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Mazzone PP, Hogg KM, Weir CJ, Stephen J, Bhattacharya S, Richer S, Chin RFM. Comparison of neurodevelopmental, educational and adult socioeconomic outcomes in offspring of women with and without epilepsy: A systematic review and meta-analysis. Seizure 2024; 117:213-221. [PMID: 38484631 DOI: 10.1016/j.seizure.2024.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 02/21/2024] [Accepted: 02/21/2024] [Indexed: 05/01/2024] Open
Abstract
BACKGROUND Adequate pre-pregnancy counselling and education planning are essential to improve outcomes for offspring of women with epilepsy (OWWE). The current systematic review and meta-analysis aimed to compare outcomes for OWWE and offspring of women without epilepsy (OWWoE). METHODS We conducted a systematic review and meta-analysis. We searched MEDLINE, EMBASE, CINAHL, PsycINFO (database inception-1st January 2023), OpenGrey, GoogleScholar, and hand-searched journals and reference lists of included studies to identify eligible studies. We placed no language restrictions and included observational studies concerning OWWE and OWWoE. We followed the PRIMSA checklist for abstracting data. The Newcastle-Ottawa Scale for risk of bias assessment was conducted independently by two authors with mediation by a third. We report pooled unadjusted odds ratios (OR) or mean differences (MD) with 95% confidence intervals (95CI) from random (I2>50%) or fixed (I2<50%) effects meta-analyses. Outcomes of interest included offspring autism, attention deficit/hyperactive disorder, intellectual disability, epilepsy, developmental disorder, intelligence, educational, and adulthood socioeconomic outcomes. RESULTS Of 10,928 articles identified, we included 21 in meta-analyses. OWWE had increased odds of autism (2 articles, 4,502,098 offspring) OR [95CI] 1·67 [1·54, 1·82], attention-deficit/hyperactivity disorder (3 articles, 957,581 offspring) 1·59 [1·44, 1·76], intellectual disability (2 articles, 4,501,786 children) 2·37 [2·13, 2·65], having special educational needs (3 articles, 1,308,919 children) 2·60 [1·07, 6·34]. OWWE had worse mean scores for full-scale intelligence (5 articles, 989 children) -6·05 [-10·31, -1·79]. No studies were identified that investigated adulthood socioeconomic outcomes. CONCLUSIONS Increased odds of poor outcomes are higher with greater anti-seizure medication burden including neurodevelopmental and educational outcomes. In fact, these two outcomes seem to be worse in OWWE compared to OWWoE, even if there was no ASM exposure during pregnancy, but further work is needed to take into account potential confounding factors.
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Affiliation(s)
- Paolo Pierino Mazzone
- Muir Maxwell Epilepsy Centre, University of Edinburgh, Edinburgh, United Kingdom; Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom; Child Life and Health, Centre for Inflammation Research, University of Edinburgh, Edinburgh, United Kingdom.
| | | | - Christopher J Weir
- Muir Maxwell Epilepsy Centre, University of Edinburgh, Edinburgh, United Kingdom; Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Jacqueline Stephen
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Sohinee Bhattacharya
- Aberdeen Centre for Women's Health Research, The Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | - Simone Richer
- The University of Edinburgh, Medical School, Edinburgh, United Kingdom
| | - Richard F M Chin
- Muir Maxwell Epilepsy Centre, University of Edinburgh, Edinburgh, United Kingdom; Royal Hospital for Children and Young People, Edinburgh, United Kingdom; Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom; Child Life and Health, Centre for Inflammation Research, University of Edinburgh, Edinburgh, United Kingdom
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Bromley RL, Bullen P, Campbell E, Craig J, Ingham A, Irwin B, Jackson C, Kelly T, Morrow J, Rushton S, García-Fiñana M, Hughes DM, Winterbottom J, Wood A, Yates LM, Clayton-Smith J. Neurodevelopment of babies born to mothers with epilepsy: A prospective observational cohort study. Epilepsia 2023; 64:2454-2471. [PMID: 37403560 DOI: 10.1111/epi.17709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 06/27/2023] [Accepted: 06/29/2023] [Indexed: 07/06/2023]
Abstract
OBJECTIVE Despite widespread monotherapy use of lamotrigine or levetiracetam during pregnancy, prospectively collected, blinded child development data are still limited. The NaME (Neurodevelopment of Babies Born to Mothers With Epilepsy) Study prospectively recruited a new cohort of women with epilepsy and their offspring for longitudinal follow-up. METHODS Pregnant women of <21 weeks gestation (n = 401) were recruited from 21 hospitals in the UK. Data collection occurred during pregnancy (recruitment, trimester 3) and at 12 and 24 months of age. The primary outcome was blinded assessment of infant cognitive, language, and motor development on the Bayley Scales of Infant and Toddler Development (3rd edition) at 24 months of age with supplementary parent reporting on the Vinelands Adaptive Behavior Scales (2nd edition). RESULTS There were 394 live births, with 277 children (70%) completing the Bayley assessment at 24 months. There was no evidence of an association of prenatal exposure to monotherapy lamotrigine (-.74, SE = 2.9, 95% confidence interval [CI] = -6.5 to 5.0, p = .80) or levetiracetam (-1.57, SE = 3.1, 95% CI = -4.6 to 7.7, p = .62) with poorer infant cognition, following adjustment for other maternal and child factors in comparison to nonexposed children. Similar results were observed for language and motor scores. There was no evidence of an association between increasing doses of either lamotrigine or levetiracetam. Nor was there evidence that higher dose folic acid supplementation (≥5 mg/day) or convulsive seizure exposure was associated with child development scores. Continued infant exposure to antiseizure medications through breast milk was not associated with poorer outcomes, but the number of women breastfeeding beyond 3 months was low. SIGNIFICANCE These data are reassuring for infant development following in utero exposure to monotherapy lamotrigine or levetiracetam, but child development is dynamic, and future follow-up is required to rule out later emerging effects.
