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Li D, Franco S, Pennell PB. The impact of pregnancy-related hormonal and physiological changes on antiseizure medications: expert perspective. Expert Rev Clin Pharmacol 2024:1-9. [PMID: 38748860 DOI: 10.1080/17512433.2024.2356617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 05/14/2024] [Indexed: 05/22/2024]
Abstract
INTRODUCTION Epilepsy is a disorder of recurrent, unprovoked seizures affecting approximately 15 million individuals of childbearing potential worldwide. Patients with epilepsy rely on regular daily therapy with antiseizure medications (ASMs). Furthermore, ASMs are also prescribed for other neuropsychiatric indications (e.g. bipolar disorder, pain, migraines) with over 2% of the pregnancies in the United States involving prenatal exposure to ASMs. AREAS COVERED ASM concentrations are affected by hormonal and physiological changes in pregnancy, including increases in renal and hepatic blood flow, decreased protein binding, and changes in enzyme activity. Clearance changes typically reverse within a few weeks after delivery. During pregnancy, many ASMs, such as lamotrigine, levetiracetam, and oxcarbazepine, should have serum concentrations monitored and doses increased to maintain the individualized target range for seizure control. ASMs metabolized via glucuronidation, primarily lamotrigine, undergo marked increases in clearance throughout pregnancy, requiring about 3-fold the pre-pregnancy daily dose by delivery. Postpartum, ASM doses are usually decreased over several weeks to prevent drug toxicity. EXPERT OPINION In the future, the development of a physiologically-based pharmacokinetic model for various ASMs may enable empiric dose adjustments in pregnancy without the difficulties of frequent therapeutic drug monitoring.
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Affiliation(s)
- Denise Li
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Susannah Franco
- Department of Pharmacy, State University of New York Downstate Health Sciences University, Brooklyn, NY, USA
| | - Page B Pennell
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Lee SK. Issues of Women with Epilepsy and Suitable Antiseizure Drugs. J Epilepsy Res 2023; 13:23-35. [PMID: 38223363 PMCID: PMC10783964 DOI: 10.14581/jer.23005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 09/12/2023] [Accepted: 12/16/2023] [Indexed: 01/16/2024] Open
Abstract
Seizure aggravation in women with epilepsy (WWE) tends to occur at two specific times during the menstrual cycle: the perimenstrual phase and the ovulation period. Antiseizure drugs (ASDs), especially those that induce enzymes, can accelerate the metabolism of hormones in oral contraceptives, rendering them less effective. Estrogen in contraceptive pills increases the metabolism of lamotrigine. Physiological changes during pregnancy can significantly impact the pharmacokinetics of ASDs, potentially necessitating adjustments in dosage for women with epilepsy to maintain seizure control. The use of valproate in pregnant women is associated with the highest risk of major congenital malformations among ASDs. Risks of major congenital malformations associated with lamotrigine, levetiracetam, and oxcarbazepine were within the range reported in the general population. Exposure to valproate can lead to lower IQ in offspring. Reduced folic acid levels are linked to orofacial clefts, cardiovascular malformations, and urogenital and limb anomalies in WWE. Decreased folate levels are expected with the use of enzyme-inducing ASDs. However, a high dose of folate was associated with an increased risk of cancer in children of mothers with epilepsy. Most ASDs are generally considered safe for breastfeeding and should be encouraged. However, no single ASD is considered ideal for childbearing WWE. Lamotrigine and levetiracetam are relatively more suitable options for this situation.
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Affiliation(s)
- Sang Kun Lee
- Department of Neurology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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Gerard EE, Meador KJ, Robalino CP, Brown CA, Matthews AG, Voinescu PE, Kalayjian LA, Gedzelman E, Hanna J, Cavitt J, Sam M, French JA, Pack AM, Hwang ST, Tsai JJ, Taylor C, Pennell PB. Initiation and Duration of Breastfeeding in the Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs Study. Neurology 2023; 101:e2266-e2276. [PMID: 37816636 PMCID: PMC10727216 DOI: 10.1212/wnl.0000000000207812] [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: 03/06/2023] [Accepted: 08/24/2023] [Indexed: 10/12/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Breastfeeding has important health benefits for both mother and child. We characterize breastfeeding initiation and duration in mothers with epilepsy relative to control mothers in a large prospective cohort. METHODS The Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs study is a prospective, multicenter observational, US cohort study. Pregnant individuals with and without epilepsy, aged 14-45 years, were enrolled between December 19, 2012, and February 11, 2016. Exclusion criteria included intelligence quotient (IQ) <70, and gestational age >20 weeks at enrollment. Breastfeeding was assessed through electronic diary and at study visits