Management of epilepsy in women

Reproductive and fetal outcomes in women with epilepsy: a systematic review and meta-analysis

OBJECTIVE

Although early evidence shows that epilepsy can increase the risks of adverse pregnancy, some outcomes are still debatable. We performed a systematic review and meta-analysis to explore the effects of maternal and fetal adverse outcomes in pregnant women with epilepsy.

METHODS

PubMed, Embase, Cochrane, and Web of Science were employed to collect studies that investigated the potential risk of obstetric complications during the antenatal, intrapartum, or postnatal period, as well as any neonatal complications. The search was conducted from inception to November 16, 2022. The Newcastle-Ottawa Scale (NOS) was used to assess the quality of the included original studies. The odds ratio (OR) values were extracted after adjusting for confounders to measure the relationship between pregnant women with epilepsy and adverse maternal or fetal outcomes. The protocol for this systematic review is registered with PROSPERO ID CRD42023391539.

RESULTS

Of 35 articles identified, there were 142,577 mothers with epilepsy and 34,381,373 mothers without epilepsy. Our study revealed a significant association between pregnant women with epilepsy (PWWE) and the incidence of cesarean section, preeclampsia/eclampsia, gestational hypertension, induction of labor, gestational diabetes and postpartum hemorrhage compared with those without epilepsy. Regarding newborns outcomes, PWWE versus those without epilepsy had increased odds of preterm birth, small for gestational age, low birth weight (<2500 g), and congenital malformations, fetal distress. The odds of operative vaginal delivery, newborn mortality, and Apgar (≤ 7) were similar between PWWE and healthy women.

CONCLUSION

Pregnant women affected by epilepsy encounter a higher risk of adverse obstetric outcomes and fetal complications. Therefore, it is crucial to develop appropriate prevention and intervention strategies prior to or during pregnancy to minimize the negative impacts of epilepsy on maternal and fetal health.

The neuropsychological presentation of women with epilepsy: Clinical considerations and future directions

Objective: Cognitive, mood, and behavioral changes are common among persons with epilepsy (PWE), resulting in a complex neuropsychological presentation. Women with epilepsy (WWE) represent a distinct cohort within the broader epilepsy population due to sex and gender-specific factors impacting epilepsy semiology and treatment. However, unique neuropsychological profiles among WWE have not been established. This narrative review aims to further define neuropsychological correlates in WWE and promote meaningful discussion related to enhancing the provision of neuropsychological care within this clinical population. Method: Current literature in PWE examining differences in cognitive function, mental health, and quality of life (QoL) between women and men was critically reviewed, emphasizing considerations for neuropsychological practice. Results: WWE demonstrate a preservation of verbal learning and memory compared to men both pre- and post-surgically, with sex-based, neurobiological mechanisms likely contributing to this association. WWE also have elevated risk for affective disorder psychopathology, suicidality, and traumatic experiences. Epidemiology related to psychotic and bipolar spectrum disorders is less clear, and findings are mixed regarding sex-specific behavioral side effects of antiseizure and psychotropic medication. Finally, hormonal and obstetric factors are highlighted as important contributors to neuropsychological symptoms in WWE, with elevated risk for low QoL and increased stigma associated with greater medical and psychiatric comorbidities compared to men. Conclusions: While emerging literature has begun to characterize the neuropsychological presentation of WWE, future research is needed to define sex and gender differences in neuropsychological sequalae among PWE to ensure consistency and quality of care for WWE.

Withaferin A protects against epilepsy by promoting LCN2-mediated astrocyte polarization to stopping neuronal ferroptosis

BACKGROUND

Epilepsy is among the most frequent severe brain diseases, with few treatment options available. Neuronal ferroptosis is an important pathogenic mechanism in epilepsy. As a result, addressing ferroptosis appears to be a promising treatment approach for epilepsy. Withaferin A (WFA) is a C28 steroidal lactone that has a broad range of neuroprotective properties. Nonetheless, the antiepileptic action of WFA and the intrinsic mechanism by which it inhibits ferroptosis following epilepsy remain unknown.

PURPOSE

This study aimed at investigating to the antiepileptic potential of WFA in epilepsy, as well as to propose a potential therapeutic approach for epilepsy therapy.

METHODS

We conducted extensive research to examine the impacts of WFA on epilepsy and ferroptosis, using the kainic acid (KA)-treated primary astrocyte as an in vitro model and KA-induced temporal lobe epilepsy mice as an in vivo model. To analyze the neuroprotective effects of WFA on epileptic mice, electroencephalogram (EEG) recording, Nissl staining, and neurological function assessments such as the Morris water maze (MWM) test, Y-maze test, Elevated-plus maze (O-maze) test, and Open field test were used. Furthermore, the mechanism behind the neuroprotective effect of WFA in epilepsy was investigated using the transcriptomics analysis and verified on epileptic patient and epileptic mouse samples using Western blotting (WB) and immunofluorescence (IF) staining. In addition, WB, IF staining and specific antagonists/agonists were used to investigate astrocyte polarization and the regulatory signaling pathways involved. More critically, ferroptosis was assessed utilizing lipocalin-2 (LCN2) overexpression cell lines, siRNA knockdown, JC-1 staining, WB, IF staining, flow cytometry, electron microscopy (TEM), and ferroptosis-related GSH and MDA indicators.

RESULTS

In this study, we observed that WFA treatment reduced the number of recurrent seizures and time in seizure, and the loss of neurons in the hippocampal area in in epileptic mice, and even improved cognitive and anxiety impairment after epilepsy in a dose depend. Furthermore, WFA treatment was proven to enhance to the transformation of post-epileptic astrocytes from neurotoxic-type A1 to A2 astrocytes in both in vivo and in vitro experiments by inhibiting the phosphoinositide 3-kinase /AKT signaling pathway. At last, transcriptomics analysis in combination with functional experimental validation, it was discovered that WFA promoted astrocyte polarity transformation and then LCN2 in astrocytes, which inhibited neuronal ferroptosis to exert neuroprotective effects after epilepsy. In addition, we discovered significant astrocytic LCN2 expression in human TLE patient hippocampal samples.

CONCLUSIONS

Taken together, for the first, our findings suggest that WFA has neuroprotective benefits in epilepsy by modulating astrocyte polarization, and that LCN2 may be a novel potential target for the prevention and treatment of ferroptosis after epilepsy.

Seizure or syncope: Is the history-based scale feasible to use in an emergency department setting?

BACKGROUND

This study aimed to assess the efficacy of a screening questionnaire, based on historical criteria, in distinguishing between seizures and syncope in patients experiencing their first episode of transient loss of consciousness (TLOC) in a neurology emergency department.

METHODS

A prospective cohort of 159 patients with initial TLOC episodes underwent clinical observation and answered a nine-question screening questionnaire. The questionnaire's predictive ability was compared to final diagnoses determined through detailed neurology, electrophysiology, and cardiology assessments during a minimum 12-month follow-up. Logistic regression (LR) analysis was performed with final diagnosis as the outcome variable. The calibration and discrimination of the models were assessed.

RESULTS

revealed that the screening score accurately classified 72.33% of patients. Among those with positive screening scores, 65 (67.71%) had seizures compared to 31 (32.29%) with syncope. Introducing a novel risk-scoring model incorporating age and gender, in addition to the screening score, significantly improved performance achieving an accurate classification rate of 81.48%. Among patients with a positive prediction, 63 (80.77%) had seizure, whereas 15 (19.23%) had syncope.

CONCLUSIONS

Employing a structured questionnaire based on common historical criteria is a valuable tool for distinguishing between seizure and syncope in the dynamic setting of the emergency department.

Teratogenesis, Perinatal, and Neurodevelopmental Outcomes After In Utero Exposure to Antiseizure Medication: Practice Guideline From the AAN, AES, and SMFM

This practice guideline provides updated evidence-based conclusions and recommendations regarding the effects of antiseizure medications (ASMs) and folic acid supplementation on the prevalence of major congenital malformations (MCMs), adverse perinatal outcomes, and neurodevelopmental outcomes in children born to people with epilepsy of childbearing potential (PWECP). A multidisciplinary panel conducted a systematic review and developed practice recommendations following the process outlined in the 2017 edition of the American Academy of Neurology Clinical Practice Guideline Process Manual. The systematic review includes studies through August 2022. Recommendations are supported by structured rationales that integrate evidence from the systematic review, related evidence, principles of care, and inferences from evidence. The following are some of the major recommendations. When treating PWECP, clinicians should recommend ASMs and doses that optimize both seizure control and fetal outcomes should pregnancy occur, at the earliest possible opportunity preconceptionally. Clinicians must minimize the occurrence of convulsive seizures in PWECP during pregnancy to minimize potential risks to the birth parent and to the fetus. Once a PWECP is already pregnant, clinicians should exercise caution in attempting to remove or replace an ASM that is effective in controlling generalized tonic-clonic or focal-to-bilateral tonic-clonic seizures. Clinicians must consider using lamotrigine, levetiracetam, or oxcarbazepine in PWECP when appropriate based on the patient's epilepsy syndrome, likelihood of achieving seizure control, and comorbidities, to minimize the risk of MCMs. Clinicians must avoid the use of valproic acid in PWECP to minimize the risk of MCMs or neural tube defects (NTDs), if clinically feasible. Clinicians should avoid the use of valproic acid or topiramate in PWECP to minimize the risk of offspring being born small for gestational age, if clinically feasible. To reduce the risk of poor neurodevelopmental outcomes, including autism spectrum disorder and lower IQ, in children born to PWECP, clinicians must avoid the use of valproic acid in PWECP, if clinically feasible. Clinicians should prescribe at least 0.4 mg of folic acid supplementation daily preconceptionally and during pregnancy to any PWECP treated with an ASM to decrease the risk of NTDs and possibly improve neurodevelopmental outcomes in the offspring.