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Affiliation(s)
- Rebecca L Bromley
- Division of Neuroscience, University of Manchester, Manchester, UK
- Royal Manchester Children's Hospital, Manchester University Hospitals NHS Foundation Trust and Manchester Academic Health Sciences Centre, Manchester, UK
| | - Philip Bullen
- Obstetric and Fetal Medicine, St. Mary's Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Ellen Campbell
- Department of Neurology, Belfast Health and Social Care Trust, Belfast, UK
| | - John Craig
- Department of Neurology, Belfast Health and Social Care Trust, Belfast, UK
| | - Amy Ingham
- Manchester Centre for Genomic Medicine, St. Mary's Hospital, University of Manchester, Manchester, UK
| | - Beth Irwin
- Department of Neurology, Belfast Health and Social Care Trust, Belfast, UK
| | - Cerain Jackson
- Department of Neuropsychology, Walton Centre for Neurology and Neurosurgery NHS Foundation Trust, Liverpool, UK
| | - Teresa Kelly
- Obstetric and Fetal Medicine, St. Mary's Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - James Morrow
- Department of Neurology, Belfast Health and Social Care Trust, Belfast, UK
| | - Sarah Rushton
- Manchester Centre for Genomic Medicine, St. Mary's Hospital, University of Manchester, Manchester, UK
| | - Marta García-Fiñana
- Department of Health Data Science, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - David M Hughes
- Department of Health Data Science, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Janine Winterbottom
- Department of Neurology, Walton Centre for Neurology and Neurosurgery NHS Foundation Trust, Liverpool, UK
| | - Amanda Wood
- School of Psychology, Deakin University, Burwood, Victoria, Australia
- Aston Institute for Health and Neurodevelopment, Aston University, Birmingham, UK
| | - Laura M Yates
- Department for Clinical Genetics, Nothern Genetics Service, Newcastle, UK
| | - Jill Clayton-Smith
- Manchester Centre for Genomic Medicine, St. Mary's Hospital, University of Manchester, Manchester, UK
- Division of Evolution and Genomic Sciences, School of Biological Sciences, University of Manchester, Manchester, UK
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Abstract
Epilepsy affects up to 15 million of people assigned female at birth of childbearing age globally. Up to 65% of these people with epilepsy and gestational capacity have an unplanned pregnancy. Seizure control during pregnancy is important for both the childbearer's and fetus' safety. There are multiple antiseizure medications (ASMs) that can be used to control epilepsy; however, each medication has its own teratogenic risk profile, which must be considered. The majority of these ASMs will require frequent plasma concentration monitoring during pregnancy with corresponding dosage adjustments. Dosages can be reduced back to prepregnancy levels within 3 weeks postpartum. Breastfeeding on ASMs is recommended.
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Meador KJ. Effects of Maternal Use of Antiseizure Medications on Child Development. Neurol Clin 2022; 40:755-768. [PMID: 36270689 PMCID: PMC9589915 DOI: 10.1016/j.ncl.2022.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Most children born to women with epilepsy (WWE) are normal, but have increased risks for malformations and poor neuropsychological outcomes. Antiseizure medications (ASMs) are among the most commonly prescribed teratogenic medications in women of childbearing age. However, WWE typically cannot avoid using ASMs during pregnancy. Teratogenic risks vary across ASMs. Valproate poses a special risk for anatomic and behavioral teratogenic risks compared with other ASMs. The risks for many ASMs remain uncertain. Women of childbearing potential taking ASMs should be taking folic acid. Breastfeeding while taking ASMs seems safe. WWE should receive informed consent outlining risks before conception.
