CPD-Education and self-assessment: Epilepsy and pregnancy

Pregnancy outcomes among women with epilepsy: A retrospective cohort study

OBJECTIVE

The objective of this study was to compare adverse pregnancy outcomes between pregnancies that involve epilepsy and those that do not and are identified as normal for the purposes of this paper.

METHODS

A retrospective cohort study was carried out by accessing the maternal-fetal medicine (MFM) database to identify and review records of singleton pregnancies with epilepsy but with no other underlying disease (study group). A parallel group of low-risk pregnancies was randomly allocated as the control group. The adverse outcomes between the two groups were compared. The primary outcomes included rates of spontaneous abortion, small for gestational age (SGA), preterm birth (PTB), low birth weight (LBW), and preeclampsia.

RESULTS

From a total of 44,708 deliveries, 148 pregnancies involving mothers with epilepsy and a control group of 1480 normal pregnancies were compared. The rates of spontaneous abortion, PTB, LBW, and cesarean section were slightly but significantly higher in the study group with a relative risk of 6.6 (95% confidence interval (CI): 1.9-23.3), 1.6 (95% CI: 1.1-2.2), 1.6 (95% CI: 1.1-2.3), and 1.5 (95% CI: 1.1-2.1), respectively, whereas other adverse outcomes were comparable. In the subgroup analysis, adverse outcomes tended to be higher in women with active epilepsy. However, only the rates of SGA in the group in which the disorder is active and PTB in the presence of seizures within 6months of conception were significantly increased.

CONCLUSIONS

Pregnancies with epilepsy, even in cases with multidisciplinary care and no other risk factors, are still significantly associated with higher adverse outcomes.

Medications and Breast-Feeding: A Guide for Pharmacists, Pharmacy Technicians, and other Healthcare Professionals Part III

Objective:

To provide a guide for practicing pharmacists, pharmacy technicians, and other healthcare professionals so that they are able to counsel and advise breast-feeding mothers and fellow healthcare professionals on the safety and use of antiinfectives, vaccines, antiepileptics, benzodiazepines, psychotherapeutic drugs, and radiopharmaceuticals during breast-feeding.

Data Sources:

Primary texts used by the breast-feeding community ( Medications and Mothers' Milk, Drugs in Pregnancy and Lactation, Drugs and Human Lactation) were searched, as well as Micromedex, MEDLINE, PubMed, EMBASE, and EMBASE2 (1984–February 2004).

Study Selection/Data Extraction:

Multiple sources were used wherever available to validate the data, and primary articles were used to verify all tertiary source information. Search terms included breast-feeding, lactation, nursing, and medications, as well as specific drug names.

Data Synthesis:

Concerns regarding medication use during breast-feeding have caused mothers to either discontinue nursing or not take necessary medications. Complete avoidance of medications or cessation of breast-feeding is often unnecessary. Although there are drugs that can be harmful to nursing infants, breast-milk concentrations of most drugs are insufficient to cause any harm.

Conclusions:

Having objective and reliable information on medications enables pharmacists, pharmacy technicians, other healthcare providers, and mothers to make educated decisions regarding drug therapy and breast-feeding.

Update on anticonvulsant drugs

In 2009, the US Food and Drug Administration approved three medications for the treatment of epilepsy: rufinamide, lacosamide, and vigabatrin. In addition, extended-release formulations of lamotrigine and levetiracetam were approved recently. When added to the dozen medications for treating epilepsy, the choice is a luxury in terms of additional options, but also a challenge for practitioners to use them all with expertise. Recently, there has been much interest surrounding medications for epilepsy and their possible association with osteoporosis, safety during pregnancy, biological equivalence to generic versions, and possible association with higher rates of suicidality. This review discusses these issues and provides a current overview for the medical management of epilepsy.

Pregnancy and perinatal outcome in epileptic women: A population-based study

OBJECTIVE

To investigate the pregnancy outcome of patients with epilepsy.

STUDY DESIGN

A population-based study comparing all singleton pregnancies of patients with and without epilepsy was performed. Patients lacking prenatal care were excluded from the analysis. Deliveries occurred between the years 1988 and 2002 in a tertiary medical center. Stratified analysis, using a multiple logistic regression model, was performed to control for confounders.

RESULTS

During the study period 139 168 singleton deliveries occurred in our medical center. Of these, 220 (0.2%) were of patients with epilepsy. With the exception of gestational diabetes mellitus (GDM), no other significant differences regarding maternal outcomes were noted between the groups. However, a higher rate of congenital malformations was noted among the epileptic population (7.7% vs. 3.8%; p < 0.001). Also, a higher rate of cesarean deliveries (CD) was found among epileptic women (17.3% vs. 11.55%, p = 0.008). This association was persistent after controlling for possible confounders, using a multivariable analysis (OR = 1.5, 95% CI 1.1-2.3; p = 0.05).

CONCLUSION

The course of pregnancy of patients with epilepsy is favorable, except for higher rates of cesarean deliveries, GDM, and congenital malformations.

Pregnancy, epilepsy, and anticonvulsants

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.

Management of a first seizure. Special problems: adults and elderly

A first seizure out of a clear blue sky can be a major life-changing event. Careful history-taking and appropriate investigation together with a clear explanation provided to patient and family are an essential requirement. Although for most patients, pharmacotherapy can be withheld and events awaited, there are circumstances where introduction of antiepileptic drug (AED) therapy should be considered. Medical causes of seizures should also be sought and treated. In addition, a first seizure in HIV-positive patients and in those with underlying neurocysticercosis should usually provoke the introduction of AED therapy. Particular problems can occur in patients with a single episode of provoked status epilepticus, a first tonic-clonic seizure during pregnancy and, particularly, an unprovoked event in older and learning disabled people. Treatment following a first seizure should balance risk factors for recurrence with the informed opinion of the patients and their family.

Gabapentin exposure in human pregnancy: results from the Gabapentin Pregnancy Registry

The objective of this study was to assess the safety of gabapentin (Neurontin) exposure in human pregnancy. Prospective and retrospective data concerning 51 fetuses, including 3 twin gestations, were collected from 39 women with epilepsy and other disorders exposed to gabapentin during pregnancy. Data were collected and evaluated about the 44 live births, including maternal demographics, diagnosis, treatment and complications, and fetal complications and outcomes. The results of this study showed that the rates of maternal complication, cesarean section, miscarriage, low birth weight, and malformation were less than or similar to those seen in the general population or among women with epilepsy. Gabapentin exposure during pregnancy did not lead to an increased risk for adverse maternal and fetal events in this study. However, because of the small number of patients examined in this study, additional data from more pregnancies and outcomes are needed.

Nutritional assessment and support during pregnancy

This article thoroughly updates the authors' previous review of nutritional assessment and support during pregnancy. After briefly reviewing nutrient metabolism and requirements, the authors discuss the nutritional assessment of the pregnant woman and review the nutritional support principles in hyperemesis gravidarum and other conditions that can compromise the nutritional health of mother or fetus.