Characterization of the intrahippocampal kainic acid model in female mice with a special focus on seizure suppression by antiseizure medications

Despite special challenges in the medical treatment of women with epilepsy, in particular preclinical animal studies were focused on males for decades and females have only recently moved into the focus of scientific interest. The intrahippocampal kainic acid (IHKA) mouse model of temporal lobe epilepsy (TLE) is one of the most studied models in males reproducing electroencephalographic (EEG) and histopathological features of human TLE. Hippocampal paroxysmal discharges (HPDs) were described as drug resistant focal seizures in males. Here, we investigated the IHKA model in female mice, in particular drug-resistance of HPDs and the influence of antiseizure medications (ASMs) on the power spectrum. After injecting kainic acid (KA) unilaterally into the hippocampus of female mice, we monitored the development of epileptiform activity by local field potential (LFP) recordings. Subsequently, we evaluated the effect of the commonly prescribed ASMs lamotrigine (LTG), oxcarbazepine (OXC) and levetiracetam (LEV), as well as the benzodiazepine diazepam (DZP) with a focus on HPDs and power spectral analysis and assessed neuropathological alterations of the hippocampus. In the IHKA model, female mice replicated key features of human TLE as previously described in males. Importantly, HPDs in female mice did not respond to commonly prescribed ASMs in line with the drug-resistance in males, thus representing a suitable model of drug-resistant seizures. Intriguingly, we observed an increased occurrence of generalized seizures after LTG. Power spectral analysis revealed a pronounced increase in the delta frequency range after the higher dose of 30 mg/kg LTG. DZP abolished HPDs and caused a marked reduction over a wide frequency range (delta, theta, and alpha) of the power spectrum. By characterizing the IHKA model of TLE in female mice we address an important gap in basic research. Considering the special challenges complicating the therapeutic management of epilepsy in women, inclusion of females in preclinical studies is imperative. A well-characterized female model is a prerequisite for the development of novel therapeutic strategies tailored to sex-specific needs and for studies on the effect of epilepsy and ASMs during pregnancy.

Retinoic Acid Upregulates METTL14 Expression and the m6A Modification Level to Inhibit the Proliferation of Embryonic Palate Mesenchymal Cells in Cleft Palate Mice

Cleft palate only (CPO) is one of the most common craniofacial birth defects. Environmental factors can induce cleft palate by affecting epigenetic modifications such as DNA methylation, histone acetylation, and non-coding RNA. However, there are few reports focusing on the RNA modifications. In this study, all-trans retinoic acid (atRA) was used to simulate environmental factors to induce a C57BL/6J fetal mouse cleft palate model. Techniques such as dot blotting and immunofluorescence were used to find the changes in m6A modification when cleft palate occurs. RNA-seq and KEGG analysis were used to screen for significantly differentially expressed pathways downstream. Primary mouse embryonic palate mesenchymal (MEPM) cells were successfully isolated and used for in vitro experimental verification. We found that an increased m6A methylation level was correlated with suppressed cell proliferation in the palatine process mesenchyme of cleft palate mice. This change is due to the abnormally high expression of m6A methyltransferase METTL14. When using siRNAs and the m6A methyltransferase complex inhibitor SAH to interfere with the expression or function of METTL14, the teratogenic effect of atRA on primary cells was partially alleviated. In conclusion, METTL14 regulates palatal mesenchymal cell proliferation and cycle-related protein expression relies on m6A methylation modification, affecting the occurrence of cleft palate.

Recurrent catamenial absence status epilepticus persisting in post-menopausal period: The pivotal role of video-EEG

Content available: Video.

Psychiatric Comorbidities in Women Veterans with Epilepsy

Background: Women Veterans with epilepsy (WVE) may have unique psychiatric comorbidities that affect presentation, treatment, and outcomes. This large, nationally representative study of Veterans Health Administration (VHA) patients explores sex differences in psychiatric diagnoses and treatment to better characterize WVE. Methods: This study included a retrospective cohort design utilizing VHA Corporate Data Warehouse administrative data. Data from 58,525 Veterans with epilepsy (8.5% women) were obtained. Psychiatric diagnoses and treatment were analyzed, with comparisons between men with epilepsy and WVE. Secondary analyses included further exploration of select gynecological conditions. Results: WVE had higher psychiatric burden than men, as evidenced by higher rates of nearly all psychiatric diagnoses, including depression (59.1% vs. 38.9%; χ2 = 771.6), posttraumatic stress disorder (42.0% vs. 26.5%; χ2 = 549.1), and anxiety disorder (44.9% vs. 24.5%; χ2 = 977.7), as well as higher use of psychotropic medication prescriptions (2.3 vs. 1.4 average number of psychotropics prescribed). Furthermore, higher percentages of women versus men utilized the emergency room for psychiatric purposes (11.7% vs. 6.9%; χ2 = 153.06) and were hospitalized with psychiatric diagnoses (9.8% vs. 6.1%; χ2 = 100.95). Discussion: Veterans with epilepsy represent a unique group with high rates of psychiatric comorbidity. These results suggest that among Veterans, men and women with epilepsy have differing psychiatric comorbidities, leading to disparate health care needs. Based on this study's findings, WVE may require a different approach to care with an increased focus on specialized psychiatric treatment for WVE.

Hormonal Changes in Women with Epilepsy

Epilepsy is a prevalent neurological disorder among women globally, often requiring long-term treatment. Hormonal fluctuations in women with epilepsy (WWE) can have reciprocal effects on epilepsy and antiseizure medications (ASMs), posing significant challenges for WWE. Notably, WWE commonly experience endocrine alterations such as thyroid dysfunctions, low bone metabolism, and reproductive hormone irregularities. On the one hand, the presence of hormones in women with epilepsy affects their susceptibility to epilepsy as well as the metabolism of antiseizure medications in various ways. On the other hand, epilepsy itself and the use of antiseizure medications impact the production, secretion, and metabolism of hormones, resulting in low fertility, increased risk of pregnancy complications, negative offspring outcomes, and so on. In order to develop more precise treatment strategies in the future, it is necessary to comprehend the explicit relationships between hormones, epilepsy, and antiseizure medications, as well as to elucidate the currently known mechanisms underlying these interactions.

Curcumin protects against lamotrigine-induced chronic ovarian and uterine toxicity in rats by regulating PPAR-γ and ROS production

Lamotrigine (LTG) is an antiepileptic drug with possible adverse effects on the female reproductive system. Curcumin was declared to improve ovarian performance. Therefore, this study aimed to clarify ovulatory dysfunction (OD) associated with LTG and the role of curcumin in ameliorating this dysfunction. Adult female Wister albino rats were assigned into four groups: negative control (received saline), positive control (received curcumin only), LTG, and LTG with curcumin groups. Drugs were administered for 90 days. The hormonal profile, including testosterone, estrogen, progesterone, luteinizing hormone, and follicle-stimulating hormone, in addition to the lipid profile and glycemic analysis, were tested. Oxidative stress biomarkers analysis in the ovaries and uterus and peroxisome proliferator-activated receptor-γ (PPAR-γ) gene expression were also included. Histopathological examination of ovarian and uterine tissues and immunohistochemical studies were also performed. Curcumin could improve the OD related to chronic LTG intake. That was proved by the normalization of the hormonal profile, glycemic control, lipidemic status, oxidative stress markers, and PPAR-γ gene expression. The histopathological and immunohistochemical examination of ovarian and uterine tissues revealed an improvement after curcumin administration. The results describe an obvious deterioration in ovarian performance with LTG through the effect on lipidemic status, PPAR-γ gene, and creating an oxidative stress condition in the ovaries of chronic users, with a prominent improvement with curcumin addition to the treatment protocol.

Association of oxcarbazepine concentration with seizure frequency in pregnant women with epilepsy

The management of epilepsy during pregnancy presents particular challenges for neurologists worldwide. Currently, there are no clear recommendations for oxcarbazepine (OXC) specific target concentration during pregnancy. We conducted this retrospective observational cohort study on pregnant women with epilepsy (WWE) who received OXC monotherapy or polytherapy, at the epilepsy outpatient clinic of a tertiary hospital in eastern China. Sixteen pregnancies of 16 WWE were split into the seizure-free group or the non-seizure-free group, according to whether they had been seizure free for more than one year prior to conception or not. There was a significantly decrease in OXC concentration throughout pregnancy, as indicated by the concentration/dose ratio and the ratio of target concentration (RTC). The second trimester of pregnancy was the period when seizure deterioration occurred the most, particularly in the non-seizure-free group. Lower RTC_OXC was identified to be a risk factor for increasing seizure frequency in both the total group and the non-seizure-free group in both univariate and multivariate analysis, with a threshold of 0.575 for differentiating patients at high-risk and low-risk for seizure deterioration. In conclusion, this study suggested an OXC concentration threshold of 0.575 during pregnancy for assisting neurologists in OXC drug monitoring and dose adaptation.