until 2 years postpartum. Odds of initiating breastfeeding was compared between cohorts using unadjusted and adjusted logistic regression models. Duration of breastfeeding was compared between cohorts using the log-rank test. RESULTS Three hundred fifty-one pregnant individuals with epilepsy and 105 pregnant controls were enrolled. Breastfeeding data were available for 325 mothers with epilepsy and 98 controls. Study cohorts were similar demographically except race (p = 0.008); 84.9% of mothers with epilepsy and 71.4% of controls were White. The mean IQ was lower in mothers with epilepsy compared with that in controls (97.7 vs 104.2, p < 0.001). Breastfeeding was initiated by 74.8% mothers with epilepsy and 88.8% controls; this difference was significant in unadjusted logistic regression (odds ratio [OR] 0.4 [95% CI 0.2, 0.7], p = 0.004), but not in adjusted model (OR 0.5 [95% CI 0.2, 1.0], p = 0.051). Factors associated with breastfeeding were higher maternal education and IQ. There was no difference in duration of breastfeeding between mothers with and without epilepsy (median duration 8.5 months vs 9.9 months, p = 0.793). Among mothers with epilepsy, both convulsive seizures and all seizures that impair awareness during pregnancy were associated with lower breastfeeding initiation (OR 0.4 [95% CI 0.2, 0.8], p = 0.013) and (OR 0.4 [95% CI 0.2, 0.8], p = 0.003, respectively). Any peripartum seizures were associated with shorter breastfeeding duration (median 6 months vs 9.7 months, [p = 0.040]). DISCUSSION Mothers with epilepsy were less likely to initiate breastfeeding compared with controls; however, this difference was not significant when controlling for maternal IQ and education level. Continuation of breastfeeding once initiated was not different between mothers with and without epilepsy. Seizure control was associated with breastfeeding initiation and duration in mothers with epilepsy. TRIAL REGISTRATION INFORMATION ClinicalTrials.gov identifier NCT01730170.
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Affiliation(s)
- Elizabeth E Gerard
- From the Northwestern University (E.E.G.), Chicago, IL; Stanford University (K.J.M.), Palo Alto, CA; The Emmes Company, LLC, (C.P.R., C.A.B., A.G.M.), Rockville, MD; Harvard University (P.E.V.), Boston, MA; University of Southern California (L.A.K.), Los Angeles, CA; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (J.H.), Minneapolis, MN; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; New York University (J.A.F.); Columbia University (A.M.P.), New York, NY; Zucker School of Medicine at Hofstra Northwell (S.T.H.), Hempsted, NY; University of Washington (J.J.T.), Seattle, WA; Geisinger Medical Center (C.T.), Danville, PA; and University of Pittsburgh (P.B.P.), PA.
| | - Kimford J Meador
- From the Northwestern University (E.E.G.), Chicago, IL; Stanford University (K.J.M.), Palo Alto, CA; The Emmes Company, LLC, (C.P.R., C.A.B., A.G.M.), Rockville, MD; Harvard University (P.E.V.), Boston, MA; University of Southern California (L.A.K.), Los Angeles, CA; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (J.H.), Minneapolis, MN; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; New York University (J.A.F.); Columbia University (A.M.P.), New York, NY; Zucker School of Medicine at Hofstra Northwell (S.T.H.), Hempsted, NY; University of Washington (J.J.T.), Seattle, WA; Geisinger Medical Center (C.T.), Danville, PA; and University of Pittsburgh (P.B.P.), PA
| | - Chelsea P Robalino
- From the Northwestern University (E.E.G.), Chicago, IL; Stanford University (K.J.M.), Palo Alto, CA; The Emmes Company, LLC, (C.P.R., C.A.B., A.G.M.), Rockville, MD; Harvard University (P.E.V.), Boston, MA; University of Southern California (L.A.K.), Los Angeles, CA; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (J.H.), Minneapolis, MN; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; New York University (J.A.F.); Columbia University (A.M.P.), New York, NY; Zucker School of Medicine at Hofstra Northwell (S.T.H.), Hempsted, NY; University of Washington (J.J.T.), Seattle, WA; Geisinger Medical Center (C.T.), Danville, PA; and University of Pittsburgh (P.B.P.), PA
| | - Carrie Anne Brown
- From the Northwestern University (E.E.G.), Chicago, IL; Stanford University (K.J.M.), Palo Alto, CA; The Emmes Company, LLC, (C.P.R., C.A.B., A.G.M.), Rockville, MD; Harvard University (P.E.V.), Boston, MA; University of Southern California (L.A.K.), Los Angeles, CA; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (J.H.), Minneapolis, MN; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; New York University (J.A.F.); Columbia University (A.M.P.), New York, NY; Zucker School of Medicine at Hofstra Northwell (S.T.H.), Hempsted, NY; University of Washington (J.J.T.), Seattle, WA; Geisinger Medical Center (C.T.), Danville, PA; and University of Pittsburgh (P.B.P.), PA
| | - Abigail G Matthews
- From the Northwestern University (E.E.G.), Chicago, IL; Stanford University (K.J.M.), Palo Alto, CA; The Emmes Company, LLC, (C.P.R., C.A.B., A.G.M.), Rockville, MD; Harvard University (P.E.V.), Boston, MA; University of Southern California (L.A.K.), Los Angeles, CA; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (J.H.), Minneapolis, MN; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; New York University (J.A.F.); Columbia University (A.M.P.), New York, NY; Zucker School of Medicine at Hofstra Northwell (S.T.H.), Hempsted, NY; University of Washington (J.J.T.), Seattle, WA; Geisinger Medical Center (C.T.), Danville, PA; and University of Pittsburgh (P.B.P.), PA