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Affiliation(s)
- Kimford J Meador
- Department of Neurology & Neurological Sciences, Stanford University, Stanford University School of Medicine, 213 Quarry Road, MC 5979, Palo Alto, CA 94304-5979, USA.
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Thomas SV, Salim S, Jacob NS, Jose M, Salini RA, Selvaraj S, Gomez TS, Sreedharan H, Jeemon P. Language, intelligence, and educational outcomes of adolescents with antenatal exposure to antiseizure medications: Prospective data from the Kerala Registry of epilepsy and pregnancy. Seizure 2022; 100:76-81. [DOI: 10.1016/j.seizure.2022.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 06/12/2022] [Accepted: 06/13/2022] [Indexed: 11/15/2022] Open
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Thomas SV, Jeemon P, Jose M, Amrithum LM, Bhaskar D, Nair MKC, George B. Differential impact of antenatal exposure to antiseizure medications on motor and mental development in infants of women with epilepsy. Epileptic Disord 2022; 24:531-540. [PMID: 35770752 DOI: 10.1684/epd.2022.1414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 01/15/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE We aimed to determine a possible association between motor and mental development in infants of women with epilepsy and antenatal exposure to antiseizure medication (ASM). METHODS Developmental paediatricians who were blinded to antenatal ASM exposure evaluated motor and mental development of infants (>12 months) using the Developmental Assessment Scale for Indian Infants (an Indian adaptation of the Bayley Scale of Infant Development). Motor (MODQ) and mental development quotients (MEDQ) were computed as ratios of respective developmental age to the chronological age of the child. We employed linear mixed models to study the relationship between antenatal exposure to ASM and the development quotients after adjustment for malformation status and age of the baby, maternal education and seizure type. RESULTS We studied 1,357 infants with mean age of 15.3±4.0 months (71.2% of all eligible infants). Infants were classified as having monotherapy or polytherapy, or unexposed in 840, 407 and 110 participants, respectively. The MEDQ of the polytherapy (92.9±14.9) and monotherapy (96.9±13.9) groups was lower than that of unexposed infants (99.8 12.5). Similarly, the MODQ of polytherapy (91.1±19.3) and monotherapy (96.6±17.5) groups was lower than that of unexposed infants (97.6 16.6). The differences in adjusted mean MEDQ were -7.4 (-11.4 to -4.3, p=0.001), -9.6 (-11.3 to -6.0, p=0.001) and -6.4 (-9.2 to -3.7, p=0.001) for valproate monotherapy, polytherapy with valproate and polytherapy without valproate, respectively. The adjusted mean MODQ also showed a similar trend. Those exposed to levetiracetam (n=62) had higher or similar adjusted MODQ (110.4±14.3; p=0.001) and MEDQ (104.3±9.1; p=0.09), compared to unexposed infants. A dose-dependent decrease in developmental indicators was observed for valproate and phenobarbitone. SIGNIFICANCE Antenatal exposure to ASM, especially valproate and phenobarbitone, adversely affects motor and mental development of exposed infants. Early developmental screening of high-risk infants is desirable.
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King A, Gerard EE. Contraception, fecundity, and pregnancy in women with epilepsy: an update on recent literature. Curr Opin Neurol 2022; 35:161-168. [PMID: 35191408 PMCID: PMC9230745 DOI: 10.1097/wco.0000000000001039] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Caring for women with epilepsy requires specialized knowledge about potential teratogenicity of antiseizure medications, interactions with hormonal contraception, and pregnancy outcomes. RECENT FINDINGS There has been an improvement in understanding the cognitive outcomes of infants exposed in utero in recent years. Folic acid supplementation helps mitigate the cognitive teratogenicity of antiseizure medications. Recent updates provide reassurance that seizure frequency tends to remain stable throughout pregnancy. There is conflicting evidence about the fecundity impact of epilepsy and antiseizure medications in women with epilepsy. SUMMARY Recent research highlights the importance of early counseling about the risks and interactions of contraception, pregnancy, and antiseizure medications. More research is needed to understand fertility in women with epilepsy.
