Epilepsy in women of childbearing age

Temporary hidden aneurysms during pregnancy. A case report

SUMMARY

There are a number of reports on cerebral aneurysmal ruptures during pregnancy. Although the cerebral aneurysmal rupture is quite rare during pregnancy, it leads to a high maternal mortality; which gives rise to a clinical significance. We have encountered a number of multiple cerebral aneurysms during pregnancy, and the ruptured cases were successfully treated with the coiling procedures. The coiling is found to be a good treatment method for ruptured aneurysms during pregnancy. The cerebral angiogram is the gold standard diagnostic method for detecting cerebral aneurysms. However, 1.8-20% of the cases are reported to be false negative in initial angiography, and only up to 20% can be diagnosed even with the additional angiographies.A special attention for a hidden aneurysm should also be required while managing the patients.

Practices of epilepsy during pregnancy: a survey of Canadian neurologists

The optimal management of epilepsy in epileptic pregnancies remains controversial. We surveyed all neurologists in Canada to determine their usual practice in managing epilepsy during pregnancy. We identified 436 neurologists in the 1990 edition of the Canadian Handbook of Medical and Surgical Specialists. We mailed a questionnaire enquiring with respect to details of management of epilepsy during pregnancy to all neurologists; in the case of nonrespondents, a follow-up questionnaire was mailed eight weeks later. We achieved a 65% response rate. We found that carbamazepine was the antiepileptic drug of first choice for the management of epilepsy during pregnancy among the majority of neurologists (75%), while phenobarbital (10%) and phenytoin (11%) were recommended much less frequently. Eight percent of respondents never used polytherapy during pregnancy. Despite recent controversy over the reproductive safety of carbamazepine, monotherapy with carbamazepine is regarded by the vast majority of Canadian neurologists as the therapy of first choice for epilepsy during pregnancy.

Anticonvulsants in pregnancy

OBJECTIVE

To review the potential problems and their management associated with the use of anticonvulsant drugs during pregnancy.

DATA SOURCES

Studies published between 1968 and 1990 assessing the effect of pregnancy on the pharmacokinetics of anticonvulsant drugs, the teratogenicity of anticonvulsants, breast feeding and anticonvulsants and use of the oral contraceptive pill in patients taking anticonvulsant medication, were reviewed.

RESULTS OF DATA SYNTHESIS

In general, plasma levels fall during pregnancy and rise during the puerperium. A number of factors including possible reduced absorption, increased volume of distribution, reduced protein binding, increased clearance and noncompliance, contribute to this fall in plasma concentration. All anticonvulsants are potentially teratogenic. The incidence of fetal malformations is higher in patients treated with multiple anticonvulsant drugs and on higher dosages with higher plasma levels. Anticonvulsants are excreted in low concentrations in breast milk. All anticonvulsants except valproic acid have been associated with failure of the oral contraceptive pill. This is due to liver enzyme induction of these drugs.

CONCLUSION

As plasma levels of anticonvulsants fall during pregnancy, concentrations should be monitored regularly. Due to the fall in protein binding, marginally low total plasma levels of highly protein bound drugs may not reflect reduced unbound levels, and hence an increase in dosage may not be required. In order to reduce teratogenicity, one should aim to use a single anticonvulsant drug and the lowest dosage able to achieve seizure control. In general, breast feeding is not contraindicated.