Interaction between vitamin D level, antiseizure medications (ASM) and seizure control in epilepsy adult patients

OBJECTIVE

To investigate vitamin D levels and factors associated with seizure control in adult patients with epilepsy (APE).

METHOD

Cross-sectional study with APE in routine outpatient follow-up at a neurology clinic. Clinical variables, antiseizure medications (ASM) and vitamin D were investigated. Data were analyzed using the Chi2 or Fisher's exact tests, Mann-Whitney, Spearman's correlation coefficient, ROC curve and univariate and multiple logistic regression analysis.

RESULTS

Mean age was 46.5±15.1 years and disease duration was 27.5±17.0 years; 52.7% (n=49) of patients used one ASM and 47.3% (n=44) used≥2 ASM. There was a significant difference in the level of vitamin D according to the number of ASM and it was higher in patients who used a single ASM (26.02±10.22 versus 22.50±8.69; P=0.048). In the logistic regression, when vitamin D level was set at 20ng/mL, the chance of seizure control for patients using a single ASM was 6.99 times greater than for those using≥2 ASM. When vitamin D level was set at 40ng/mL, the number of ASM did not modify seizure control. There was no correlation between vitamin D and disease duration, patient age and age at the time of the first seizure. In the logistic regression, it was observed that satisfactory levels of vitamin D did not modify potential seizure control.

CONCLUSION

Thirty-three percent (33%) of patients presented with vitamin D deficiency (values below 20ng/mL) and 80% had vitamin D levels below what is recommended (30ng/mL). The use of ASM, when associated with different levels of vitamin D, modified the probability of seizure control in APE. Vitamin D levels and intrinsic epilepsy factors are associated with failure to effectively control seizures.

Alterations in salivary biochemical composition and redox state disruption induced by the anticonvulsant valproic acid in male rat salivary glands

OBJECTIVE

To investigate the effects of the anticonvulsant valproic acid (VPA) on salivary glands in male rat using biochemical, functional, histomorphometric, and redox state parameters.

MATERIALS AND METHODS

Twenty-four male Wistar rats were randomly distributed into three groups (n = 8 per group): Control (0.9% saline solution), VPA100 (100 mg/kg), and VPA400 (400 mg/kg). After 21 consecutive days of treatment with by intragastric gavage. Pilocarpine-induced saliva was collected to determine salivary flow rate, pH, buffering capacity, and biochemical composition. Analyses of histomorphometric parameters and redox balance markers were performed on the parotid and submandibular glands.

RESULTS

Salivary flow rate, pH, buffering capacity, total protein, potassium, sodium, and chloride were similar between groups. However, phosphate and calcium were reduced in VPA400, while amylase was increased in both VPA100 and VPA400. We did not detect significant differences in the areas of acini, ducts, and connective tissue in the salivary glands between the groups. There were no significant changes in the redox status of the submandibular glands. In turn, in the parotid glands we detected reduced total oxidizing capacity and lipid peroxidation, measured as thiobarbituric acid reactive substances (TBARs) and higher uric acid concentration in both the VPA100 and VPA400 groups, and increased superoxide dismutase (SOD) in the VPA400 group.

CONCLUSION

Chronic treatment with VPA modified the salivary biochemical composition and caused disruption in the redox state of the parotid gland in rats.

Epilepsy and Issues Related to Reproductive Health

Sexual disorders are prevalent and vary in men and women with epilepsy (WWE). Infertility and reproductive abnormalities are twice as common in females with epilepsy. Antiepileptic medications and seizures can both have an impact on sexual health in people with epilepsy. Seizures can alter the release of pituitary and hypothalamic hormones, and some antiepileptic drugs (AEDs) can alter sex steroid hormones (gonadal steroids and gonad corticoids). Females with epilepsy are more susceptible to menstrual cycle irregularity and polycystic ovary syndrome. Females and males had lower reproductive rates, and the causes are likely psychological and physiological, with epilepsy and AEDs again playing a role. Sexual disorders are common in WWE and men with epilepsy and can be caused by psychological, physical, or social factors. Specialists must address the gender-based biology of epilepsy and the impact of AEDs on sexual well-being to offer the best treatment possible for patients with epilepsy, particularly women of sexual maturity.

Sex steroid hormones and epilepsy: Effects of hormonal replacement therapy on seizure frequency of postmenopausal women with epilepsy-A systematic review

BACKGROUND AND PURPOSE

Hormonal replacement therapy (HRT) is used for symptomatic treatment of menopause. Some evidence suggests a proconvulsant effect of estrogen and an anticonvulsant role of progesterone. Thus, the use of exogenous sex steroid hormones might influence the course of epilepsy in peri- and postmenopausal women with epilepsy (WWE). We conducted a systematic review on the impact of HRT on the frequency of seizures of WWE.

METHODS

PubMed and Scopus were searched for articles published from inception until August 2022. Abstracts from the past 5 years from the European Academy of Neurology and European Epilepsy Congresses were also reviewed. Article reference lists were screened, and relevant articles were retrieved for consultation. Interventional and observational studies on WWE and animal models of estrogen deficiency were included. Critical appraisal was performed using the revised Cochrane risk-of-bias tool for randomized trials and ROBINS-E tool.

RESULTS

Of 497 articles screened, 13 studies were included, including three human studies. One cross-sectional study showed a decrease in seizure frequency in WWE using combined HRT, a case-control study showed an increase in comparison with controls, and a randomized clinical trial found a dose-dependent increase in seizure frequency in women with focal epilepsy taking combined HRT. Ten studies addressing the impact of HRT in rat models were also included, which showed conflicting results.

CONCLUSIONS

There is scarce evidence of the impact of HRT in WWE. Further studies should evaluate the harmful potential, and prospective registries are needed for monitoring this population.

Differential effects of carbamazepine and levetiracetam monotherapy on reproductive endocrine function in Nigerian women with epilepsy

Objective

This study is aimed at comparing differential effect of Levetiracetam (LTC) monotherapy and Carbamazepine (CZP) monotherapy in W omen with epilepsy (WWE) on gonadal hormone.

Methods

87 WWE were recruited comprising randomly of 46 and 41 on CZP and LTC group respectively with diagnosis and classification based on International League Against Epilepsy (ILAE). Reproductive hormones (Luteinizing Hormone (LH), Follicle stimulating hormone, progesterone, estradiol and testosterone) were assayed. National Hospital Seizure Severity Scale (NHSS) and Zung self-reporting depression scale (ZSRDS) were used to assess the seizure severity and the mood respectively. Data was analyzed using Statistical Package for Social Sciences (SPSS) version 20. The Chi-square test was used to compare categorical variables while Student's t-test or its non-parametric equivalent where appropriate were used to compare continuous variables.

Results

Clinical characteristics were comparable in both groups except for ZSRDS (p = 0.048), NHSS (p = 0.012) and hip circumference (p = 0.037). The CZP group had a higher ASEX score and proportion of WWE with clinically significant sexual dysfunction (p < 0.001). WWE on LTC had similar hormonal profiles with those on CZP except for a higher median serum testosterone level (p = 0.004), and lower median serum LH (p = 0.006). Age was negatively associated with serum testosterone level for the 25th, 50th, and 75th quartile. However, the differential effect for AED type was only significant for the 25th quartile; with higher values in LTC.

Conclusion

The therapeutics implication of lower LH and testosterone levels in the LTC group compared to CZP group need to be explored.

Adherence to epilepsy quality indicators in a tertiary referral center

BACKGROUND

Quality indicators play an important role in healthcare quality and patient safety. The aim of this study is to identify specific clinical pharmacy interventions to improve adherence to quality indicators and minimize risks among patients with epilepsy.

MATERIAL AND METHODS

A prospective, two-phase, observational study was conducted in a neurology outpatient clinic of a tertiary university hospital. In the first phase of the study, the rate of adherence to the quality indicators was evaluated with a checklist containing the quality indicators. In the second phase of the study, an expert panel meeting was convened to identify clinical pharmacist interventions to reduce the risks associated with non-adherence. The Fine-Kinney method was used to prioritize risks, and adherence rates with each quality improvement indicator (QI) were calculated.

RESULTS

The study found that adherence rates were highest for QIs involving estimating the number and type of seizures, providing medical treatment or referring patients with evidence of mood disorders to mental healthcare, and co-managing prenatal care for women with epilepsy. The most non-adherence rates were found in QIs involving quality-of-life assessment, daily folate supplementation, and addressing the decreased effectiveness of oral contraception. The annual review of information about educational issues was also poorly provided. An expert panel decided to integrate a clinical pharmacist into the outpatient clinic to improve medication adherence, side-effect assessment, drug interaction assessment, patient education, lifestyle-modification education, depression/suicide-related behavior screening, quality-of-life assessment, and effectiveness evaluation of oral contraceptives for female patients using enzyme-inducing ASM.