| | - P Emanuela Voinescu
- From the Northwestern University (E.E.G.), Chicago, IL; Stanford University (K.J.M.), Palo Alto, CA; The Emmes Company, LLC, (C.P.R., C.A.B., A.G.M.), Rockville, MD; Harvard University (P.E.V.), Boston, MA; University of Southern California (L.A.K.), Los Angeles, CA; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (J.H.), Minneapolis, MN; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; New York University (J.A.F.); Columbia University (A.M.P.), New York, NY; Zucker School of Medicine at Hofstra Northwell (S.T.H.), Hempsted, NY; University of Washington (J.J.T.), Seattle, WA; Geisinger Medical Center (C.T.), Danville, PA; and University of Pittsburgh (P.B.P.), PA
| | - Laura A Kalayjian
- From the Northwestern University (E.E.G.), Chicago, IL; Stanford University (K.J.M.), Palo Alto, CA; The Emmes Company, LLC, (C.P.R., C.A.B., A.G.M.), Rockville, MD; Harvard University (P.E.V.), Boston, MA; University of Southern California (L.A.K.), Los Angeles, CA; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (J.H.), Minneapolis, MN; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; New York University (J.A.F.); Columbia University (A.M.P.), New York, NY; Zucker School of Medicine at Hofstra Northwell (S.T.H.), Hempsted, NY; University of Washington (J.J.T.), Seattle, WA; Geisinger Medical Center (C.T.), Danville, PA; and University of Pittsburgh (P.B.P.), PA
| | - Evan Gedzelman
- From the Northwestern University (E.E.G.), Chicago, IL; Stanford University (K.J.M.), Palo Alto, CA; The Emmes Company, LLC, (C.P.R., C.A.B., A.G.M.), Rockville, MD; Harvard University (P.E.V.), Boston, MA; University of Southern California (L.A.K.), Los Angeles, CA; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (J.H.), Minneapolis, MN; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; New York University (J.A.F.); Columbia University (A.M.P.), New York, NY; Zucker School of Medicine at Hofstra Northwell (S.T.H.), Hempsted, NY; University of Washington (J.J.T.), Seattle, WA; Geisinger Medical Center (C.T.), Danville, PA; and University of Pittsburgh (P.B.P.), PA
| | - Julie Hanna
- From the Northwestern University (E.E.G.), Chicago, IL; Stanford University (K.J.M.), Palo Alto, CA; The Emmes Company, LLC, (C.P.R., C.A.B., A.G.M.), Rockville, MD; Harvard University (P.E.V.), Boston, MA; University of Southern California (L.A.K.), Los Angeles, CA; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (J.H.), Minneapolis, MN; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; New York University (J.A.F.); Columbia University (A.M.P.), New York, NY; Zucker School of Medicine at Hofstra Northwell (S.T.H.), Hempsted, NY; University of Washington (J.J.T.), Seattle, WA; Geisinger Medical Center (C.T.), Danville, PA; and University of Pittsburgh (P.B.P.), PA
| | - Jennifer Cavitt
- From the Northwestern University (E.E.G.), Chicago, IL; Stanford University (K.J.M.), Palo Alto, CA; The Emmes Company, LLC, (C.P.R., C.A.B., A.G.M.), Rockville, MD; Harvard University (P.E.V.), Boston, MA; University of Southern California (L.A.K.), Los Angeles, CA; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (J.H.), Minneapolis, MN; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; New York University (J.A.F.); Columbia University (A.M.P.), New York, NY; Zucker School of Medicine at Hofstra Northwell (S.T.H.), Hempsted, NY; University of Washington (J.J.T.), Seattle, WA; Geisinger Medical Center (C.T.), Danville, PA; and University of Pittsburgh (P.B.P.), PA
| | - Maria Sam
- From the Northwestern University (E.E.G.), Chicago, IL; Stanford University (K.J.M.), Palo Alto, CA; The Emmes Company, LLC, (C.P.R., C.A.B., A.G.M.), Rockville, MD; Harvard University (P.E.V.), Boston, MA; University of Southern California (L.A.K.), Los Angeles, CA; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (J.H.), Minneapolis, MN; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; New York University (J.A.F.); Columbia University (A.M.P.), New York, NY; Zucker School of Medicine at Hofstra Northwell (S.T.H.), Hempsted, NY; University of Washington (J.J.T.), Seattle, WA; Geisinger Medical Center (C.T.), Danville, PA; and University of Pittsburgh (P.B.P.), PA
| | - Jacqueline A French
- From the Northwestern University (E.E.G.), Chicago, IL; Stanford University (K.J.M.), Palo Alto, CA; The Emmes Company, LLC, (C.P.R., C.A.B., A.G.M.), Rockville, MD; Harvard University (P.E.V.), Boston, MA; University of Southern California (L.A.K.), Los Angeles, CA; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (J.H.), Minneapolis, MN; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; New York University (J.A.F.); Columbia University (A.M.P.), New York, NY; Zucker School of Medicine at Hofstra Northwell (S.T.H.), Hempsted, NY; University of Washington (J.J.T.), Seattle, WA; Geisinger Medical Center (C.T.), Danville, PA; and University of Pittsburgh (P.B.P.), PA
| | - Alison M Pack
