Management of epilepsy in women

Developmental Toxicity Study of DL-4-Hydroxy-4-Phenylhexanamide (DL-HEPB) in Rats

Antiepileptic drugs affect embryonic development when administered during pregnancy, generating severe alterations, such as as cleft lip, spina bifida, heart abnormalities, or neuronal alterations. The compound DL-4-hydroxy-4-phenylhexanamide (DL-HEPB), a phenyl alcohol amide structurally different from known anticonvulsants, has shown good anticonvulsant effects in previous studies. However, its effects on intrauterine development are unknown. So, the purpose of this study was to determine the potential of DL-HEPB to produce alterations in conceptus. Pregnant Wistar rats were orally exposed to 0, 50, 100, and 200 mg/kg of DL-HEPB during organogenesis, and their food consumption and weight gain were measured. On gestation day 21, pregnant females were euthanized to analyze the fetuses for external, visceral, and skeletal malformations. A significant decrease in food consumption and body weight was observed in mothers, without any other manifestation of toxicity. In fetuses, no external malformations, visceral, or skeletal abnormalities, were observed under the dose of 100 mg/kg, while the dose of 200 mg/kg caused malformations in low frequency in brain and kidneys. In view of the results obtained, DL-HEPB could be a good starting point for the design of new highly effective anticonvulsant agents, with much lower developmental toxicity than that shown by commercial anticonvulsants.

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.

Life-threatening complications of hyperemesis gravidarum

Hyperemesis gravidarum (HG) refers to severe nausea and emesis noted during pregnancy. However, no consensus exists on the specific diagnostic criteria that can be used for this condition. The aim of the present systematic review was to summarize the available evidence regarding the severe complications observed during HG with a heightened risk of fatality. A systematic search was conducted on PubMed, Cochrane Library, EMBASE and WILEY databases for the relevant publications regarding the severe and life-threatening complications of HG. The search terms were as follows: '(Hyperemesis gravidarum)' AND ('complications' OR 'severe' OR 'adverse pregnancy outcomes' OR 'stroke' OR 'seizures' OR 'Wernicke's encephalopathy' OR 'arrhythmias' OR 'pneumomediastinum' OR 'coagulopathy' OR 'electrolytic imbalance'). Abstracts, conference presentations, letters to the editor, studies written in languages other than English and editorials were all excluded. This search identified 43 studies analyzing life-threatening complications of HG, of which 11, seven, eight and 17 articles analyzed neurological, cardiovascular, thoracic and systemic complications, respectively. Reports on life-threatening complications were exceptionally rare in HG. The most frequent severe complications noted were Wernicke's encephalopathy, electrolyte imbalance and vitamin K deficiency. The low mortality rate for patients with HG over the last decade could be explained by the high efficiency of modern therapy, and the precise management of every complication according to current guidelines.

Obstetric outcomes and effects on babies born to women treated for epilepsy during pregnancy in a resource limited setting: a comparative cohort study

BACKGROUND

Management of epilepsy during pregnancy in a resource-limited setting (RLS) is challenging. This study aimed to assess obstetric outcomes and effects on babies of women with epilepsy (WWE) exposed to Anti-epileptic drugs (AEDs) compared to non-exposed controls in a RLS.

METHODS

Pregnant WWE were recruited from antenatal and neurology clinics of a tertiary care hospitals in Sri Lanka. Patients were reviewed in each trimester and post-partum. Medication adherence, adverse effects, seizure control and carbamazepine blood levels were monitored. Post-partum, measurements for anthropometric and dysmorphic features of the babies and congenital abnormalities were recorded. Age and sex matched babies not exposed to AED recruited as controls were also examined.