CONCLUSION

The study shows that medication adherence, assessment of side effects, drug interactions, and patient education are inadequately provided by neurologists in patients with epilepsy. Clinical pharmacists have a crucial role in reducing potential risks of non-adherence with quality indicators. By integrating clinical pharmacy services into routine epilepsy care processes, the quality of care can be improved. Future studies should focus on implementing these interventions and evaluating their impact on patient outcomes.

Pregnancy characteristics and adverse outcomes in offspring of women with epilepsy: a prospective registry study from Mainland China

Objective

This study aimed to explore the influencing factors of adverse outcomes in the offspring of women with epilepsy (WWE) and to analyze the changes brought about by the epilepsy knowledge popularization campaign in China (EKPCIC).

Methods

This nested case-control study focused on WWE and their offspring from a female epilepsy cohort in mainland China. From January 2009 to August 2022, WWE was prospectively enrolled in 32 study centers. This study aimed to observe the health outcomes of their offspring within 1 year of age. The main outcome measure assessed the health status of the offspring within their first year of age. We aimed to analyze the effects of seizures, anti-seizure medicines (ASMs), and a lack of folic acid supplementation on adverse outcomes in the offspring of WWE and to explore the changes in perinatal management and adverse outcomes of the offspring after dissemination of the EKPCIC in 2015. Additionally, subgroup analyses were conducted to compare seizure control during pregnancy between the valproate and non-valproate groups.

Results

In total, 781 pregnancies in 695 WWE were included, of which 186 (23.69%) had adverse outcomes. The National Hospital Epilepsy Severity Scale score, number of seizures, status epilepticus, ASM type, and valproate and folic acid doses were associated with a high risk of adverse outcomes. After the EKPCIC, the use of ASMs (P = 0.013) and folic acid (P < 0.001), the seizure-free rate during pregnancy (P = 0.013), and the breastfeeding rate (P < 0.001) increased, whereas the incidence of complications during pregnancy decreased (P = 0.013). However, there was no significant difference in the incidence of adverse outcomes between the analyzed offspring pre-/post-EKPCIC. Additionally, there was no association between the frequency of seizures at different time points during pregnancy and the use of valproate (F = 1.514, P = 0.221).

Conclusion

Possible factors influencing adverse outcomes in the offspring of WWE include seizures, type and number of ASM usage, and a lack of folic acid supplementation. Although the management of WWE during pregnancy is now more standardized, further efforts are needed to reduce adverse outcomes in offspring.

Outpatient visit behavior in patients with epilepsy: Generalized Epilepsy is more frequently non-attendance than Focal Epilepsy

BACKGROUND

Patients with epilepsy (PWE), especially those with Idiopathic Epilepsy (GE), are at a high risk of disadvantage caused by non-adherence. It has been suggested that medical visit behavior may be a surrogate indicator of medication adherence. We hypothesized that patients with IGE would adhere poorly to visits.

METHODS

This was a retrospective study of PWE who visited the Department of Psychiatry and Neurology at Hokkaido University Hospital between January 2017 and December 2019. Demographic and clinical information on PWE were extracted from medical records and visit data from the medical information system. Non-attendance of outpatient appointments was defined as "not showing up for the day of an appointment without prior notice." Mixed-effects logistic regression analysis was conducted with non-attendance as the objective variable.

RESULTS

Of the 9151 total appointments, 413 were non-attendances, with an overall non-attendance rate of 4.5%. IGE was a more frequent non-attendance than Focal Epilepsy (FE) (odds ratio (OR) 1.94; 95% confidence interval (CI) 1.17-3.21; p = 0.010). History of public assistance receipt was associated with higher non-attendance (OR 2.04; 95% CI 1.22-3.43; p = 0.007), while higher education (OR 0.64; 95% CI 0.43-0.93; p = 0.021) and farther distance to a hospital (OR 0.33; 95% CI 0.13-0.88; p = 0.022), and higher frequency of visits (OR 0.18; 95% CI 0.04-0.86; p = 0.031) were associated with fewer non-attendances. In a subgroup analysis of patients with GE, women were associated with fewer non-attendance (OR 0.31; 95% CI 0.14-0.72; p = 0.006).

CONCLUSIONS

GE was more frequent in the non-attendance group than in the FE group. Among patients with GE, females were found to have non-attendance less frequently; however, there was no clear difference in the odds of non-attendance between Juvenile Myoclonic Epilepsy (JME) and IGE other than JME.

Changes in seizure frequency and anti-seizure medication therapy during pregnancy and one year postpregnancy

Seizure control in women with epilepsy (WWE) during pregnancy is a vital concern. The aim of this study was to compare changes in seizure frequency and anti-seizure medication (ASM ) therapy in WWE in a real-world setting over three epochs (prepregnancy, pregnancy, and postpregnancy). We screened WWE who were pregnant between 1 January 2010 and 31 December 2020 from the epilepsy follow-up registry database of a tertiary hospital in China. We reviewed and collected follow-up data for the following time periods: 12 months before pregnancy (epoch 1), throughout pregnancy and the first 6 weeks postpartum (epoch 2), and from 6 weeks to 12 months postpartum (epoch 3). Seizures were classified into two categories: tonic‒clonic/focal to bilateral tonic‒clonic seizures and non-tonic‒clonic seizures. The main indicator was the seizure-free rate over the three epochs. Using epoch 1 as a reference, we also compared the percentage of women with an increased seizure frequency, as well as changes in ASM treatment, in epochs 2 and 3. Ultimately, 271 eligible pregnancies in 249 women were included. The seizure-free rates in epoch 1, epoch 2, and epoch 3 were 38.4%, 34.7%, and 43.9%, respectively (P = 0.09). The top three ASMs used in the three epochs were lamotrigine, levetiracetam, and oxcarbazepine. Using epoch 1 as a reference, the percentages of women with increased frequencies of tonic‒clonic/focal to bilateral tonic‒clonic seizures in epoch 2 and epoch 3 were 17.0% and 14.8%, respectively, while the percentages of women with an increased frequency of non-tonic‒clonic seizures in epoch 2 and epoch 3 were 31.0% and 21.8% (P = 0.02). The percentage of women whose ASM dosages were increased in epoch 2 was higher than that in epoch 3 (35.8% vs. 27.3%, P = 0.03). The seizure frequency during pregnancy may not differ significantly from that during prepregnancy and postpregnancy if WWE are treated according to the guidelines.

A retrospective textual analysis of sexual and reproductive health counseling for adolescent and young adult people with epilepsy of gestational capacity

Rationale The American Academy of Neurology (AAN) recommends annual sexual and reproductive health (SRH) counseling for all people with epilepsy of gestational capacity (PWEGC). Child neurologists report discussing SRH concerns infrequently with adolescents. Limited research exists regarding documentation of such counseling.

METHODS

We retrospectively studied clinical notes using natural language processing to investigate child neurologists' documentation of SRH counseling for adolescent and young adult PWEGC. We segmented notes into sentences and evaluated for references to menstruation, sexual activity, contraception, folic acid, teratogens, and pregnancy. We developed training sets in a labeling application and used machine learning to identify additional counseling instances. We repeated this iteratively until we identified no new relevant sentences. We validated results using external reviewers; after removing sentences reviewers disagreed on (n = 13/400), we calculated Cohen's kappa values between the model and reviewers (>0.98 for all categories). We evaluated labeled texts for each patient per calendar year with descriptive statistics and logistic regression, adjusting for race/ethnicity, age, and teratogen use.

RESULTS

Data comprised 971 PWEGC age 13-21 years with 2277 patient-years and 3663 outpatient child neurology notes. Nearly half of patient-years lacked SRH counseling documentation (49.1%). Among all patients, 38.0% never had SRH counseling documented. Documentation was present regarding menstruation in 26.7% of patient-years, folic acid in 25.0%, contraception in 21.9%, pregnancy in 3.5%, teratogens in 3.0%, and sexual activity in 1.8%. Documentation regarding menstruation and contraception was associated with prescription of antiseizure medications that have a higher risk of teratogenic effects (OR = 1.27, p = 0.020, 95% CI = [1.04,1.54]; OR = 1.27, p = 0.027, 95% CI = [1.03,1.58]). Documentation regarding contraception, folic acid, and sexual activity was increased among older patients (OR = 1.28, p < 0.001, 95% CI = [1.21,1.35]; OR = 1.26, p < 0.001, 95% CI = [1.19,1.32]; OR = 1.26, p = 0.004, 95% CI = [1.08,1.47]). Documentation regarding sexual activity was decreased among patients identifying as White/Non-Hispanic (OR = 0.39, p = 0.007, 95% CI = [0.20,0.78]).

CONCLUSION

Child neurologists counsel PWEGC on SRH less frequently than recommended by the AAN based on documentation.

Utilization of epilepsy care among Women Veterans: A population-based study

OBJECTIVE

Higher healthcare utilization in epilepsy correlates with better clinical and quality of life outcomes. Women Veterans with epilepsy (WVE) have unique characteristics that may affect access and utilization of care. This study investigates epilepsy care in WVE, with respect to utilization of outpatient, inpatient, and emergency room care.

METHODS

Data were collected from 58,525 Veterans with epilepsy using the Veterans Health Administration (VHA) Corporate Data Warehouse administrative data. Overall, 8.5% of the sample were women (n = 4983). Neurology visits, comprehensive epilepsy care, neuroimaging, ASM prescription and hospital and emergency care were analyzed, and comparisons were made with men Veterans with epilepsy to identify gender differences.

