The management of epilepsy in pregnancy

Treatment and care of women with epilepsy before, during, and after pregnancy: a practical guide

Women with epilepsy (WWE) wishing for a child represent a highly relevant subgroup of epilepsy patients. The treating epileptologist needs to delineate the epilepsy syndrome and choose the appropriate anti-seizure medication (ASM) considering the main goal of seizure freedom, teratogenic risks, changes in drug metabolism during pregnancy and postpartum, demanding for up-titration during and down-titration after pregnancy. Folic acid or vitamin K supplements and breastfeeding are also discussed in this review. Lamotrigine and levetiracetam have the lowest teratogenic potential. Data on teratogenic risks are also favorable for oxcarbazepine, whereas topiramate tends to have an unfavorable profile. Valproate needs special emphasis. It is most effective in generalized seizures but should be avoided whenever possible due to its teratogenic effects and the negative impact on neuropsychological development of in utero-exposed children. Valproate still has its justification in patients not achieving seizure freedom with other ASMs or if a woman decides to or cannot become pregnant for any reason. When valproate is the most appropriate treatment option, the patient and caregiver must be fully informed of the risks associated with its use during pregnancies. Folate supplementation is recommended to reduce the risk of major congenital malformations. However, there is insufficient information to address the optimal dose and it is unclear whether higher doses offer greater protection. There is currently no general recommendation for a peripartum vitamin K prophylaxis. During pregnancy most ASMs (e.g. lamotrigine, oxcarbazepine, and levetiracetam) need to be increased to compensate for the decline in serum levels; exceptions are valproate and carbamazepine. Postpartum, baseline levels are reached relatively fast, and down-titration is performed empirically. Many ASMs in monotherapy are (moderately) safe for breastfeeding and women should be encouraged to do so. This review provides a practically oriented overview of the complex management of WWE before, during, and after pregnancy.

An in vitro Study on the Contractility of Epileptic Myometrium and Effects of Antiepileptic Agents on Oxytocin-Induced Contractions of Myometrium Isolated from Absence Epileptic WAG/Rij Rats

BACKGROUND/AIMS

The aim of this study was to determine whether spontaneous and stimulated contractile activity of myometrium in epileptic rats is different from healthy ones, and whether antiepileptic drugs (AEDs) have any direct influence on myometrial contractility.

METHODS

Myometrial strips from nonpregnant and pregnant adult epileptic WAG/Rij and Wistar rats were suspended in organ bath containing physiological salt solution (37°C and pH 7.4, aerated with 95% oxygen-5% CO2), and isometric contractions were recorded. Effects of cumulative concentrations of selected AEDs including phenytoin, levetiracetam, and valproic acid alone and in combination on oxytocin-induced contractions was examined. Contractile parameters assessed included the area under curve, amplitude, and frequency of contractions, evaluated by 10-min periods. Data were analyzed using one-way analysis of variance and Tukey HSD test.

RESULTS

Spontaneous myometrial contractility and responses to oxytocin showed species difference. Compared with that of control Wistar rats, spontaneous contractions of myometrium from nonpregnant epileptic WAG/Rij rats were significantly higher while being significantly lower in pregnant preparations. Upon stimulation with oxytocin, WAG/Rij myometrium showed significantly lower contractile response compared with preparations from healthy control Wistars (p < 0.01). Phenytoin and valproate caused concentration-dependent significant attenuation (p < 0.05) of spontaneous and oxytocin-induced contractions of myometrium from WAG/Rij and Wistar rats, both nonpregnant and pregnant.

CONCLUSION

Myometrial smooth muscle from epileptic rats showed different spontaneous and oxytocin-induced contractility, and AEDs showed contractile modulatory actions, phenytoin being the most and levetiracetam the least effective. Although in vitro, our findings may be of clinical implications with regard to obstetric complications in epileptics and use of AEDs during pregnancy, and warrants further investigations.

Pregnancy-related complications and risk of postpartum readmission for seizures and epilepsy: A national study

OBJECTIVE

Peripartum seizures remain a leading cause of maternal morbidity and mortality worldwide. Therefore, recognition of high-risk individuals is essential. We aimed to determine the rate and identify risk factors for postpartum seizure/epilepsy readmissions.