RESULTS

Ninety-six pregnant WWE were recruited (mean period of gestation 22.9 weeks). Mean age was 28 years and 48(50%) were primigravidae. Fifty percent (48) were on monotherapy, while 23.8, 15.9 and 4.1% were on two, three and four AEDs respectively. AEDs in first trimester (TM1) were carbamazepine (71%), valproate (25.8%) clobazam (29.5%), lamotrigine (7%) topiramate (5%) and others (3.4%). Sodium valproate use reduced significantly from T1 to T2(p < 0.05). Sub-therapeutic carbamazepine levels correlated positively (r = 0.547) with poor medication adherence (p = 0.009) and negatively (r = 0.306) with adverse effects (p = 0.002). Seventy-six WWE completed follow-up reporting w 75 (98.6%) live births and one T1 miscarriage (1.3%). Three (4.3%) were preterm. Majority (73.33%) were normal vaginal deliveries. Cesarean sections were not increased in WWE. Fifty-nine (61.45%) babies were examined. For those examined during infancy, 53 age and sex matched controls were recruited and examined.. Congenital abnormalities occurred in 5 (9.43%) babies of WWE [atrio-ventricular septal defect (2), renal hypoplasia (1), cryptorchidism (1), microcephaly (1)] compared to 2 (3.77%) in controls (2 microcephaly; p = 0.24). Fetal exposure to AEDs increased a risk of low birth weight (RR 2.8; p = 0.049). Anthropometric parameters of AED exposed babies were lower at birth but not statistically significant between the two groups (weight p = 0.263, length p = 0.363, occipito-frontal circumference (OFC) p = 0.307). However, weight (p = 0.009), length (p = 0.016) and OFC (p = 0.002) were significantly lower compared to controls at an average of 3.52 months.

CONCLUSION

Most pregnancies are unplanned in the RLS studied, and AEDs were altered during pregnancy. Congenital anomalies occurred at rates comparable to previous reports. Fetal exposure to AED had growth retardation in infancy compared to non-exposed babies.

Medication management of bipolar disorder during the reproductive years

The management of bipolar disorder during reproductive years is a challenge to both patient and clinician. The rapidly changing landscape of medical literature, newly available medications, and implementation of the Pregnancy and Lactation Labeling Final Rule by the Food and Drug Administration can be dizzying. This article serves as a brief, practical guide on the use of medications for the treatment of bipolar disorder before, during, and immediately after pregnancy. Special focus is devoted to the risk-benefit analysis of using potentially teratogenic medications during pregnancy. Availability and appropriateness of various contraceptive methods and folic acid supplementation in combination with mood stabilizers is also addressed. Every clinician managing bipolar disorder in adult women should be knowledgeable of family planning resources and what to do in the setting of unintended pregnancy.

Which information on women's issues in epilepsy does a community pharmacist need to know? A Delphi consensus study

OBJECTIVE

The aim of this study was to develop and achieve consensus on a core list of important knowledge items that community pharmacists should know on women's issues in epilepsy.

METHODS

This was a consensual study using a modified Delphi technique. Knowledge items were collected from the literature and from nine key contacts who were interviewed on their views on what information community pharmacists should have on women's issues in epilepsy. More knowledge items were suggested by five researchers with interest in women's issues who were contacted to rate and comment on the knowledge items collected. Two iterative Delphi rounds were conducted among a panel of pharmacists (n=30) to achieve consensus on the knowledge items to be included in the core list. Ten panelists ranked the knowledge items by their importance using the Analytical Hierarchy Process (AHP).

RESULTS

Consensus was achieved to include 68 knowledge under 13 categories in the final core list. Items ranked by their importance were related to the following: teratogenicity (10.3%), effect of pregnancy on epilepsy (7.4%), preconception counseling (10.3%), bone health (5.9%), catamenial epilepsy (7.4%), menopause and hormonal replacement therapy (2.9%), contraception (14.7%), menstrual disorders and infertility (8.8%), eclampsia (2.9%), breastfeeding (4.4%), folic acid and vitamin K (5.9%), counseling on general issues (14.7%), and sexuality (4.4%).

CONCLUSION

Using consensual knowledge lists might promote congruence in educating and/or training community pharmacists on women's issues in epilepsy. Future studies are needed to investigate if such lists can improve health services provided to women with epilepsy (WWE).

Pregnancy in epilepsy: management and delivery

We evaluated 129 epileptic pregnant women between 2014 and 2016. Demographic features of the patients, along with type and duration of epileptic seizure, time of diagnosis, date of last seizure prior to pregnancy, number and duration of seizures during pregnancy, type of antiepileptic drugs, result and week of termination of pregnancy, and birth weight were registered, and also, we evaluated perinatal complications and fetal malformations.

Rapid Quantification of Medroxyprogesterone Acetate (MPA) in Human Plasma by LC-MS/MS

BACKGROUND

Medroxyprogesterone acetate (MPA) is a common contraceptive agent taken both orally and as a subcutaneous or intramuscular injection. Current LC-MS/MS methods for MPA quantification require large sample volumes and low-throughput analytical run times. Therefore, there are opportunities to improve upon existing methods for MPA quantification.