- From the Northwestern University (E.E.G.), Chicago, IL; Stanford University (K.J.M.), Palo Alto, CA; The Emmes Company, LLC, (C.P.R., C.A.B., A.G.M.), Rockville, MD; Harvard University (P.E.V.), Boston, MA; University of Southern California (L.A.K.), Los Angeles, CA; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (J.H.), Minneapolis, MN; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; New York University (J.A.F.); Columbia University (A.M.P.), New York, NY; Zucker School of Medicine at Hofstra Northwell (S.T.H.), Hempsted, NY; University of Washington (J.J.T.), Seattle, WA; Geisinger Medical Center (C.T.), Danville, PA; and University of Pittsburgh (P.B.P.), PA
| | - Sean T Hwang
- From the Northwestern University (E.E.G.), Chicago, IL; Stanford University (K.J.M.), Palo Alto, CA; The Emmes Company, LLC, (C.P.R., C.A.B., A.G.M.), Rockville, MD; Harvard University (P.E.V.), Boston, MA; University of Southern California (L.A.K.), Los Angeles, CA; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (J.H.), Minneapolis, MN; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; New York University (J.A.F.); Columbia University (A.M.P.), New York, NY; Zucker School of Medicine at Hofstra Northwell (S.T.H.), Hempsted, NY; University of Washington (J.J.T.), Seattle, WA; Geisinger Medical Center (C.T.), Danville, PA; and University of Pittsburgh (P.B.P.), PA
| | - Jeffrey J Tsai
- From the Northwestern University (E.E.G.), Chicago, IL; Stanford University (K.J.M.), Palo Alto, CA; The Emmes Company, LLC, (C.P.R., C.A.B., A.G.M.), Rockville, MD; Harvard University (P.E.V.), Boston, MA; University of Southern California (L.A.K.), Los Angeles, CA; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (J.H.), Minneapolis, MN; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; New York University (J.A.F.); Columbia University (A.M.P.), New York, NY; Zucker School of Medicine at Hofstra Northwell (S.T.H.), Hempsted, NY; University of Washington (J.J.T.), Seattle, WA; Geisinger Medical Center (C.T.), Danville, PA; and University of Pittsburgh (P.B.P.), PA
| | - Cora Taylor
- From the Northwestern University (E.E.G.), Chicago, IL; Stanford University (K.J.M.), Palo Alto, CA; The Emmes Company, LLC, (C.P.R., C.A.B., A.G.M.), Rockville, MD; Harvard University (P.E.V.), Boston, MA; University of Southern California (L.A.K.), Los Angeles, CA; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (J.H.), Minneapolis, MN; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; New York University (J.A.F.); Columbia University (A.M.P.), New York, NY; Zucker School of Medicine at Hofstra Northwell (S.T.H.), Hempsted, NY; University of Washington (J.J.T.), Seattle, WA; Geisinger Medical Center (C.T.), Danville, PA; and University of Pittsburgh (P.B.P.), PA
| | - Page B Pennell
- From the Northwestern University (E.E.G.), Chicago, IL; Stanford University (K.J.M.), Palo Alto, CA; The Emmes Company, LLC, (C.P.R., C.A.B., A.G.M.), Rockville, MD; Harvard University (P.E.V.), Boston, MA; University of Southern California (L.A.K.), Los Angeles, CA; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (J.H.), Minneapolis, MN; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; New York University (J.A.F.); Columbia University (A.M.P.), New York, NY; Zucker School of Medicine at Hofstra Northwell (S.T.H.), Hempsted, NY; University of Washington (J.J.T.), Seattle, WA; Geisinger Medical Center (C.T.), Danville, PA; and University of Pittsburgh (P.B.P.), PA
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Reitan Riibe S, Heitmann K, Schjøtt J, Riedel B. Healthcare professionals' information need related to antiseizure medication use in breastfeeding patients with epilepsy. Retrospective analysis of enquiries to Norwegian medicines information and pharmacovigilance centers. Epilepsy Behav Rep 2023; 24:100629. [PMID: 37954010 PMCID: PMC10632412 DOI: 10.1016/j.ebr.2023.100629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 10/19/2023] [Accepted: 10/22/2023] [Indexed: 11/14/2023] Open
Abstract
Background Safety information of antiseizure medication (ASM) during breastfeeding is scarce and conflicting. We aimed to identify characteristic traits of safety concerns among healthcare professionals by reviewing enquiries to the Norwegian Regional Medicines Information and Pharmacovigilance Centres (RELIS). Method Enquiries related to breastfeeding, epilepsy, and ASM identified by their ATC-numbers were retrieved from the RELIS database of question-and-answer pairs (QAPs) by combining indexed and Boolean database searches and manual inspection. 112 QAPs were analyzed retrospectively using descriptive statistics. Results Hospital-employed physicians and nurses were puzzled by ambiguous or conflicting drug information advice and called for general information about the compatibility of an ASM with breastfeeding, mainly related to lamotrigine and levetiracetam. Other enquiries were related to co-medication with other drugs, mainly antidepressants. Half of the enquiries were posed after birth, 12 of these motivated by suspected adverse events in the infants. Conclusion Healthcare professionals with acknowledged high competence in the topic were uncertain about the prevailing safety information of ASM during breastfeeding. The fear to harm the infant may lead to the decision not to recommend breastfeeding. Future information strategies should aim to reach these professions, and support their information need on this topic.