METHODS

In this retrospective cohort study, the Nationwide Readmissions Database was used to identify index admissions for delivery and readmissions for seizures in the year 2013, defined by International Classification of Disease, Ninth Revision, Clinical Modification codes for epilepsy, convulsions, and eclampsia in the primary diagnostic position. Logistic regression analysis was used to examine 30-day readmission for seizures as well as associations between demographic, medical, psychiatric, and pregnancy-related factors.

RESULTS

There were 1 633 714 index admissions for delivery, with a 30-day readmission rate for seizures/epilepsy of 19.69 per 100 000 index admissions. The mean age of index participants was 28.6 years (SD = 5.8). Postpartum 30-day readmissions for eclampsia represented 80% of seizure/epilepsy readmissions. Higher income was associated with lower odds of seizure/epilepsy readmission (odds ratio [OR] = 0.50, 95% confidence interval [CI] = 0.34-0.72, P = .03) for the highest income group. Eclampsia (OR = 19.9, 95% CI = 9.38-42.2, P < .001), preexisting epilepsy (OR = 10.63, 95% CI = 6.43-17.56, P < .001), pre-eclampsia (OR = 3.23, 95% CI = 2.31-4.51, P < .001), and gestational hypertension (OR = 2.78, 95% CI = 1.94-3.98, P < .001) were associated with readmission for seizures.

SIGNIFICANCE

Readmissions for seizures are fortunately rare, but are important to minimize given morbidity and mortality. Most seizure readmissions occurring within 30 days postpartum were coded as eclampsia rather than convulsions or pre-existing epilepsy. These findings suggest that early identification of women with pre-eclampsia and eclampsia may play a role in the prevention of postpartum seizures. Women with these risk factors should be identified to optimize care and monitored closely for seizure-associated complications.

Shifting Valproic Acid to Levetiracetam in Women of Childbearing Age With Epilepsy: A Retrospective Investigation and Review of the Literature

Objective: Valproic acid is the most high-risk teratogenic antiepileptic drug, and it may lead to fetal major congenital malformations. However, it is still used in women of childbearing age with epilepsy. The aim of this study was to report our experience of discontinuing or lowering valproic acid by adding levetiracetam, a low-risk teratogenic antiepileptic drug.

Methods: We reviewed the medical records of childbearing age female patients with epilepsy who were treated with valproic acid initially and then switched to levetiracetam. The clinical profiles were recorded. The primary outcome was successful switching, which was defined as a decrease in the daily valproic acid dosage, after levetiracetam had been added.

Results: Twenty-four female patients were enrolled (median age 22 years). The successful switching rate was 83.3% (20/24), and 55% (11/20) discontinued valproic acid after levetiracetam had been added. There were no significant differences between the successful and unsuccessful groups in etiology, electroencephalogram, and magnetic resonance imaging findings. Pharmacoresistant to levetiracetam was much higher in the unsuccessful group (45 vs. 100%). The median switching duration was 19.5 months in the successful group. There were improvements in metrorrhagia and alopecia in all of the patients in the successful group after valproic acid had been tapered.

Conclusions: Our experience supports switching valproic acid to levetiracetam in childbearing age women with epilepsy as an effective strategy to lower the teratogenic rate and adverse effects. A long switching period was noted in this study. We suggest starting early in childbearing age women with epilepsy.

Risk of impaired cognition after prenatal exposure to psychotropic drugs

OBJECTIVE

Prenatal exposure to psychotropic drugs may affect the trajectories of brain development. In a register study, we investigated whether such exposure is associated with long-term impaired cognitive abilities.

METHOD

Individuals born in Denmark in 1995-2008 were included. As proxies for cognitive impairment, requiring special needs education, attending special needs school, diagnoses of neurological/mental disorder, missed final examinations, and low school grade average were used. We accounted for maternal confounders.