RESULTS

Compared to men, a greater proportion of WVE utilized services including neurology (73.8% vs. 62.0%), comprehensive epilepsy care (16.1% vs. 11.7%), epilepsy monitoring unit evaluation (EMU; 6.1% vs. 2.9%), neuroimaging (CT: 39.1% vs. 36.6%; MRI: 43.7% vs. 32.5%), and electroencephalograms: (EEG: 36.5% vs. 29.1%). WVE also evidenced higher percentages of seizure-related emergency room care usage vs. men (15.2 vs. 12.6) and hospitalizations (12.3 vs. 10.0) and were prescribed a greater number of ASMs (average:2.3 vs. 1.9). Valproate was prescribed to 17.6% of WVE, despite potential teratogenic concerns.

SIGNIFICANCE

WVE have greater utilization of epilepsy care within the VHA system compared to men, which could lead to better epilepsy management and quality of life. However, higher rates of emergency care, hospitalizations, and concurrent ASMs among WVE highlight the clinical complexity and raise concern for potentially comorbid conditions including psychogenic non-epileptic seizures.

Gender Issues in Epileptic Patients

Treatment approaches for epilepsy for both women and men are similar, however, there are special aspects that must be considered when caring for women with epilepsy. This includes how hormonal fluctuations may affect seizure frequency, contraception, and potential drug-drug interactions, and pregnancy planning to minimize and potentially mitigate any adverse neurodevelopmental outcomes and major congenital malformations. Adequate counseling for women across the lifespan can help prepare women for the future and optimize outcomes.

Current safety concerns about the use of antiseizure medications in pregnancy

INTRODUCTION

Given the high prevalence of epilepsy in women of childbearing potential (15 million out of 50 million people worldwide), antiseizure medication (ASM) use in pregnancy is common. Identifying the safest and most effective ASM to use during pregnancy is often difficult, but also crucially important. The challenge is to balance two needs: maintaining seizure control while minimizing teratogenicity.

AREAS COVERED

This review looks at seizure- and treatment-related risks to mother and fetus during pregnancy, existing healthcare information programmes, strengths and pitfalls of the main pregnancy registries, known and supposed pharmacokinetic changes during gestation, the utility of therapeutic drug monitoring, and safety concerns. Articles and related content were screened on available publications after January 2000.

EXPERT OPINION

The use of newer ASMs during pregnancy is still limited, as shown by the paucity of data collected by different pregnancy registries. Choosing these medications can be challenging, partly due to unknown pharmacokinetic modifications in pregnancy, an aspect that serum drug monitoring might help to clarify. The safest treatment is chosen also taking into account the woman's needs, concerns and wishes, but adequate pre-pregnancy counseling is necessary to properly inform her about personal and fetal risks related both to seizures and to medications.

Characteristics of menstrual disorders and reproductive hormones in women with epilepsy at an Indonesian national referral hospital

Objective

Menstrual disorders are more common in women with epilepsy than in those without epilepsy. This study aimed to examine the characteristics of reproductive function in women with epilepsy at an Indonesian national referral hospital.

Methods

A case-control study was conducted from March 2020 to March 2021. Women with and without epilepsy aged ≥18 years were enrolled. All women were premenopausal before epilepsy diagnosis. Data on demographic characteristics, menstrual profiles, epileptic syndrome, seizure type, seizure frequency, etiology, localization, and anticonvulsant medication were collected. Hormone levels (follicle stimulating hormone, luteinizing hormone, prolactin, and estradiol) were measured.

Results

A total of 72 women with and 50 without epilepsy (controls) were included. Dysmenorrhea was more common in women with epilepsy than in those without (59.7 vs. 20%, p &lt; 0.001; odds ratio: 5.931 [95% confidence interval: 2.566–13.709]). Marriage rates were higher in women without epilepsy (82 vs. 45.8%, p &lt; 0.001). No difference was found in hormone levels between the groups. The frequency of seizures was associated with prolactin and estradiol levels (p &lt; 0.001). Polytherapy with clobazam was associated with menstrual cycle regularity. In women with epilepsy with menstrual disorders, valproic acid was associated with higher estradiol levels (p = 0.001) and lamotrigine with lower follicle stimulating hormone levels (p = 0.008).

Significance

Women with epilepsy experienced more dysmenorrhea. A higher frequency of seizures associated with lower prolactin and estradiol levels. Polytherapy with clobazam was associated with irregular menstrual cycles, while valproic acid and lamotrigine was associated with estradiol and follicle stimulating hormone levels.

Sex and gender differences in epilepsy

Sex and gender differences in epilepsy are important influencing factors in epilepsy care. In epilepsy, the hormonal differences between the sexes are important as they impact specific treatment considerations for patients at various life stages particularly during early adulthood with establishment of the menstrual cycle, pregnancy, perimenopause and menopause. Choice of antiseizure medication may have direct consequences on hormonal cycles, hormonal contraception, pregnancy and fetal risk of major congenital malformation. Conversely hormones whether intrinsic or extrinsically administered may have direct impact on antiseizure medications and seizure control. This chapter explores these important influences on the management of persons with epilepsy.

Persistent knowledge gaps between 2005 and 2020 in women with epilepsy: Comparison of multicenter studies from Germany

OBJECTIVE

Epilepsy is a chronic condition that can affect patients of all ages. Women with epilepsy (WWE) require access to specific counseling and information regarding issues related to contraception, pregnancy, and hormonal effects on seizure control and bone mineral density. This study investigated the knowledge among WWE regarding their condition, and whether epilepsy-specific knowledge has improved over the last 15 years.

METHODS

A total of 280 WWE aged 18 to 82 years participated in this multicenter, questionnaire-based study. The study was conducted at four epilepsy centers in Germany, between October 2020 and December 2020. Sociodemographic and epilepsy-specific data for participating women were analyzed and compared with the results of a similar survey performed in 2003-2005 among 365 WWE in Germany.

RESULTS

The questionnaire-based survey revealed considerable knowledge deficits without significant improvements over the last 15 years, particularly among those with less education and with regards to information on the more pronounced effects of epilepsy in older WWE (>50 years), including interactions with menopause and osteoporosis. In WWE ≤29 years, a significant increase in the knowledge score was observed in 2020 compared with this age group in 2005 (mean 7.42 vs. 6.5, p = .036). Mothers frequently reported epilepsy-related concerns regarding childrearing, particularly of seizures scaring their child and the need to rely on other people.

CONCLUSION

WWE continue to demonstrate inadequate epilepsy-related knowledge. Despite increasing information availability and the aspiration toward better awareness among medical professionals, overall knowledge has not increased sufficiently compared with the levels observed in recent studies.

Prevalence of self-reported emotional, physical, and sexual abuse and association with fear of childbirth in pregnant women with epilepsy: The Norwegian Mother, Father, and Child Cohort Study

OBJECTIVE

This study was undertaken to examine the prevalence of self-reported experiences with abuse in pregnant women with epilepsy and the association between having experienced abuse and childbirth expectations, particularly the fear of childbirth.

METHODS

We performed a cross-sectional study of women with and without epilepsy enrolled in the Norwegian Mother, Father, and Child Cohort Study 1999-2008. Data on epilepsy diagnosis; antiseizure medication (ASM) use; emotional, physical, and sexual abuse; and childbirth expectations were collected from questionnaires completed during gestational Weeks 17-19 and 30.

RESULTS

Our study population included 295 women with ASM-treated epilepsy, 318 women with ASM-untreated epilepsy, and 93 949 women without epilepsy. A total of 115 women (47%) with ASM-treated and 132 women (57%) with ASM-untreated epilepsy reported any emotional, physical, or sexual abuse, compared to 25 100 women (32%) without epilepsy. The adjusted odds ratios (aORs) for having experienced any abuse were 1.8 (95% confidence interval [CI] = 1.4-2.3) and 1.8 (95% CI = 1.4-2.2) for ASM-treated and ASM-untreated epilepsy, respectively. A total of 29 women (11%) with ASM-treated and 34 women (11%) with ASM-untreated epilepsy reported having been raped, compared to 3088 women (4%) without epilepsy (aORs = 2.8 [95% CI = 1.8-4.1] and 2.9 [95% CI = 2.0-4.2], respectively). In nulliparous women with ASM-untreated epilepsy, having experienced abuse was associated with fear of childbirth; 22 women (31%) with abuse experiences reported fear of childbirth compared to five women (7%) with no experience of abuse (aOR = 5.4 [95% CI = 1.7-17.2]). This association was not seen in multiparous women or in women with ASM-treated epilepsy.

SIGNIFICANCE

More women with epilepsy reported emotional, physical, and sexual abuse than women without epilepsy. Such experiences may be associated with childbirth expectations.

Reproductive Health Counseling in Adolescent Women With Epilepsy: A Single-Center Study

BACKGROUND

Counseling adolescent women with epilepsy (WWE) about reproductive health (contraception, sexual activity, and menstruation) is important given the teratogenicity of many antiseizure medications and high rates of contraception failure. Only a third of adolescent WWE report discussing contraception with their epileptologists, demonstrating a significant gap in counseling.