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Affiliation(s)
- Sunniva Reitan Riibe
- Department of Clinical Science, University of Bergen, 5021 Bergen, Norway
- Sandnessjøen Helgeland Hospital, Prestmarkveien 1, 8800 Sandnessjøen, Norway
| | - Kristine Heitmann
- Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, 5021 Bergen, Norway
- Regional Medicines Information and Pharmacovigilance Centre (RELIS Vest), Haukeland University Hospital, 5021 Bergen, Norway
| | - Jan Schjøtt
- Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, 5021 Bergen, Norway
- Regional Medicines Information and Pharmacovigilance Centre (RELIS Vest), Haukeland University Hospital, 5021 Bergen, Norway
| | - Bettina Riedel
- Department of Clinical Science, University of Bergen, 5021 Bergen, Norway
- Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, 5021 Bergen, Norway
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Hope OA, Harris KM. Management of epilepsy during pregnancy and lactation. BMJ 2023; 382:e074630. [PMID: 37684052 DOI: 10.1136/bmj-2022-074630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/10/2023]
Abstract
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.
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Affiliation(s)
- Omotola A Hope
- Houston Methodist Sugarland Neurology Associates, Houston, TX, USA
| | - Katherine Mj Harris
- Department of Neurology, McGovern Medical School at UTHealth, Houston, TX, USA
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Uguz F, Sharma V, Boyce P, Clark CT, Galbally M, Koukopoulos A, Marsh W, Stevens A, Viguera A. Prophylactic Management of Women With Bipolar Disorder During Pregnancy and the Perinatal Period: Clinical Scenario-Based Practical Recommendations From A Group of Perinatal Psychiatry Authors. J Clin Psychopharmacol 2023; 43:434-452. [PMID: 37683233 DOI: 10.1097/jcp.0000000000001740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Abstract
ABSTRACT Many women with bipolar disorder experience episodes of illness or relapses over the perinatal period, especially in the immediate postpartum period. Risks associated with treated/untreated psychopathologies and fetal exposure to bipolar medications make the management of bipolar disorder during these periods challenging for clinicians and patients. In light of the available effectiveness and reproductive safety data, the current clinical update based on the opinions of a group of international perinatal psychiatry authors recommends general considerations and specific management strategies for each possible clinical scenario, including mixed features, predominant polarity, diagnosis of subtypes of bipolar disorder, severity of previous episodes, and risk of recurrence of mood episodes.
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Affiliation(s)
- Faruk Uguz
- From the Department of Psychiatry, Meram Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Verinder Sharma
- Schulich School of Medicine and Dentistry, The University of Western Ontario; Lawson Health Research Institute; Parkwood Institute Mental Health, Perinatal Mental Health Clinic, London Health Sciences Center, London, Ontario, Canada
| | - Philip Boyce
- Westmead Institute of Medical Research, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Crystal T Clark
- Department of Psychiatry and Behavioral Sciences and Obstetrics and Gynecology, Northwestern Feinberg School of Medicine, Chicago, IL
| | - Megan Galbally
- Department of Psychiatry, School of Clinical Sciences, Monash University, Melbourne, Australia
| | - Alexia Koukopoulos
- University Hospital Policlinico Umberto I, La Sapienza University of Rome; Centro Lucio Bini, Rome, Italy
| | - Wendy Marsh
- Department of Psychiatry, University of Massachusetts Medical School/UMass Memorial Medical Center, Worcester, MA.
