PMID: 16773452 PMCID: PMC1592246 DOI: 10.1007/s10995-006-0100-4] [Citation(s) in RCA: 162] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2005] [Accepted: 04/20/2006] [Indexed: 11/26/2022]
Affiliation(s)
- Hani K Atrash
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, 1600 Clifton Rd. NE, E-87, Atlanta, GA, 30333, USA.
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Turner K, Piazzini A, Franza A, Fumarola C, Chifari R, Marconi AM, Canevini MP, Canger R. Postpartum depression in women with epilepsy versus women without epilepsy. Epilepsy Behav 2006; 9:293-7. [PMID: 16861045 DOI: 10.1016/j.yebeh.2006.06.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2005] [Revised: 05/29/2006] [Accepted: 06/05/2006] [Indexed: 11/28/2022]
Abstract
The goal of this study was to determine if there is a significant difference in the rate of postpartum depression among patients with epilepsy and healthy controls. All patients were recruited from the Epilepsy Center and the Department of Obstetrics and Gynecology, University of Milan, St. Paolo Hospital (Milan, Italy). Thirty-five pregnant women with epilepsy and an equal number of pregnant women without epilepsy were assessed with the Edinburgh Postnatal Depression Scale (EPDS), a clinical interview used to screen for postpartum depression (PPD), and a sociodemographic questionnaire. The rate of PPD in patients with epilepsy was statistically significantly higher than that of the controls (P<0.05). PPD was present in 29% of the patients with epilepsy and 11% of the controls. In conclusion, it is very important to point out that in our pilot study, the rate of PPD was higher among women with epilepsy than among women without epilepsy. In this regard, women at higher PPD risk can be identified earlier and treated as soon as possible to alleviate their symptoms and improve their quality of life.
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Affiliation(s)
- Katherine Turner
- Epilepsy Center, St. Paolo Hospital, University of Milan, Milan, Italy.
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Abstract
Optimal epilepsy management in teenage patients represents a particular challenge. These patients are often likely to respond more positively to a regimen that least disrupts their activities. In addition, as a patient group, they are more sensitive to peer perception. Current perceptions of older antiepilepsy drugs do not take into account frequent undesirable side effects or potential adverse interactions with other drugs. Furthermore, they often do not completely control seizures. Recent data suggest that not only do the newer antiepileptic drugs appear to be as efficacious as the older drugs, they also often have more favorable cognitive, cosmetic, and teratogenic side-effect profiles. In addition, newer antiepileptic drugs are being used more often in monotherapy. Successful management of epilepsy in teenagers requires that physicians not only understand the advantages that the newer antiepileptic drugs appear to provide but also consider the social impact of treatment on their patients.
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Affiliation(s)
- Raj D Sheth
- Department of Neurology, University of Wisconsin-Madison, 600 Highland Avenue H6-575, Madison, WI 53792, USA.
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Abstract
Valproic acid (sodium valproate) is widely used as a first-line antiepileptic agent. As with many antiepileptic drugs, there are a number of consequences associated with the use of valproic acid in women of child-bearing potential. Most pregnancies have a favourable outcome in women with epilepsy, and these women should not be discouraged from becoming pregnant. Unlike many other antiepileptic drugs, valproic acid has no significant pharmacokinetic interactions with the steroid hormones used in oral contraceptives. During pregnancy, the major risks to mother and child result from loss of seizure control on the one hand, and an elevated risk of major congenital malformations due to antiepileptic drug treatment on the other. In particular, an elevated risk of major congenital malformations associated with valproic acid use has been a consistent finding in studies of patient registries and several large case series. In addition, developmental delay, characterised by low verbal IQ, has also been reported in children exposed to valproic acid in utero, although the relative risk is not precisely known. For these reasons, pregnancies in women being treated with valproic acid need to be planned, and the benefit-risk ratios associated with continuing valproic acid or changing treatment need to be discussed with the patient. When treatment with valproic acid is the most appropriate treatment to achieve optimal seizure control, a number of measures can be implemented to minimise risk to the fetus. These include the use of the lowest possible effective dose of valproic acid in monotherapy (ideally <1000 mg/day), appropriate folic acid supplementation and close antenatal monitoring. Regular counselling is a prerequisite for informed planning of pregnancies and optimisation of the probability of a healthy outcome. Future research on valproic acid and pregnancy should involve risk assessment in large, population-based prospective studies.
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Affiliation(s)
- Pierre Genton
- Centre Saint-Paul, Hôpital Gastaut, Marseille, France.