METHODS

MPA was extracted from 600 μL plasma, evaporated to dryness, and the reconstituted solution was injected onto a Waters Acquity liquid chromatography (LC) system via an Agilent Zorbax Eclipse-Plus C18 2.1 × 50 mm (5.0 μm) column. MPA and its internal standard were monitored on a QTRAP® 5500 mass analyzer operated in positive ionization mode. The method was validated according to the Food and Drug Administration Bioanalytical Method Validation guidelines.

RESULTS

The analytical measuring range of the assay was 200-10 000 pg/mL. QC samples prepared at the lower limit of quantification (LLOQ; 200 pg/mL) and low (600 pg/mL), mid (1750 pg/mL), and high (8500 pg/mL) levels showed interassay precision and accuracy ≤15.2% and ≤±9.6%, respectively. Stability-challenged samples yielded ≤15% from freshly prepared samples. Dilutional and matrix effects studies were also acceptable. The assay was also assessed in participants prescribed depot medroxyprogesterone acetate; observed concentrations were within the dynamic range of the assay.

CONCLUSIONS

An LC-MS/MS method for the quantification of MPA in plasma has been developed and validated. The described method is sufficiently sensitive and robust to quantify MPA in plasma and meets the criteria to support clinical trials.

Margiad Evans (1909-1958): a history of epilepsy in a creative writer

The author Margiad Evans (1909-1958), a celebrated Anglo-Welsh writer of the 1930s and 1940s, developed epilepsy in 1950, and subsequently wrote accounts of her experiences of seizures, their diagnosis, and their management. These documents are among the first patient accounts of epilepsy, and remain of value today, not least because they prefigure ongoing problems in epilepsy management such as pregnancy and the adverse effects of antiepileptic drugs. They also give some insights into the consequences of epilepsy for a creative writer.

[Treatment of epilepsy]

Epilepsy is a chronic neurological disorder that affects one million people in Japan. Medical treatment is highly effective for this disorder. The antiepileptic treatment brings 70% of the patients to seizure freedom. Current guidelines recommend carbamazepine for partial (focal) seizures and valproate for generalized seizures as the first-line drug; however, indivizualized drug selection in accordance to the patients' condition is mandatory. Modern antiepileptic medications have better tolerability and less dug-to-drug interaction, and some of them are waiting to be approved in Japan. Special attention is necessary for the care of woman in child-bearing age, adolescents, and elderly persons. Advances of surgical treatment of the epilepsy brought many medically intractable patients to be seizure free. Early identification of the surgical candidate is an important task for clinicians.

Pharmacokinetic interactions between contraceptives and antiepileptic drugs

The occurrence of bi-directional drug interactions between antiepileptic drugs (AEDs) and combined oral contraceptives (OCs) pose potential risks of un-intended pregnancy and as well as seizure deterioration. It is well established that several of the older AEDs (carbamazepine, phenytoin and phenobarbital), are strong inducers of the hepatic cytochrome P450 (CYP) 3A4 enzyme system, and are associated with increased the risk of contraceptive failure. In addition, it is demonstrated that also some of the newer AEDs, oxcarbazepine and topiramate influence on the pharmacokinetics of OCs, which is thought to be due to a more selective induction of subgroups of the hepatic enzyme system. Estrogens containing OCs induce the glucuronosyltransferase and may reduce the plasma levels and the effect of AEDs cleared by glucuronidation. This has been most intensively studied for lamotrigine but also other AEDs, which undergoes glucuronidation processes, such as valproate and oxcarbazepine, may be affected by OCs. The magnitude of the drug-drug interactions show in general wide inter-individual variability and the change in the elimination rate is often unpredictable and can be influenced by a number of co-variants such as co-medication of other drugs, as well as genetic and environmental factors. It is therefore recommended that change in OC use is assisted by AED monitoring whenever possible.