| | - Anja Stevens
- Centre for Bipolar Disorders, Dimence Group, Deventer, the Netherlands; Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Psychiatry, the Netherlands
| | - Adele Viguera
- Cleveland Clinic, Cleveland Clinic Neurological Institute, Cleveland, OH
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Sokou R, Parastatidou S, Iliodromiti Z, Lampropoulou K, Vrachnis D, Boutsikou T, Konstantinidi A, Iacovidou N. Knowledge Gaps and Current Evidence Regarding Breastfeeding Issues in Mothers with Chronic Diseases. Nutrients 2023; 15:2822. [PMID: 37447149 DOI: 10.3390/nu15132822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 06/16/2023] [Accepted: 06/19/2023] [Indexed: 07/15/2023] Open
Abstract
The prevalence of chronic maternal disease is rising in the last decades in the developed world. Recent evidence indicated that the incidence of chronic maternal disease ranges from 10 to 30% of pregnancies worldwide. Several epidemiological studies in mothers with chronic diseases have mainly focused on the risk for adverse obstetric outcomes. Evidence from these studies supports a correlation between maternal chronic conditions and adverse perinatal outcomes, including increased risk for preeclampsia, cesarean section, preterm birth, and admission in the Neonatal Intensive Care Unit (NICU). However, there is a knowledge gap pertaining to the management of these women during lactation. This review aimed at summarizing the available research literature regarding breastfeeding in mothers with chronic diseases. Adjusted and evidence-based support may be required to promote breastfeeding in women with chronic diseases; however, our comprehension of breastfeeding in this subpopulation is still unclear. The literature related to breastfeeding extends in various scientific areas and multidisciplinary effort is necessary to compile an overview of current evidence and knowledge regarding breastfeeding issues in mothers with chronic diseases.
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Affiliation(s)
- Rozeta Sokou
- Neonatal Intensive Care Unit, "Agios Panteleimon" General Hospital of Nikea, 3 D.Mantouvalou Str., Nikea, 18454 Piraeus, Greece
- Neonatal Department, School of Medicine, National and Kapodistrian University of Athens, Aretaieio Hospital, 11528 Athens, Greece
| | - Stavroula Parastatidou
- Neonatal Intensive Care Unit, "Elena Venizelou" Maternity Hospital, 11521 Athens, Greece
| | - Zoi Iliodromiti
- Neonatal Department, School of Medicine, National and Kapodistrian University of Athens, Aretaieio Hospital, 11528 Athens, Greece
| | - Katerina Lampropoulou
- Neonatal Intensive Care Unit, School of Medicine, University of Ioannina, 45110 Ioannina, Greece
| | - Dionysios Vrachnis
- Endocrinology Unit, 2nd Department of Obstetrics and Gynecology, School of Medicine, National and Kapodistrian University of Athens, Aretaieio Hospital, 11528 Athens, Greece
| | - Theodora Boutsikou
- Neonatal Department, School of Medicine, National and Kapodistrian University of Athens, Aretaieio Hospital, 11528 Athens, Greece
| | - Aikaterini Konstantinidi
- Neonatal Intensive Care Unit, "Agios Panteleimon" General Hospital of Nikea, 3 D.Mantouvalou Str., Nikea, 18454 Piraeus, Greece
| | - Nicoletta Iacovidou
- Neonatal Department, School of Medicine, National and Kapodistrian University of Athens, Aretaieio Hospital, 11528 Athens, Greece
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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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9
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Yan R, Tuo J, Tai Z, Zhang H, Yang J, Yu C, Xu Z. Management of anti-seizure medications in lactating women with epilepsy. Front Neurol 2022; 13:1005890. [DOI: 10.3389/fneur.2022.1005890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 10/28/2022] [Indexed: 11/18/2022] Open
Abstract
Epilepsy is a common neurological disease. At present, there are about 70 million epilepsy patients in the world, half of them are women, and 30–40% of women with epilepsy are of childbearing potential. Patients with epilepsy who are of childbearing potential face more challenges, such as seizures caused by hormonal fluctuations and the risk of adverse effects on the mother and baby from taking anti-seizure medications (ASMs). Breast milk is one of the best gifts that a mother can give her baby, and breastfeeding can bring more benefits to the baby. Compared with healthy people, people with epilepsy have more concerns about breastfeeding because they are worried that ASMs in their milk will affect the growth and development of the baby, and they are always faced with the dilemma of whether to breastfeed after childbirth. Regarding, whether women with epilepsy can breastfeed while taking ASMs, and whether breastfeeding will adversely affect the baby is still an important topic of concern for patients and doctors. This article reviews the existing research on breastfeeding-related issues in women with epilepsy to guide clinical practice, and improve the breastfeeding compliance of women with epilepsy.