METHODS

We assessed factors associated with reproductive health counseling by pediatric neurologists via a retrospective chart review of adolescent (aged 12-18 years) WWE seen at a pediatric neurology clinic from 2018 to 2020.

RESULTS

We analyzed 219 visits among 89 unique WWE. There were 23 documented discussions on contraception (11% of visits), 8 on sexual activity (4%), and 127 on menstruation (58%). When contraception was discussed, sexual activity and menstruation were more frequently discussed. Female providers were more likely to document a discussion of menstruation (OR = 3.2, 95% CI = [1.6, 6.4]). WWE who were older at the time of visit or who had their first seizure at an older age were more likely to have documented discussions of contraception and sexual activity. Neither details of treatment regimen nor epilepsy type was associated with documentation of counseling.

CONCLUSIONS

A minority of adolescent WWE have documented reproductive health discussions, demonstrating a need for quality improvement projects to address this gap in care.

Caring for women with epilepsy in Palestine: A qualitative study of the current status

OBJECTIVE

This qualitative study was conducted to explore the current status of caring for women with epilepsy (WWE) in the Palestinian healthcare system.

METHODS

This study used an explorative qualitative design. A purposive sampling technique was used to recruit the participants. Semi-structured in-depth interviews were conducted with neurologists (n = 6), gynecologists (n = 5), psychiatrists (n = 3), an internist (n = 1), and clinical pharmacists (n = 5). The interpretive description methodology was used to thematically analyze the qualitative data.

RESULTS

A total of 745 min (12.4 h) of interview time were analyzed. The qualitative data collected in this study were categorized under 3 major themes and multiple subthemes. The 3 major themes were: (1) diagnosis and care for patients with epilepsy, (2) general issues in caring for patients with epilepsy, and (3) consideration of women's issues in the pharmacotherapy of epilepsy. Formally adopted protocols/criteria for the diagnosis and care for WWE were lacking.

CONCLUSION

Findings of this qualitative study showed a need to formally adopt uniform guidelines that can guide the diagnosis and care of WWE in the Palestinian healthcare system. The findings of this study might be informative to healthcare providers, decision-makers in healthcare authorities, WWE, and patient advocacy groups who could be interested in improving and benchmarking healthcare services provided to WWE. Future studies are still needed to quantitatively measure adherence to the international guidelines in caring for WWE.

Status epilepticus in pregnancy: a literature review and a protocol proposal

INTRODUCTION

Status epilepticus (SE) in pregnancy represents a life-threatening medical emergency for both mother and fetus. Pregnancy-related pharmacokinetic modifications and the risks for fetus associated with the use of antiseizure medications (ASMs) and anesthetic drugs complicate SE management. No standardized treatment protocol for SE in pregnancy is available to date.

AREAS COVERED

In this review, we provide an overview of the current literature on the management of SE in pregnancy and we propose a multidisciplinary-based protocol approach.

EXPERT OPINION

Literature data are scarce (mainly anecdotal case reports or small case series). Prompt treatment of SE during pregnancy is paramount and a multidisciplinary team is needed. Benzodiazepines are the drugs of choice for SE in pregnancy. Levetiracetam and phenytoin represent the most suitable second-line agents. Valproic acid should be administered only if other ASMs failed and preferably avoided in the first trimester of pregnancy. For refractory SE, anesthetic drugs are needed, with propofol and midazolam as preferred drugs. Magnesium sulfate is the first-line treatment for SE in eclampsia. Termination of pregnancy, via delivery or abortion, is recommended in case of failure of general anesthetics. Further studies are needed to identify the safest and most effective treatment protocol.

Women's Issues in Epilepsy

PURPOSE OF REVIEW

Issues pertaining to women with epilepsy have advanced with a better understanding of multidirectional influences among hormones, seizures, and antiseizure medications, as well as pregnancy-related concerns around fertility, seizure destabilization, and antiseizure medication-associated teratogenicity. This article highlights important developments in this field and reviews best practices in the management of women with epilepsy.

RECENT FINDINGS

Important external hormonal influences may impact women with epilepsy particularly in the context of gender-affirming medications, hormonal replacement therapy, and fertility therapies. Fertility for women with epilepsy is influenced by multiple variables; however, in the absence of preexisting fertility issues, epilepsy per se is not associated with significantly impaired fertility. Once women with epilepsy are pregnant, the majority have a stable course. Antiseizure medication use in pregnancy is associated with major congenital malformations 2 to 5 times that of the general population and is highest with high-dose (≥1500 mg or greater total daily) valproate. Carefully considered changes in drug choice and dose may mitigate these risks. Therapeutic drug monitoring plays an important role in pregnancy care, and under expert supervision, women with epilepsy in pregnancy have similar seizure risks as women with epilepsy who are not pregnant. As women with epilepsy age, bone health and menopause may further be impacted by seizures and antiseizure medications.

SUMMARY

The care of women with epilepsy is a multifaceted discipline that recognizes the life-long impact of sex and gender influences on epilepsy care.

Caring for women with epilepsy: Qualitative exploration of key challenges and future directions in a resource poor healthcare system

OBJECTIVE

This qualitative explorative study was conducted to explore the key challenges and future directions of caring for women with epilepsy (WWE) from the perspectives of healthcare professionals who provide care for WWE in Palestine.

METHODS

A qualitative explorative design was used in this study in adherence to the consolidated criteria for reporting qualitative research. The study participants were interviewed in semi-structured in-depth interviews using a pre-validated and pilot-tested interview schedule. The interpretative description approach was used to qualitatively analyze the contents of the interviews.

RESULTS

Interviews were conducted with 6 neurologists, 5 gynecologists, 3 psychiatrists, 5 clinical pharmacists, and 1 internal medicine specialist. The current challenges and future directions in caring for WWE were grouped under healthcare system-, healthcare provider-, patient-, and society-related. Lack of adequate availability, accessibility, and affordability of neurology services and safe antiepileptic drugs (AEDs) were the main challenges. Increasing access of WWE to specialized neurology services and improving acceptance in the society were the main future directions.

CONCLUSION

Findings of this study highlighted the key challenges and future directions of caring for WWE in a resource-poor healthcare system. Decision makers in health authorities, professional bodies, and patient advocacy groups should consider improving availability, accessibility, and affordability of neurology services and safe AEDs for WWE. Future studies are still needed to investigate if addressing these challenges can improve the care of WWE in Palestine.

Concentrations of antiseizure medications in breast milk of lactating women with epilepsy: A systematic review with qualitative synthesis

BACKGROUND

Recent position papers and guidelines encourage women with epilepsy (WWE) to exclusively breastfeed their infants because the benefits to their infants outweigh the potential adverse effects caused by exposure to antiseizure medications (ASMs).

OBJECTIVE

The objectives of this review were: to evaluate concentrations of ASMs in breastmilk of lactating WWE, qualitatively synthesize evidence that can be used to estimate theoretical doses as estimated daily intake (EDI) and relative infant dose (RID) of ASMs, and to evaluate potential risks to infants as a result of exposure to ASMs from breastmilk.

METHODS

This systematic review was registered in the International Prospective Register of Systematic Reviews (PROSPERO) as CRD42020223645. The databases: MEDLINE/PubMed, EMBASE, CINAHL/EBSCO, COCHRANE, SpringerLink, ScienceDirect, Summon, WHO International Clinical Trials Registry Platform, and SCOPUS were systematically searched. A qualitative synthesis was adopted in this study.

RESULTS

A total of 15 records were included in this systematic review. The included studies reported levels of 8 ASMs in the breastmilk of WWE. The highest RIDs of carbamazepine, lamotrigine, primidone, phenobarbital, gabapentin, valproic acid, ethosuximide, levetiracetam, and topiramate were 3.70%, 36.33%, 4.96%, 3.15%, 4.37%, 1.90%, 31.49%, 12.50%, and 12.18%, respectively. Breastfeeding might be limited or even discontinued when signs of excessive sedation/drowsiness and/or poor weight gain are evident on infants exposed to primidone and phenobarbital, ethosuximide/primidone, or ethosuximide/phenobarbital.

CONCLUSIONS

Concentrations of ASMs can be detected in breastmilk of WWE and plasma/serum of infants exposed via breastmilk. Healthcare providers and WWE might use the findings of this study to make informed decisions on the safety of breastfeeding while taking ASMs.

Effect of levetiracetam on the gene expression of placental transporters in a murine model

OBJECTIVE

Levetiracetam (LEV) is an antiseizure medication prescribed to women during childbearing age. The impact of LEV on placental transporters is poorly understood. This study aimed to assess the effect of LEV exposure on the messenger RNA (mRNA) expression of placental transporters for hormones and nutrients and to correlate their expression with the drug's serum concentration in pregnant mice.

METHODS

Studies were conducted on gestational days (GD) 13 and 18, following oral treatment with 100 mg/kg LEV or the vehicle every 24 h after weaning. Serum LEV measurements were performed by High-performance liquid chromatography with a UV detector (HPLC-UV). The weight, height, and width of the fetuses were also analyzed. In addition, the placental expression of transporters xCt, Lat1, Oatp4a1, Fr-α, Rfc, and Snat4 was evaluated through semi-quantitative real-time polymerase chain reaction (qPCR). The Kruskal-Wallis and the Mann-Whitney U tests were used to determine the statistical significance (p < .05). The correlation between serum LEV concentration and placental gene expression was evaluated using the Spearman test.