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Abstract
BACKGROUND Neurologic dysfunction, coma, and seizures are common in obstetric patients in the intensive care unit. OBJECTIVE To review common neurologic disorders resulting in critical illness in pregnancy. REVIEW Obstetric disorders causing coma and seizures include eclampsia, acute fatty liver of pregnancy, and amniotic fluid embolism. Preexisting disorders such as epilepsy may worsen in one-third of pregnant patients, and seizures are common during labor. Changes in hemodynamics, blood volume, and hormonal effects on the vessel wall increase risk of bleeding from berry aneurysms and arteriovenous malformations during pregnancy and the postpartum period. Acute intermittent porphyria produces seizures and hypertension, closely mimicking eclampsia. Cerebral venous sinus thrombosis is common in postpartum patients, especially in developing countries. Brain tumors invariably enlarge during pregnancy because of fluid retention and the presence of estrogen and progesterone receptors on tumor cells. Infections such as cerebral malaria and acute viral hepatitis with fulminant hepatic failure are common causes of coma and seizures during pregnancy in tropical regions of Asia, Africa, and Latin America. Patients may be admitted to the intensive care unit with type II respiratory failure due to myasthenic crisis, Guillain-Barre syndrome and spinal cord disease. Relapses of multiple sclerosis are infrequent during pregnancy but increase in the postpartum period. CONCLUSIONS In all instances, the effects of the disorders, diagnostic tests, and treatment on the fetus must be carefully weighed. Prompt delivery may be lifesaving for mother and fetus in conditions such as eclampsia and acute fatty liver of pregnancy; expectant treatment may be more appropriate in others.
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Affiliation(s)
- Dilip R Karnad
- Medical-Neuro-Intensive Care Unit, Department of Medicine, Seth G. S. Medical College and King Edward Memorial Hospital (DRK), Mumbai, India
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Abstract
BACKGROUND Exposure to antiepileptic drugs (AEDs) in the first trimester of pregnancy has been associated with an increased risk of major congenital anomalies (MCAs) in offspring. Most of the studies, however, have been fraught with methodological shortcomings, and differences in ascertainment methods and classifications prevent meaningful data pooling. Individual studies lacked the statistical power to assess comparative risks associated with specific AEDs. RECENT DEVELOPMENTS Several larger-scale studies, including collaborative multinational registries, have been set up to compare MCA risks associated with different treatments, including newer generation AEDs. Results have largely been consistent with the notion that monotherapy with the most commonly used AEDs is associated with an increase in risk of MCAs by two to three times, and that the magnitude of risk increases in offspring exposed to polytherapy. Available evidence does not suggest that epilepsy per se is associated with a major increase in the risk of MCAs. Almost all studies have suggested that exposure to valproic acid is associated with a greater incidence of MCAs than other AEDs. Valproic acid is also the only AED for which a dose-dependency has been confirmed in several studies: the increase in risk of MCAs, compared with other AEDs, is especially evident at doses above 800-1000 mg/day. Data from the North American registry have suggested that phenobarbital may also have a higher teratogenic risk compared with AEDs other than valproic acid, but evidence remains inconclusive. Information about effects on fetuses of newer generation AEDs other than lamotrigine and oxcarbazepine is scant. Although teratogenic effects of lamotrigine and oxcarbazepine have not been established with certainty, none of the investigations to date identified any statistically significant difference in rates of MCAs between infants exposed to lamotrigine or oxcarbazepine and infants exposed to carbamazepine. In the case of lamotrigine, moreover, a positive correlation between maternal dose and rates of MCAs has been identified. WHERE NEXT?: Collaborative pregnancy registries worldwide are at work to fill remaining gaps in knowledge. Issues to be addressed include the comparative risks associated with phenobarbital, with low-dose valproic acid, with newer generation AEDs, and with specific AED combinations; the influence of potential confounders; and the interaction of AED-associated risks with other risk factors, such as genetic profiles. Large scale studies may also clarify whether individual AEDs differ in their ability to cause specific anomalies. Finally, studies are urgently needed to investigate other potential adverse effects of AED exposure, with special reference to effects on postnatal intellectual development.
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Affiliation(s)
- Emilio Perucca
- Clinical Pharmacology Unit, Department of Internal Medicine and Therapeutics, University of Pavia, and Laboratories for Diagnostics and Applied Biological Research, Institute of Neurology, IRCCS C Mondino Foundation, Pavia, Italy.
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Abstract
The following is a comprehensive review of the current understanding of the many important roles of folic acid in the health of patients with epilepsy. A review of past and current literature reveals that folic acid plays important roles in the areas of hematology, neurology, development, and reproduction. Also highlighted are new areas for exploration.
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Affiliation(s)
- James Layne Moore
- Department of Neurology, Ohio State University College of Medicine, 1654 Upham Drive, 4th Floor, Columbus, OH 43210, USA.
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