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10
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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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11
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Morbidity and rehospitalization postpartum among women with epilepsy and their infants: A population-based study. Epilepsy Behav 2022; 136:108943. [PMID: 36252288 DOI: 10.1016/j.yebeh.2022.108943] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 09/15/2022] [Accepted: 09/29/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE We compared the relative occurrence of selected pregnancy outcomes and postpartum rehospitalizations among women with and without epilepsy and their infants. Using linked vital-hospital discharge records of women with deliveries in Washington State 1987-2014, comparisons were made overall, by epilepsy type, and by time periods related to antiepileptic drug (AED) marketing changes. METHODS This population-based retrospective cohort study identified women with, and without epilepsy per diagnosis codes in the hospital discharge record from among all deliveries during 1987-2014 to examine maternal and infant outcomes, rehospitalization and mortality <2 years postpartum. Relative risks (RRs) and 95 % confidence intervals (CI) overall, and by epilepsy type were calculated using Poisson regression. We assessed the validity of epilepsy identification based on diagnosis codes by conducting a medical chart review for a sample of women. RESULTS Women with epilepsy had increased risks of preeclampsia (RR 1.23; 95 % CI 1.08-1.41) and gestational diabetes (RR 1.18; 95 % CI 1.02-1.36). Their infants had increased malformation (RR 1.23; 95 % C: 1.08-1.42) and small for gestational age (SGA, RR 1.39; 95 % CI 1.25-1.54) risks, and were nearly three times as likely to not be breastfed. Affected mothers (RR 5.25; 95 % CI 2.46-11.23) and their infants (RR 1.64, 95 % CI 1.41-1.89) required more ICU admissions during the delivery hospitalizations, and more postpartum rehospitalization, with greatest risk in the first six months. Maternal mortality < 2 years after delivery was increased (RR 7.11; 95 % CI 2.47-20.49). Increased risks were observed for all epilepsy subtypes for nearly all outcomes examined. Risks of preterm delivery and low birthweight increased over time (p <.05). Suggestive, but not statistically significant temporal decreases in risks of gestational diabetes and malformations and increased risk of preterm labor were noted. We observed high sensitivity of diagnosis codes for identifying pregnant women with epilepsy. CONCLUSION These population-based results emphasize the need for frequent postpartum monitoring of women with epilepsy. Increases in risks of low birthweight and preterm delivery over time are of concern. Possible temporal changes in other outcomes warrant further investigation.
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12
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Al-Faraj AO, Pang TD. Breastfeeding recommendations for women taking anti-seizure medications. Epilepsy Behav 2022; 136:108769. [PMID: 35690572 DOI: 10.1016/j.yebeh.2022.108769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/13/2022] [Accepted: 05/23/2022] [Indexed: 12/14/2022]
Abstract
The literature regarding breastfeeding and effects of anti-seizure medication (ASM) exposure on the breastfed infant has been evolving rapidly over the last decade as new studies advance our understanding of the extent of medication exposure via breastfeeding and the long-term developmental outcomes of breastfed infants. Currently, strong evidence supports the safety of breastfeeding for women with epilepsy (WWE) taking most prescribed ASMs. In this review, we present a comprehensive overview of the data regarding ASM exposure in breastfed infants and neurodevelopmental outcomes in breastfed infants of mothers taking various ASMs. In addition, we present current breastfeeding recommendations and the reported adverse effects of various ASMs to facilitate decision making in the clinical care of WWE.
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Affiliation(s)
- Abrar O Al-Faraj
- Boston Medical Center, Boston University School of Medicine, United States.
| | - Trudy D Pang
- Beth Israel Deaconess Medical Center, Harvard Medical School, United States.
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13
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Shi X, Wang Y, Zhang Y, Song C, Jiang Y, Zhao J, Xia L, Ma L, Jiang W. Effects of antiepileptic drugs polytherapy on pregnancy outcomes in women with epilepsy: An observation study in northwest China. Epilepsy Behav 2022; 135:108904. [PMID: 36095876 DOI: 10.1016/j.yebeh.2022.108904] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 08/01/2022] [Accepted: 08/26/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The management of pregnant women with epilepsy (WWE) treated with antiepileptic drugs (AEDs) polytherapy poses a great challenge. The purpose of this study was to evaluate the major congenital malformations (MCMs) associated with AED polytherapy, to assess the impacts of polytherapy regimens on seizure control and breastfeeding, and to determine the potential predictors for pregnancy outcomes. METHODS This study was based on prospectively acquired data from a registry enrolling WWE in early pregnancy from Feb 2010 to July 2019, in which 123 pregnancies in 110 WWE were exposed to 27 different AED combinations. RESULTS There were 123 pregnancies in 110 WWE analyzed in our study. The live birth rate was 86.2 % and the risk of MCMs was 10.4 %. Multivariate analysis indicated that prenatal exposure to phenobarbital (odds ratio [OR], 17.424; 95 %CI, 1.510-201.067; P = 0.022) and topiramate (OR, 9.469; 95 %CI, 1.149-62.402; P = 0.036) was associated with increased risk of MCMs. Valproate (OR, 4.441; 95 %CI, 1.165-16.934; P = 0.029), phenobarbital (OR, 13.636; 95 %CI, 2.146-86.660; P = 0.006) and topiramate (OR, 7.527; 95 %CI, 1.764-32.118; P = 0.006) were significantly correlated with adverse pregnancy outcomes. Among 67 pregnancies in four combinations over 10 patients, 15 (22.4 %) remained seizure free through pregnancy, seizure frequency increased in 17 (25.4 %), decreased in 24 (35.8 %) women, in 26 (38.8 %) remained unchanged. Only 23.6 % of mothers undertook exclusive breastfeeding. Planned pregnancy was the only independent factor significantly associated with decreased risk of adverse pregnancy outcomes (OR, 0.139; 95 % CI, 0.051-0.382; P < 0.001). Notably, no adverse pregnancy outcome was recorded in pregnancies exposed to the combination of lamotrigine plus levetiracetam. CONCLUSION Prenatal exposure to the combinations containing valproate, phenobarbital, or topiramate was associated with increased risk of adverse pregnant outcomes. AED-related teratogenicity may be reduced by planned pregnancy in WWE exposed to polytherapy. Our findings also suggest the combination of lamotrigine and levetiracetam seems to be most desirable to balance seizure control and fetal safety.