RESULTS

We identified 868 159 individuals of whom 13 983 (1.6%) were prenatally exposed. The adjusted odds ratio (OR) was 0.97[0.92-1.02] for requiring special needs education, 1.28[1.14-1.43] for attending special needs school, 1.32[1.20-1.46] for a neurological/mental disorder diagnosis, 1.37[1.22-1.54] for missing the final examinations, and 1.13[0.82-1.55] for obtaining a low school grade average. Exposure to psycholeptics (primarily antipsychotics and sedatives) was correlated with significantly increased risk for four outcomes. The highest was the risk of missing the primary school examinations (OR: 1.51[1.29-1.76]). The overall highest risk concerned the presence of a neurological/mental disorder after prenatal exposure to psychoanaleptics (primarily antidepressants) (OR: 1.86[1.24-2.78).

CONCLUSION

Prenatal exposure to psychotropic drugs affects proxy outcomes of cognitive disabilities at school age. Exposure to psycholeptics carries the largest risk. The role of psychoanaleptics is currently unclear.

Risks and benefits of psychotropic medication in pregnancy: cohort studies based on UK electronic primary care health records

BACKGROUND

Although many women treated with psychotropic medication become pregnant, no psychotropic medication has been licensed for use in pregnancy. This leaves women and their health-care professionals in a treatment dilemma, as they need to balance the health of the woman with that of the unborn child. The aim of this project was to investigate the risks and benefits of psychotropic medication in women treated for psychosis who become pregnant.

OBJECTIVE(S)

(1) To provide a descriptive account of psychotropic medication prescribed before pregnancy, during pregnancy and up to 15 months after delivery in UK primary care from 1995 to 2012; (2) to identify risk factors predictive of discontinuation and restarting of lithium (multiple manufacturers), anticonvulsant mood stabilisers and antipsychotic medication; (3) to examine the extent to which pregnancy is a determinant for discontinuation of psychotropic medication; (4) to examine prevalence of records suggestive of adverse mental health, deterioration or relapse 18 months before and during pregnancy, and up to 15 months after delivery; and (5) to estimate absolute and relative risks of adverse maternal and child outcomes of psychotropic treatment in pregnancy.

DESIGN

Retrospective cohort studies.

SETTING

Primary care.

PARTICIPANTS

Women treated for psychosis who became pregnant, and their children.

INTERVENTIONS

Treatment with antipsychotics, lithium or anticonvulsant mood stabilisers.

MAIN OUTCOME MEASURES

Discontinuation and restarting of treatment; worsening of mental health; acute pre-eclampsia/gestational hypertension; gestational diabetes; caesarean section; perinatal death; major congenital malformations; poor birth outcome (low birthweight, preterm birth, small for gestational age, low Apgar score); transient poor birth outcomes (tremor, agitation, breathing and muscle tone problems); and neurodevelopmental and behavioural disorders.

DATA SOURCES

Clinical Practice Research Datalink database and The Health Improvement Network primary care database.

RESULTS

Prescribing of psychotropic medication was relatively constant before pregnancy, decreased sharply in early pregnancy and peaked after delivery. Antipsychotic and anticonvulsant treatment increased over the study period. The recording of markers of worsening mental health peaked after delivery. Pregnancy was a strong determinant for discontinuation of psychotropic medication. However, between 40% and 76% of women who discontinued psychotropic medication before or in early pregnancy restarted treatment by 15 months after delivery. The risk of major congenital malformations, and neurodevelopmental and behavioural outcomes in valproate (multiple manufacturers) users was twice that in users of other anticonvulsants. The risks of adverse maternal and child outcomes in women who continued antipsychotic use in pregnancy were not greater than in those who discontinued treatment before pregnancy.

LIMITATIONS

A few women would have received parts of their care outside primary care, which may not be captured in this analysis. Likewise, the analyses were based on prescribing data, which may differ from usage.

CONCLUSIONS

Psychotropic medication is prescribed before, during and after pregnancy. Many women discontinue treatment before or during early pregnancy and then restart again in late pregnancy or after delivery. Our results support previous associations between valproate and adverse child outcomes but we found no evidence of such an association for antipsychotics.