RESULTS

The weight, height, and width were lower in the fetuses exposed to LEV compared with the control group (p < .05). The number of fetuses was lower in the LEV-exposed group than in the control GD 13 group (p < .001). No significant differences were detected in the mRNA expression level at GD 13. At GD 18, the expression of Lat1, Oatp4a1, xCT, and Snat4 was higher in the group treated with LEV compared with the control group (p < .05), whereas the expression of Rfc was lower (p < .05). No correlation was identified between serum LEV concentrations and gene expression levels.

SIGNIFICANCE

The repression of the Rfc transcript by LEV at GD 18 suggests that the protein expression would be abolished contributing to the observed intrauterine growth restriction (IUGR). Furthermore, the significant increase in mRNA of xCt, Snat4, Oatp4a1, and Lat1 might be a compensatory mechanism for fetal survival at GD 18.

Epilepsy and Pregnancy

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

A Survey of Healthcare Providers About Reproductive Healthcare for Adolescent Women With Epilepsy

STUDY OBJECTIVE

To evaluate knowledge, attitudes, and practices about sexual and reproductive health (SRH) for adolescent and young adult (AYA) women with epilepsy among general pediatricians, adolescent medicine specialists, and pediatric gynecologists.

DESIGN

Survey comprising previously validated and novel items that underwent content validity testing and was distributed through specialty listservs. Categorical variables analyzed with χ² or Fisher exact tests, and continuous variables with Kruskal-Wallis tests.

SETTING

Online.

PARTICIPANTS

Physicians and Advanced practice providers.

INTERVENTIONS

Online survey.

MAIN OUTCOME MEASURE(S)

Questions testing SRH knowledge, assessing confidence in SRH counseling practices and frequency of intended SRH counseling, and identifying barriers and facilitators to SRH provision for AYA women with epilepsy.

RESULTS

Of 329 participants, 57% were general pediatricians, 27% were adolescent medicine specialists, and 16% were pediatric gynecologists. On 15 items assessing knowledge, general pediatricians scored significantly lower than respondents in the other specialties (P < .01). Among 11 items about confidence in SRH skills, general pediatricians were significantly less confident than respondents in the other specialties (P < .01). General pediatricians reported that they would perform annual counseling less often on 7 SRH counseling topics compared with respondents in the other specialties (P < .01). In all, 54% of the respondents reported that barriers to SRH provision include limited time during visits and lack of epilepsy knowledge. Respondents identified facilitators including guidelines/algorithms for managing SRH (83%), provider education (61%), and electronic health record alerts (60%).

CONCLUSION

Responses suggest suboptimal knowledge, confidence, and care provision regarding SRH for AYA women with epilepsy, particularly among general pediatricians. Identified barriers and facilitators may serve as targets for interventions to improve SRH provision.

Pharmacokinetic changes for newer antiepileptic drugs and seizure control during pregnancy

Objective

To investigate pharmacokinetic changes in newer antiepileptic drugs (AEDs) and assess seizure frequencies and risk factors of increased seizures during pregnancy in women with epilepsy (WWE).

Methods

A total of 56 pregnancies in 53 WWE who received newer antiepileptic drugs (AEDs) were enrolled. Data on seizure activity and types, daily dose, and AEDs blood levels were derived from routine clinical follow‐up. Changes in AEDs clearance were compared between each trimester and nonpregnant baseline. The ratio of AED levels of each trimester to their targets (nonpregnant baseline) concentrations (RTC) was compared between patients with and without an increased seizure. A binary logistic regression was used to investigate the risk factors contributing to seizure worsening during pregnancy.

Results

Increased clearances of LTG, LEV, and OXC were observed in all trimesters versus nonpregnant baseline. The peak changes in the clearance of LTG (3.42‐fold baseline clearance) (p < 0.001) and LEV (2.78‐fold) (p < 0.001) occurred in the second trimester during pregnancy, followed by oxcarbazepine (2.11‐fold) in the third trimester (p < 0.03). Plasma concentrations of LTG and LEV during pregnancy were significantly decreased compared to baseline levels, except for OXC. However, no significant differences in RTC values were observed between patients with and without seizure worsening. Some risk factors as seizures for the prior nine months could significantly affect seizure frequency during pregnancy.

Conclusion

We found substantial changes in the pharmacokinetics of multiple newer AEDs in WWE, reinforcing the need for therapeutic drug monitoring (TDM) during pregnancy. We would encourage at least one monitoring every trimester and probably more frequently for women with poorly seizure control before pregnancy, and AEDs dose adjustment should keep up with clearance changes. In addition, a well‐controlled seizure nine months before pregnancy could lower the risks of seizure during pregnancy, highlighting the importance of pre‐pregnancy counseling and seizure management before pregnancy.

Pediatric Neurologists' Perspectives on Sexual and Reproductive Health Care for Adolescent and Young Adult Women With Epilepsy and Intellectual Disability

OBJECTIVE

To explore perspectives of pediatric neurologists regarding sexual and reproductive health care for adolescent women with epilepsy (WWE) and intellectual disability.

METHODS

We interviewed pediatric neurologists regarding sexual and reproductive health for WWE with intellectual disability. We audio-recorded and transcribed interviews and conducted qualitative analysis.

RESULTS

16 pediatric neurologists participated. Themes included the following: (1) Pediatric neurologists have differing perspectives about how intellectual disability affects WWE's sexual and reproductive health needs, (2) pediatric neurologists provide sexual and reproductive health counseling variable in content and frequency to this population, (3) pediatric neurologists tend to recommend longer-term methods of contraception for this population, and (4) pediatric neurologists are asked to be involved in decision-making around sterilization, yet express ethico-legal reservations.

CONCLUSION

Our findings suggest pediatric neurologists provide variable, often suboptimal, sexual and reproductive health care for WWE and intellectual disability. Themes reveal ethical concerns among neurologists about sexual and reproductive health practices including sterilization. More tailored clinical guidelines and provider training on sexual and reproductive health for this population may be beneficial.

Strategies for the Emergency Treatment of Pregnant Women with Neurological Symptoms during the COVID-19 Pandemic

Coronavirus disease-19 (COVID-19) has been spreading all over the world for more than two years. Though several kinds of vaccines are currently available, emergence of new variants, spike mutations and immune escape have raised new challenges. Pregnant women are vulnerable to respiratory infections due to their altered immune defence and surveillance functions. Besides, whether pregnant persons should receive a COVID-19 vaccine is still under debate because limited data are available on the efficacy and safety of receiving a vaccine during pregnancy. Physiological features and lack of effective protection making pregnant women at high risk of getting infected. Another concern is that pregnancy may trigger the onset of underlying existing neurological disease, which is highly similar to those neurological symptoms of pregnant women caused by COVID-19. These similarities interfere with diagnosis and delay timely and effective management. Therefore, providing efficient emergency support for pregnant women suffering from neurological symptoms caused by COVID-19 remains a challenge among neurologists and obstetricians. To improve the diagnosis and treatment efficiency of pregnant women with neurological symptoms, we propose an emergency management framework based on the clinicians' experience and available resources. This emergency care system aimed at addressing the conundrums faced by the emergency guarantee system under COVID-19 pandemic and could serve as a potential multisystem project for clinical practice and medical education.

Pregnancy and the Control of Epileptic Seizures: A Review

Over the past 50 years, published studies have provided quantitative data on the control of epileptic seizures during pregnancy. The studies have varied in quality, and particularly in the ways in which seizure control has been assessed. However, most studies have shown that seizure occurrence rates are more likely to worsen than improve during pregnancy, though in most pregnancies the rates have been unaltered. Nearly all of the studies have involved women with antiseizure medication-treated epilepsy, but there is a little evidence that seizure control also tends to worsen in pregnancies of women with untreated epilepsy. The factors likely to contribute to the seizure worsening are (i) patient non-compliance, (ii) increased antiseizure medication clearance during pregnancy resulting in lower circulating drug concentrations relative to dose, (iii) the effects of the higher female sex hormone levels during pregnancy, oestrogens being pro-epileptogenic and progesterone anti-epileptogenic, and (iv) reluctance to use the potential teratogen valproate in women capable of pregnancy, depriving them of the most effective drug for certain types of epilepsy. Compliance can be encouraged, but at the present time only one other factor is readily correctable, i.e. the increased drug clearance. This can be compensated for by raising antiseizure medication dosage during pregnancy, guided by measurement of circulating drug concentrations. This course of action appears to reduce the chance of seizure disorder worsening during pregnancy, but so far it has not provided a complete solution to the issue.