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Affiliation(s)
- Alexa King
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Gerard EE. What Should We Do When the Kids Grow Up? Studying the Long-Term Cognitive Effects of In-Utero Anti-Seizure Medication Exposure. Epilepsy Curr 2021; 21:165-167. [PMID: 34867094 PMCID: PMC8609582 DOI: 10.1177/15357597211005477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Enduring Language Deficits in Children of Women With Epilepsy and the Potential Role of Intrauterine Exposure to Antiepileptic Drugs Unnikrishnan G, Jacob NS, Salim S, et al. Epilepsia . 2020;61(11):2442-2451. doi:10.1111/epi.16685 Objective: Exposure to certain intrauterine antiepileptic drugs (AEDs) can negatively influence the language skills and intelligence of young children. It remains unanswered whether these deficits are transient or persist as children grow up. This study aims to evaluate the language function of children of women with epilepsy (CWE) aged 9 to 13 years in comparison with their peers, and its relationship with intrauterine AED exposure. Methods: We included 191 CWE in our study from the Kerala Registry of Epilepsy and Pregnancy. Children in the same age group (n = 144) and without maternal epilepsy or antenatal AED exposure served as controls. We used Clinical Examination for Language Function version IV to assess language in both groups. Relevant data related to maternal epilepsy and AED use were obtained from the registry records. Results: The average Core Language Scaled Score (CLSS) was significantly lower in CWE as compared to controls (83.19 vs 90.18, P = .001). Similarly, the mean scaled scores in other language parameters were also significantly lower in CWE. In the multivariate analysis, compared to control children, the average CLSS in CWE was 4.5 units lower (95% CI = −8.8 to −0.2, P = .04) with AED monotherapy exposure and 7.3 units lower with exposure to AED polytherapy (95% CI = −13.8 to −0.8, P = .03). Intrauterine exposure to phenobarbitone (n = 61) and valproate (n = 55) as either monotherapy or polytherapy showed a negative effect on CLSS in CWE as compared to control children. However, carbamazepine (n = 75) and phenytoin (n = 37) use was not associated with significant variation of CLSS. In head-to-head comparisons between AED monotherapies in CWE, phenobarbitone showed a negative effect on CLSS (−14.7, 95% CI = −23.1 to −6.4, P = .001) as compared to carbamazepine. Significance: Intrauterine exposure to phenobarbitone and valproate impairs language development in CWE, with effects persisting into the second decade.
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Seshachala BB, Jose M, Lathikakumari AM, Murali S, Kumar AS, Thomas SV. Valproate usage in pregnancy: An audit from the Kerala Registry of Epilepsy and Pregnancy. Epilepsia 2021; 62:1141-1147. [PMID: 33782943 DOI: 10.1111/epi.16882] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 03/03/2021] [Accepted: 03/04/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE This is an audit of the use of valproate (VPA) during pregnancy in women with epilepsy (WWE). METHODS We identified all pregnancies exposed to VPA in the Kerala Registry of Epilepsy and Pregnancy between January 2010 and December 2019. Subjects' past usage of antiepileptic drugs (AEDs), seizure count before and during pregnancy, fetal outcome, and major congenital malformations (MCMs) were abstracted from the registry records. The presumed reason for usage of VPA was deducted from the clinical records. RESULTS There were 221 pregnancies (17.75%) exposed to VPA (monotherapy, n = 149) during the audit period. The MCM rate for the completed pregnancies exposed to VPA was higher (n = 20, 10.36%) than that of VPA-unexposed pregnancies (n = 39, 4.96%). The relative risk for MCM with VPA exposure was 2.1 (95% confidence interval = 1.24-3.48, number needed to treat with VPA to result in MCM = 19). Reasons for using VPA during pregnancy (some women had more than one reason) were (1) VPA was the first AED prescribed and was effective (68, 29.06%), (2) other AEDs were ineffective (128, 54.70%), and (3) other AEDs were discontinued due to adverse effects (17, 7.28%). Other reasons (21, 8.97%) were (1) VPA was selected after the epilepsy classification was revised (3, 1.28%), (2) other AEDs were expensive (2, .85%), and (3) patient switched to VPA from other AEDs for unspecified reason (16, 6.83%). VPA was discontinued during pregnancy for 6 (2.71%) persons. Less than 10% of women were tried on lamotrigine or levetiracetam before switching to VPA. SIGNIFICANCE Nine MCMs per thousand pregnancies can be avoided if VPA is not used in WWE. Safe and effective AEDs as alternatives to VPA are the need of the hour. Professional bodies and regulatory authorities need to implement updated guidelines on AED usage in girls and women.
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Affiliation(s)
- Balaji B Seshachala
- Kerala Registry of Epilepsy and Pregnancy, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Manna Jose
- Kerala Registry of Epilepsy and Pregnancy, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Arya M Lathikakumari
- Kerala Registry of Epilepsy and Pregnancy, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Sruthy Murali
- Kerala Registry of Epilepsy and Pregnancy, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Arjun S Kumar
- Kerala Registry of Epilepsy and Pregnancy, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Sanjeev V Thomas
- Kerala Registry of Epilepsy and Pregnancy, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
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