FUTURE WORK

Future research should focus on (1) curtailing the use of sodium valproate; (2) estimating the benefits of psychotropic drug use in pregnancy; and (3) investigating the risks associated with lifestyle choices that are more prevalent among women using psychotropic drugs.

FUNDING DETAILS

The National Institute for Health Research Health Technology Assessment programme.

Development of a core outcome set for epilepsy in pregnancy (E-CORE): a national multi-stakeholder modified Delphi consensus study

OBJECTIVE

To develop a set of core outcomes for studies on pregnant women with epilepsy.

DESIGN

Delphi consensus study.

POPULATION

Healthcare professionals, and patient representatives with lived experience of epilepsy in the UK.

METHODS

We used a modified Delphi method and a consultation meeting to achieve consensus. Potential outcomes were identified by systematic review, and were scored using a Likert scale anchored between 1 (least important) and 5 (most important). We included outcomes that scored ≥4 by >70% of participants, and outcomes that scored ≤2 by <15% of participants.

MAIN OUTCOME MEASURES

Outcomes in studies on epilepsy in pregnancy.

RESULTS

Seventy-five healthcare professionals completed the first round, 48 (64%) completed the second round, and 37 (49%) completed the third round of the survey. Twenty-four patient representatives participated. The final core outcome set included 31 outcomes in three domains: neurological, offspring, and obstetric. Outcomes in the neurological domain were seizure control in pregnancy and postpartum, status epilepticus, maternal mortality, drowning, sudden unexpected death in epilepsy, postnatal depression, and quality of life. Offspring domain included congenital abnormalities (major and minor), fetal anticonvulsant syndrome, neurodevelopment, autism disorder, neonatal clinical complications, admission to a neonatal intensive care unit, and anthropometric measurements. The obstetric domain included live birth, stillbirth, miscarriage, ectopic, termination of pregnancy, admission to a high dependency or intensive care unit, breastfeeding, mode of delivery, preterm birth, pre-eclampsia, and eclampsia. Outcomes specific for studies on anti-epileptic drugs (AEDs) included maternal AED toxicity, AED compliance, neonatal withdrawal symptoms, and neonatal haemorrhagic disease.

CONCLUSION

Embedding this core set in future clinical trials will promote the standardisation of reporting to inform clinical practice.

TWEETABLE ABSTRACT

A Delphi method identifying core outcomes for epilepsy in pregnancy. Final core set includes 31 outcomes.

Obstetric and birth outcomes in pregnant women with epilepsy: A hospital-based study

Introduction:

In addition to changes in seizure frequency, pregnant women with epilepsy (WWE) are at increased risk of complications during pregnancy or delivery. In the absence of a nationwide WWE registry, hospital-based studies may provide important information regarding current management and outcomes in these patients.

Objectives:

The aims of this study were to determine changes in seizure frequency, and pregnancy and birth outcomes among pregnant WWE.

Materials and Methods:

We conducted a retrospective review of medical records of pregnant patients with epilepsy, who obtained medical care (from 2006 to 2011) at one of the general hospitals in the North-Eastern State of Malaysia. Data were collected for seizure frequency before and during the pregnancy, concurrent medications, pregnancy complications, and neonatal outcomes.

Results:

We reviewed records of 25 patients with a total of 33 different pregnancies. All patients were treated with antiepileptic medications during their pregnancies, with 42% monotherapy and 58% polytherapy. Seizure frequency decreased in 5 (15.2%), increased in 18 (54.5%) and unchanged in 10 (30.3%) cases of pregnancies. Pregnancy complications were anemia, gestational diabetes mellitus, gestational hypertension, intrauterine growth retardation, premature rupture of membrane, and vaginal bleeding. Preterm deliveries were recorded in 11 (33.3%) infants.

Conclusion:

In our setting, many patients were being on polytherapy during their pregnancies. This underscores the need for planned pregnancies so that antiepileptic medications can be optimized prior to pregnancy.