Effect of anti-epileptic drugs in pregnancy and teratogenesis

Epilepsy raises special concern in women during pregnancy. Antiepileptic drugs are known to induce major and minor malformations in the foetus. Aim of the study was to find an association between maternal serum alpha fetoprotein levels, foetal abnormalities and antiepileptic drugs mediated teratogenicity. Maternal serum alpha feto protein levels, kidney and liver function tests in age matched normal pregnant women and seizure free epileptic pregnant women during 12-14 weeks of gestation were estimated. Cases were subjected to ultrasonography at 11(th)-14(th) week of pregnancy and again at 20(th) week of pregnancy. maternal serum alfa feto protein was assayed by a specific Electro Chemiluminescence Immuno Assay test. There was no significant difference in kidney and liver function tests in cases as compared to controls. There were elevated levels of alpha feto protein in cases as compared to controls but this was not statistically significant. No anomalies were detected in ultrasound reports. Most women had normal full term delivery with healthy children but of low birth weight. No correlation was seen between maternal serum alfa feto protein levels and antiepileptic drug leading to teratogenesis.

Do women with epilepsy have more fear of childbirth during pregnancy compared with women without epilepsy? A case-control study

BACKGROUND

Although anxiety and depression in populations with epilepsy have been studied, no research on fear of childbirth in women with epilepsy have been conducted. The purposes of this study were to examine whether a significant difference occurred in fear of childbirth between pregnant women with epilepsy and pregnant healthy controls and to evaluate the most common fears.

METHODS

Fifty pregnant women with epilepsy and 50 pregnant women without epilepsy were assessed at a gestational age between 32 and 36 weeks of pregnancy, using two questionnaires for the measurement of fear of childbirth, an open question, and a clinical interview.

RESULTS

We found that during pregnancy, women with epilepsy experienced a significantly higher rate of fear of childbirth when compared with healthy controls, whereas after delivery, the experiences and feelings about childbirth are almost the same as those of women without epilepsy.

CONCLUSIONS

Our findings signify the importance of the assessment of the fear of childbirth, especially in women with epilepsy, and the need to offer professional and ad hoc support to those who suffer from it.

Women with epilepsy: hormonal issues from menarche through menopause

Epilepsy is a multilayered disorder complicated by numerous comorbid conditions and hormonal changes. More than 1.5 million girls and women with epilepsy face side effects that are compounded at different ages by menstruation, fertility, pregnancy, fetal health, bone health, and other health issues. Changes in hormonal balance during maturation, from menarche through menopause, affect seizure thresholds and antiepileptic drugs, and vice versa. This overview provides physicians with a background on the multiple issues relevant to women of all ages in the reproductive years, including those planning to conceive and those who are pregnant, and beyond the childbearing years.

Management of epilepsy in women of childbearing age: practical recommendations

Women with epilepsy should not be discouraged from becoming pregnant as the likelihood of having a healthy baby is very high. However, in such women, early and individualised counselling about pregnancy and contraception is essential. Ideally, pregnancies should be planned, folic acid (5 mg/day) given and antiepileptic drug (AED) treatment optimised well before conception to ensure that the lowest dosage that controls seizures is administered. When initiating AEDs in a woman of childbearing age, the most appropriate drug for the seizure type and syndrome should be chosen, although it is preferable to avoid valproate, because of a possible elevated risk of fetal malformations, when equi-effective agents are available for a given syndrome. In women who become pregnant while taking AEDs, fetal monitoring should include high-resolution ultrasonography before week 20 and measurement of serum alpha-fetoprotein levels. Amniocentesis is not routinely indicated. The measurement of blood concentrations of AEDs can be useful to ensure that the lowest possible maintenance dosage is being used, especially for those drugs whose pharmacokinetics are likely to change during pregnancy. Breastfeeding should be encouraged whatever the treatment administered.

The impact of antiepileptic drug therapy on steroidal contraceptive efficacy

Women with epilepsy face unique challenges in maintaining steroidal contraceptive efficacy because some antiepileptic drugs (AEDs) increase the rate of hepatic metabolism of contraceptive steroids, leading to higher potential for contraceptive failure in this population. Planned pregnancy is of great clinical and social importance for women with epilepsy because of the increased risk of birth defects from fetal exposure to AEDs. Current clinical guidelines for contraceptive management in women with epilepsy provide misleading information by focusing on the estrogen content of the formulation, which regulates the menstrual cycle, rather than on the progestin content of the formulation, which provides contraceptive efficacy. This article reviews studies of AED-contraceptive interaction and misconceptions about maintaining contraceptive efficacy and makes recommendations for contraceptive management in women with epilepsy who receive concomitant AED therapy.