FERTILITY IN WOMEN WITH ACTIVE EPILEPSY

Management of epilepsy during pregnancy and lactation

Epilepsy is a group of neurological diseases characterized by susceptibility to recurrent seizures. Antiseizure medications (ASMs) are the mainstay of treatment, but many antiseizure medications with variable safety profiles have been approved for use. For women with epilepsy in their childbearing years, the safety profile is important for them and their unborn children, because treatment is often required to protect them from seizures during pregnancy and lactation. Since no large randomized controlled trials have investigated safety in this subgroup of people with epilepsy, pregnancy registries, cohort and case-control studies from population registries, and a few large prospective cohort studies have played an important role. Valproate, in monotherapy and polytherapy, has been associated with elevated risk of major congenital malformations and neurodevelopmental disorders in children born to mothers who took it. Topiramate and phenobarbital are also associated with elevated risks of congenital malformations and neurodevelopmental disorders, though the risks are lower than those of valproate. Lamotrigine and levetiracetam are relatively safe. Insufficient data exist to reach strong conclusions about the newest antiseizure medications such as eslicarbazepine, perampanel, brivaracetam, cannabidiol, and cenobamate. Besides antiseizure medications, other treatments such as vagal nerve stimulation, responsive neurostimulation, and deep brain stimulation are likely safe. In general, breastfeeding does not appear to add any additional long term risks to the child. Creative ways of optimizing registry enrollment and data collection are needed to enhance patient safety.

Antiepileptic Drugs Usage in Pregnant Women with Epilepsy in Saudi Arabia

Background and Purpose

Epilepsy is one of the most common neurological disorders requiring continuous treatment during pregnancy. In Saudi Arabia, there is only one publication that studied the outcome of pregnancies in women with epilepsy, published in 1999. The aim of the study is to determine the major congenital malformations in infants resulting from exposure to antiepileptic drugs in pregnant women with epilepsy.

Methods

This is a retrospective observational study that was conducted at King Abdulaziz Medical City, Jeddah, Saudi Arabia, involving pregnant women with epilepsy using antiepileptic drugs during pregnancy. We also studied babies born to those mothers. The study period was 5 years from 2014 to 2018.

Results

Six hundred babies were included in the study, born to 154 mothers with epilepsy using antiepileptic drugs during pregnancy. In addition, there were 111 losses of fetuses before 20 weeks of gestation. The only malformation detected was a ventricular septal defect in one child, whose mother was using polytherapy (valproic acid and levetiracetam). Three babies were born with epilepsy, and four babies had other associated disorders (Down syndrome, osteoporosis, esotropia, and hearing impairment).

Conclusions

The results of this small study are an urgent call for the establishment of congenital malformations registry in Saudi Arabia. In addition, specialized epilepsy clinics utilizing multidisciplinary care are highly recommended. A specific group of interest for such clinics are married women, who have epilepsy and are using antiepileptic drugs since planning of pregnancy is not part of the culture in Saudi Arabia.

Infertility, impaired fecundity, and live birth/pregnancy ratio in women with epilepsy in the USA: Findings of the Epilepsy Birth Control Registry

OBJECTIVE

To determine the current risks of infertility and impaired fecundity as well as the live birth/pregnancy ratio among women with epilepsy (WWE) in the USA and whether antiepileptic drug (AED) use is a factor.

METHODS

These retrospective survey data come from the 2010-2014 Epilepsy Birth Control Registry (EBCR) Web-based survey of 1000 WWE in the USA, aged 18-47 years, who provided demographic, epilepsy, AED, reproductive, and contraceptive data. We report risks of infertility and impaired fecundity, live birth/pregnancy ratio, and whether outcomes differ by AED use or category versus No AED.

RESULTS

A total of 978 of the 1000 USA WWE reported reproductive data; 373 WWE had 724 pregnancies and 445 births. An additional 38 WWE (9.2%, 95% confidence interval [CI] = 6.7-12.4%) tried to conceive but were infertile. A total of 72.5% had a live birth outcome for their first pregnancy, 89.0% had at least one live birth for their first two pregnancies, and 61.6% had two live births for their first two pregnancies. Eighty-four of 406 WWE (20.7%, 95% CI = 17.0-2.9%) had impaired fecundity. The risk of impaired fecundity trended higher on AED polytherapy than on No AED (risk ratio [RR] = 1.79, 95% CI = 0.94-3.11, P = .08). The ratio of live birth/unaborted pregnancy (445/594, 74.9%) was similar among WWE on No AED (71.3%), AED monotherapy (71.8%), and polytherapy (69.7%). None of the AED categories differed significantly from No AED. Note that glucuronidated AED (lamotrigine), which had the highest ratio of live birth/pregnancy (89.1%), compared favorably to enzyme-inhibiting AED (valproate), which had the lowest (63.3%; RR = 1.41, 95% CI = 1.05-1.88, P = .02).

SIGNIFICANCE

The EBCR finds 9.2% infertility risk and 20.7% impaired fecundity risk among WWE in the USA. Impaired fecundity trended higher on AED polytherapy than on No AED. Live birth/pregnancy ratio was higher with the use of lamotrigine than valproate. These findings may provide WWE a more objective basis for pregnancy planning.

Evaluation of a Decision Aid for Women with Epilepsy Who Are Considering Pregnancy: A Randomized Controlled Trial

BACKGROUND

For many women with epilepsy (WWE), decision making about pregnancy is complicated by considerations such as the potential teratogenicity of antiepileptic drugs, offspring risk of epilepsy, seizure occurrence during pregnancy, and the challenges of parenting amidst poorly controlled seizures.