The management of epilepsy in pregnancy at the Whittington Hospital: a retrospective audit 2004-2006 and 2007-2010

BACKGROUND

In the last maternal death enquiries report there were 14 indirect deaths due to epilepsy.

METHODS

Retrospective case-note analysis of epileptic women seen antenatally over two separate time periods were examined. Care in the routine antenatal clinic (ANC) was compared with that in the obstetric medicine clinic (OMC).

RESULTS

1st audit, 65 epileptic women seen. In OMC 14% had documented preconception counselling, 58% were on anti-epileptic drugs (AEDs). In ANC 0% had documented preconception counselling, 34% were on AEDs. 2nd audit, 88 epileptic women seen. In OMC 37.5% of women had preconception counselling, 84% were on AEDs. In ANC, 4.2% had preconception counselling, 31% were on AEDs.

CONCLUSIONS

Women seen in OMC received care more compliant with Scottish Obstetric Group and Audit Project recommendations. All women with epilepsy should be reviewed in an OMC.

Gynecologic and reproductive health concerns of adolescents using selected psychotropic medications

Psychiatric disorders are common in adolescent girls and may require chronic therapies with psychotropic medications. Antipsychotic medications and mood stabilizers have been increasingly prescribed to and widely used by adolescents for a variety of both "on" an "off" label indications. Studies on the safety and monitoring of these medications in adolescent girls have shown important potential for gynecologic and reproductive adverse effects. The objective of this article is to review the mechanisms for and management of menstrual disorders mediated by hyperprolactinemia associated with antipsychotic medications, hypothyroidism associated with lithium and quetiapine, and the independent association of polycystic ovary syndrome (PCOS) in girls using valproic acid. Beyond their susceptibility to these disruptions in the menstrual cycle, adolescent girls with psychiatric illness also have increased sexual risk behaviors. These behaviors makes it all the more important to review teratogenicity and clinically relevant contraceptive drug interactions in adolescent girls using these psychotropic medications.

Lamotrigine serum concentration in children with epilepsy

The correlation between lamotrigine serum concentration, efficacy, and toxicity in children is controversial. The database of the Clinical Pharmacology Laboratory at Assaf Harofeh Medical Center was retrospectively searched to identify lamotrigine serum concentrations in children aged 2-19 years with refractory epilepsy who received lamotrigine as monotherapy or polytherapy from 2007-2010. Data collected included age at epilepsy onset, additional antiepileptic drugs, lamotrigine dose, monthly seizure frequency before and after lamotrigine treatment, and side effects. Sixty blood samples were collected from 42 children aged 10.1 ± 4.9 years (range, 2-20 years). Seizure types included complex partial (n = 28), simple partial (n = 7), absence (n = 2), and generalized tonic-clonic (n = 23). Decreased seizure frequency was observed in 38 (63.3%) patients. No correlation with lamotrigine serum concentration was evident, but seizure frequency was significantly influenced by age and lamotrigine dose. Side effects were reported in 21 (35%) patients. Only diplopia was significantly correlated with lamotrigine serum concentration. Lamotrigine was more effective at lower doses and in older children. Lamotrigine serum concentration correlated significantly with diplopia, but not with other side effects or with clinical efficacy. Overall, lamotrigine is effective and safe in children with refractory epilepsy.

Use of topiramate in pregnancy and risk of oral clefts

OBJECTIVE

The objective of this study was to evaluate the association between the use of monotherapy topiramate in pregnancy and cleft lip with or without cleft palate (CL/P) in the offspring.

STUDY DESIGN

Data from the Slone Epidemiology Center Birth Defects Study (BDS) from 1997 to 2009 and the National Birth Defects Prevention Study (NBDPS) from 1997 to 2007 were analyzed. Conditional logistic regression was used to compare the first-trimester use of topiramate monotherapy to no antiepileptic drug use during the periconceptional period between the mothers of infants with CL/P and the mothers of controls for each study separately and in pooled data.

RESULTS

The BDS contained 785 CL/P cases and 6986 controls; the NBDPS contained 2283 CL/P cases and 8494 controls. The odds ratios (exact 95% confidence intervals) for the association between topiramate use and CL/P were 10.1 (1.1-129.2) in the BDS, 3.6 (0.7-20.0) in the NBDPS, and 5.4 (1.5-20.1) in the pooled data.