Maternal folic acid and multivitamin supplementation: International clinical evidence with considerations for the prevention of folate-sensitive birth defects

More evidence is available for maternal intake, absorption, distribution, tissue specific concentrations, and pregnancy outcomes with folic acid (fortification/supplementation) during preconception - first trimester. This Quality Improvement prevention review used expert guidelines/opinions, systematic reviews, randomized control trials/controlled clinical trials, and observational case control/case series studies, published in English, from 1990 to August 2021. Optimization for an oral maternal folic acid supplementation is difficult because it relies on folic acid dose, type of folate supplement, bio-availability of the folate from foods, timing of supplementation initiation, maternal metabolism/genetic factors, and many other factors. There is continued use of high dose pre-food fortification 'RCT evidenced-based' folic acid supplementation for NTD recurrence pregnancy prevention. Innovation requires preconception and pregnancy use of 'carbon one nutrient' supplements (folic acid, vitamin B12, B6, choline), using the appropriate evidence, need to be considered. The consideration and adoption of directed personalized approaches for maternal complex risk could use serum folate testing for supplementation dosing choice. Routine daily folic acid dosing for low-risk women should consider a multivitamin with 0.4 mg of folic acid starting 3 months prior to conception until completion of breastfeeding. Routine folic acid dosing or preconception measurement of maternal serum folate (after 4-6 weeks of folate supplementation) could be considered for maternal complex risk group with genetic/medical/surgical co-morbidities. These new approaches for folic acid oral supplementation are required to optimize benefit (decreasing folate sensitive congenital anomalies; childhood morbidity) and minimizing potential maternal and childhood risk.

Sexual and reproductive health concerns of women with epilepsy beginning in adolescence and young adulthood

BACKGROUND

Women with epilepsy (WWE) have potentially unique concerns regarding their sexual and reproductive health (SRH). Prior studies of WWE have focused narrowly on pregnancy and preconception experiences, and have not addressed concerns of nulliparous adolescent and young adult women not actively seeking pregnancy.

METHODS

We conducted individual semi-structured interviews with WWE 18-45 years of age. We sampled to maximize diversity of age and parity, and intentionally included many adolescent and young adult nulliparous women not actively planning pregnancy. Interviews broadly addressed participants' SRH concerns and experiences. Interviews were audio-recorded and transcribed. Two coders performed qualitative analysis using thematic analysis with deductive and inductive approaches.

RESULTS

Twenty WWE (median age 23 years, range 18-43 years) completed interviews. Twelve were nulliparous, six had children, one had a history of miscarriage only, and two were currently pregnant. WWE's narratives revealed significant concerns about family planning and reproductive health in the context of epilepsy, including: 1) seizures endangering pregnancies and children 2) teratogenic effects of antiseizure medication, 3) heritability of epilepsy, 4) antiseizure medication and epilepsy impacting fertility, and 5) interactions between antiseizure medication and contraception.

CONCLUSION

WWE, including nulliparous adolescent and young adult women who are not actively planning pregnancy, have significant concerns about how their epilepsy interacts with SRH. SRH counseling for WWE should begin during adolescence and be incorporated into the transition process from pediatric to adult healthcare. Insights from WWE may aid in the creation of relevant patient-facing educational resources as well as provider-facing training and tools to meaningfully support the reproductive decision-making of WWE throughout their childbearing years.

Association of Epilepsy and Severe Maternal Morbidity

OBJECTIVE

To evaluate severe maternal morbidity (SMM) among patients with epilepsy and patients without epilepsy.

METHODS

We retrospectively examined SMM using linked birth certificate and maternal hospital discharge records in California between 2007 and 2012. Epilepsy present at delivery admission was the exposure and was subtyped into generalized, focal and other less specified, or unspecified. The outcomes were SMM and nontransfusion SMM from delivery up to 42 days' postpartum, identified using Centers for Disease Control and Prevention indicators. Multivariable logistic regression models were used to adjust for confounders, which were selected a priori. We also estimated the association between epilepsy and SMM independent of comorbidities by using a validated obstetric comorbidity score. Severe maternal morbidity indicators were then compared using the same multivariable logistic regression models.

RESULTS

Of 2,668,442 births, 8,145 (0.3%) were to patients with epilepsy; 637 (7.8%) had generalized, 6,250 (76.7%) had focal or other less specified, and 1,258 (15.4%) had unspecified subtypes. Compared with patients without epilepsy, patients with epilepsy had greater odds of SMM (4.3% vs 1.4%, adjusted odds ratio [aOR] 2.91, 95% CI 2.61-3.24) and nontransfusion SMM (2.9% vs 0.7%, aOR 4.16, 95% CI 3.65-4.75). Epilepsy remained significantly associated with increased SMM and nontransfusion SMM after additional adjustment for the obstetric comorbidity score, though the effects were attenuated. When grouped by organ system, all SMM indicators were significantly more common among patients with epilepsy-most notably those related to hemorrhage and transfusion.

CONCLUSION

Severe maternal morbidity was significantly increased in patients with epilepsy, and SMM indicators across all organ systems contributed to this.

Targeted drug delivery for maternal and perinatal health: Challenges and opportunities

Pre-existing conditions at reproductive age, and complications arising during pregnancy can be detrimental to maternal and fetal health. Current therapies to combat obstetric disorders are limited due to the inherent complexity of pregnancy, and can have harmful effects on developing fetus. Emerging research shows intricate signaling between the cells from mother and fetus at maternal-fetal interface, providing unique opportunities for interventions specifically targeted to the mother, fetus, or placenta. Advancements in nanotechnology, stem-cell biology and gene therapy have resulted in target-specific treatments with promising results in pre-clinical maternal and fetal disorder models. Comprehensive understanding of the effect of physicochemical properties of delivery systems on their uptake, retention and accumulation across placenta will help in the better diagnosis and treatment of perinatal disorders. This review describes the factors leading to obstetric complications along with their effect on pregnancy outcomes, and discusses key targeted therapeutic strategies for addressing conditions related to maternal and fetal health.

Efficacy and tolerability of antiseizure drugs

Drug-resistant epilepsy occurs in 25-30% of patients. Furthermore, treatment with a first-generation antiseizure drug (ASD) fails in 30-40% of individuals because of their intolerable adverse effects. Over the past three decades, 20 newer- (second- and third-)generation ASDs with unique mechanisms of action and pharmacokinetic profiles have been introduced into clinical practice. This advent has expanded the therapeutic armamentarium of epilepsy and broadens the choices of ASDs to match the individual patient's characteristics. In recent years, research has been focused on defining the ASD of choice for different seizure types. In 2017, the International League Against Epilepsy published a new classification for seizure types and epilepsy syndrome. This classification has been of paramount importance to accurately classify the patient's seizure type(s) and prescribe the ASD that is appropriate. A year later, the American Academy of Neurology published a new guideline for ASD selection in adult and pediatric patients with new-onset and treatment-resistant epilepsy. The guideline primarily relied on studies that compare the first-generation and second-generation ASDs, with limited data for the efficacy of third-generation drugs. While researchers have been called for investigating those drugs in future research, epilepsy specialists may wish to share their personal experiences to support the treatment guidelines. Given the rapid advances in the development of ASDs in recent years and the continuous updates in definitions, classifications, and treatment guidelines for seizure types and epilepsy syndromes, this review aims to present a complete overview of the current state of the literature about the efficacy and tolerability of ASDs and provide guidance to clinicians about selecting appropriate ASDs for initial treatment of epilepsy according to different seizure types and epilepsy syndromes based on the current literature and recent US and UK practical guidelines.

Perceived quality of life (QOLIE-31-P), depression (NDDI-E), anxiety (GAD-7), and insomnia in patients with epilepsy attended at a refractory epilepsy unit in real-life clinical practice

Objectives

This study aims to evaluate the relationship between psychiatric comorbidity (anxiety and depression), somnolence, and quality of life, using validated scales in patients with epilepsy in real-life clinical practice and clinical and demographic variables.

Methods

A cross-sectional observational study was conducted. Self-administered scales of anxiety disorders (GAD-7), depression (NDDI-E), somnolence (Epworth Sleepiness Scale (ESS)), and quality of life (QOLIE-31-P) in patients with epilepsy treated in the refractory epilepsy unit of a tertiary hospital were employed.

Results

Eighty-four patients, 44.3 ± 17.4 years, 48.2% women, epilepsy duration 21.5 ± 15.9 years, and number of antiepileptic drugs 1.9 ± 1.2 were included. Severe anxiety was present in 14.3%, depression in 20.2%, and somnolence in 14.3% of patients. QOLIE-31-P score was 62.0 ± 19.2. Depression and focal epilepsy (OR = 4.5[1.3, 20.7], p = 0.029), as well as anxiety and temporal lobe epilepsy (OR = 4.3 [1.0, 18.1], p = 0.044), were associated. Moreover, relationships between worse quality of life and higher scores from NDDI-E (β =  − 1.42, adjusted p = 0.006) and GAD-7 (β =  − 1.21, adjusted p = 0.006), especially in drug-resistant epilepsy (β =  − 8.08, adjusted p = 0.045) and female sex (β =  − 7.83, adjusted p = 0.034), were identified. Statistically significant negative associations were observed between problems to fall asleep and overall quality of life score (β =  − 11.64, adjusted p = 0.022), sleep disturbance and energy (β =  − 14.78, adjusted p = 0.027), and mood (β = 12.40, adjusted p = 0.027) scores.

Conclusions

The multidimensional evaluation revealed that higher levels of anxiety and depression are associated with worse quality of life in real clinical practice in patients with epilepsy, especially in females and drug-resistant epilepsy. In addition, sleep disturbances are associated with particular aspects of the quality of life. Further studies with longitudinal follow-up would be useful to adequately manage these comorbidities in patients with epilepsy.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10072-021-05595-3.