OBJECTIVE

This proof-of-concept, randomized controlled trial aimed to evaluate a decision aid (DA) developed to help WWE decide if they should start or enlarge their families.

METHODS

Seventy-nine WWE of childbearing age were recruited from Epilepsy Action Australia between October and November 2013 and randomized to receive the intervention (the DA) or not, and to complete a set of questionnaires pre- and post- intervention. The DA, delivered as a PDF booklet, provided balanced evidence-based information about options, risks and benefits, including probabilities; as well as steps for clarifying values and considering options within one's personal situation.

RESULTS

Compared with the control group, the DA group had statistically significant improvements in knowledge about pregnancy and epilepsy (Cohen's d = 1.24; 95%CI = 0.77 to 1.83) and reduced decisional conflict (Cohen's d = 0.59; 95%CI = 0.21 to 0.99). Changes in decision self-efficacy, certainty of choice, patient-practitioner communication abilities and value congruence with choice were comparable between the DA and control group. Importantly, women's decisions about motherhood were not biased towards either direction, and there were no adverse effects on depression or anxiety. All women who received the DA indicated they would recommend it to other WWE.

CONCLUSIONS

The DA has the potential to serve as a useful support tool for WWE who are considering motherhood. Future research is needed to test the DA in clinical settings with guidance from a health professional. The trial was registered with the Australian New Zealand Clinical Trials Registry (ID ACTRN12613001082796).

Age-specific birth rates in women with epilepsy: a population-based study

OBJECTIVE

The aim of this study was to investigate birth rates and use of hormonal contraception in different age groups among women with epilepsy (WWE) in comparison to women without epilepsy.

MATERIALS AND METHODS

Demographic data and medical information on more than 25,000 pregnant women (40,000 births), representing 95% of all pregnancies in Oppland County, Norway, were registered in the Oppland Perinatal Database in the period 1989-2011. Data were analyzed with respect to epilepsy diagnoses, and 176 women with a validated epilepsy diagnosis (303 pregnancies) were identified. Age-specific birth rates in these women were estimated and compared with age-specific birth rates in women without epilepsy in the same county.

RESULTS

In WWE over 25 years of age, birth rates were significantly lower than in those of the same age group without epilepsy. In women below 20 years of age, birth rates were similar in those with and without epilepsy. The use of hormonal contraceptives prior to pregnancy was lower among WWE under 25 years than in the corresponding age group without epilepsy.

CONCLUSIONS

Health professionals who counsel WWE who are of fertile age should be aware of the strongly reduced birth rates in WWE over 25 years of age, and the lower rates of use of contraceptives among young WWE.

Pregnancy and epilepsy

PURPOSE OF REVIEW

This review encompasses issues regarding the management of women with epilepsy and pregnancy, including preconception planning, antiepileptic drug (AED) effects on the exposed offspring, and consequences of seizures during pregnancy, with an emphasis on counseling points and risk management.

RECENT FINDINGS

In utero valproate exposure continues to show the highest risk of congenital malformations and of adverse cognitive outcomes, including autism, compared to other AEDs. In utero topiramate exposure is associated with facial clefts. In utero exposure to lamotrigine, carbamazepine, phenytoin, and levetiracetam has been evaluated in large numbers of offspring, and all of these AEDs have a low risk of major congenital malformations, near 2.5%. The risk of major congenital malformations due to in utero AED exposure is dose associated. Folic acid taken at the time of conception decreases the risk of adverse cognitive outcomes. AED polytherapy may adversely affect fertility, and in utero exposure of AED polytherapy is associated with infants who are small for their gestational age. Seizure freedom before pregnancy is a good predictor of remaining seizure free during pregnancy.

SUMMARY

Counseling points are complex for managing women with epilepsy contemplating pregnancy, including evaluation of AED choice and dose. The physician must have knowledge of the issues to enable an honest discussion and appropriate decision making in partnership with the patient.

Infertility treatment and umbilical cord length-novel markers of childhood epilepsy?

Background

Epilepsy is one of the most common neurologic disorders of childhood, affecting about 0.4−0.8% of all children up to the age of 20.

Methodology

A population-based retrospective cohort study. Aim was to determine incidence and identify perinatal and reproductive risk factors of epilepsy in children born between 1989 and 2008 among women (n = 43,389) delivered in Kuopio University Hospital. Risk factors of childhood epilepsy were determined by using logistic regression analysis.

Principal Findings

The incidence of childhood epilepsy was 0.7% (n = 302 of 43,389). Maternal epilepsy, major congenital anomalies and use of assisted reproductive technology (ART) were associated with 4.25-, 3.61-, and 1.67- fold increased incidence of childhood epilepsy. A 10 cm increase in umbilical cord length was associated with a 15% decrease in the incidence of epilepsy (adjusted OR 0.85, 95% CI 0.78−0.94). However, the above reproductive factors accounted for less than 2% of total incidence, whereas maternal epilepsy proved to be the highest risk factor.

Conclusions

Perinatal and reproductive factors were shown to be minor risk factors of childhood epilepsy, implying that little can be done in obstetric care to prevent childhood epilepsy. Infertility treatment and umbilical cord length, independent of gestational age and congenital malformations, may be novel markers of childhood epilepsy.