CONCLUSION

First-trimester use of topiramate may be associated with CL/P.

Obstetric outcome in women with epilepsy: a hospital-based, retrospective study

OBJECTIVE

To report the complications during pregnancy and delivery in women with epilepsy, compared with a control group without epilepsy, with special focus on potential risk factors, such as epilepsy severity and dosage of antiepileptic drugs.

DESIGN

Hospital-based retrospective study.

SETTING

Data from pregnancy notification forms and hospital case records.

POPULATION

Women with a past or present history of epilepsy (n = 205) delivered in Bergen, Norway, in the period 1999-2006, and a matched control group of women (n = 205) without epilepsy.

METHODS

Data were compared and odds ratios (ORs) with 95% confidence intervals (CIs) were calculated by multiple logistic regression models.

MAIN OUTCOME MEASURES

Pre-eclampsia (mild and severe), gestational hypertension, vaginal bleeding (early and late), caesarean section, vaginal operative delivery, postpartum haemorrhage and major malformations.

RESULTS

Women with epilepsy using antiepileptic drugs had an increased risk of severe pre-eclampsia (OR, 5.0; 95% CI, 1.3-19.9), bleeding in early pregnancy (OR, 6.4; 95% CI, 2.7-15.2), induction (OR, 2.3; 95% CI, 1.2-4.3) and caesarean section (OR, 2.5; 95% CI, 1.4-4.7) adjusted for maternal age, parity, education, smoking, medical conditions and body mass index ≥30 kg/m(2) . There was also an increased risk of malformations in the offspring (OR, 7.1; 95% CI, 1.4-36.6). Women without antiepileptic drug use had increased risks of forceps delivery and preterm birth. Active epilepsy (seizures during the last 5 years) versus nonactive epilepsy did not discriminate for any of these complications; 84.5% of women with epilepsy and antiepileptic drug use were using folate.

CONCLUSION

Women with epilepsy using antiepileptic drugs had an increased risk of pregnancy and delivery complications, whereas women not using antiepileptic drugs had few complications. Seizures, high doses of antiepileptic drugs, obesity and lack of folate could not explain these increased risks.

Anaesthesia for the obstetric patient with (non-obstetric) systemic disease

The number of women with serious (non-obstetric) systemic diseases achieving pregnancy and requiring obstetric anaesthetic management is increasing. The conditions that are most likely to cause maternal morbidity and mortality are cardiac disease, respiratory disease, neuromuscular disease, haematological disease, connective and metabolic diseases and psychiatric conditions including substance abuse. This article discusses the anaesthetic management of the pregnant mother with such serious systemic diseases.

Management of antipsychotic and mood stabilizer medication in pregnancy: recommendations for antenatal care

The aim of the present study was to develop recommendations for antenatal care and monitoring for women with bipolar disorder and schizophrenia who are on lithium carbonate, antipsychotic or anti-epileptic medication during pregnancy. A literature search and review of original research, published reviews and guidelines was undertaken for mood stabilizers and antipsychotics in pregnancy and for the management of bipolar disorder and schizophrenia in pregnancy. This information was summarized, condensed and then reviewed by representatives of psychiatry, pharmacy, paediatrics and obstetrics to produce an information booklet and subsequently monitoring recommendations and tables. A model of antenatal monitoring and care for women with schizophrenia, bipolar disorder and related disorders who are maintained on psychotropic medication was developed. This included an online and published booklet for clinicians summarizing psychotropic medication in pregnancy, and lactation and monitoring tables that could be part of patient case files. These were to assist in reminding and educating staff on the need for additional monitoring and assessment above standard antenatal care for women on mood stabilizers and antipsychotic medication. Women with bipolar disorder and schizophrenia have an increased risk of complications in pregnancy from their illness and from the medications they are prescribed. A summary of the risks and a model of suggested additional monitoring during pregnancy have been developed in consultation across a number of clinical disciplines.