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Affiliation(s)
- Xiaojing Shi
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
| | - Yuanyuan Wang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
| | - Yaoyao Zhang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
| | - Changgeng Song
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
| | - Yongli Jiang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
| | - Jingjing Zhao
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
| | - Liang Xia
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
| | - Lei Ma
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
| | - Wen Jiang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
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14
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Hophing L, Kyriakopoulos P, Bui E. Sex and gender differences in epilepsy. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2022; 164:235-276. [PMID: 36038205 DOI: 10.1016/bs.irn.2022.06.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Sex and gender differences in epilepsy are important influencing factors in epilepsy care. In epilepsy, the hormonal differences between the sexes are important as they impact specific treatment considerations for patients at various life stages particularly during early adulthood with establishment of the menstrual cycle, pregnancy, perimenopause and menopause. Choice of antiseizure medication may have direct consequences on hormonal cycles, hormonal contraception, pregnancy and fetal risk of major congenital malformation. Conversely hormones whether intrinsic or extrinsically administered may have direct impact on antiseizure medications and seizure control. This chapter explores these important influences on the management of persons with epilepsy.
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Affiliation(s)
- Lauren Hophing
- Krembil Brain Institute, University Health Network, University of Toronto, Toronto, Canada
| | | | - Esther Bui
- Krembil Brain Institute, University Health Network, University of Toronto, Toronto, Canada.
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15
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The Use of Antiepileptic Drugs During Pregnancy and Fetal Outcomes. Neonatal Netw 2022; 41:226-231. [PMID: 35840331 DOI: 10.1891/nn-2021-0048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Epilepsy affects approximately 1 percent of the population and roughly 1 million women of childbearing age. Estimates suggest that 0.3-0.7 percent of pregnancies occur in women with epilepsy. Epilepsy itself increases the risk of congenital malformation and medications add to this risk. Also, approximately one-half of the use of medications for epilepsy are used for other indications, possibly increasing exposure in some women. As controlled trials with these medications are not performed during pregnancy, data has been accumulated primarily through databases and case studies. This review is intended to update the practitioner about the use and concerns of antiepileptic medications in the presnant woman and the potential effects on the fetus and neonate.
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16
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Nucera B, Brigo F, Trinka E, Kalss G. Treatment and care of women with epilepsy before, during, and after pregnancy: a practical guide. Ther Adv Neurol Disord 2022; 15:17562864221101687. [PMID: 35706844 PMCID: PMC9189531 DOI: 10.1177/17562864221101687] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 05/03/2022] [Indexed: 01/16/2023] Open
Abstract
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.
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Affiliation(s)
- Bruna Nucera
- Department of Neurology, Hospital of Merano (SABES-ASDAA), Merano-Meran, Italy
| | - Francesco Brigo
- Department of Neurology, Hospital of Merano (SABES-ASDAA), Merano-Meran, Italy
| | - Eugen Trinka
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University and Centre for Cognitive Neuroscience, Member of the ERN EpiCARE, Salzburg, Austria
| | - Gudrun Kalss
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University and Centre for Cognitive Neuroscience, Member of the ERN EpiCARE, Ignaz-Harrer-Str. 79, 5020 Salzburg, Austria
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17
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Abstract
PURPOSE OF REVIEW Seizure disorders are the most frequent major neurologic complication in pregnancy, affecting 0.3% to 0.8% of all gestations. Women of childbearing age with epilepsy require special care related to pregnancy. This article provides up-to-date information to guide practitioners in the management of epilepsy in pregnancy. RECENT FINDINGS Ongoing multicenter pregnancy registries and studies continue to provide important information on issues related to pregnancy in women with epilepsy. Valproate poses a special risk for malformations and cognitive/behavioral impairments. A few antiseizure medications pose low risks (eg, lamotrigine, levetiracetam), but the risks for many antiseizure medications remain uncertain. Although pregnancy rates differ, a prospective study found no difference in fertility rates between women with epilepsy who were attempting to get pregnant and healthy controls. During pregnancy, folic acid supplementation is important, and a dose greater than 400 mcg/d during early pregnancy (ie, first 12 weeks) is associated with better neurodevelopmental outcome in children of women with epilepsy. Breastfeeding is not harmful and should be encouraged in women with epilepsy even when they are on antiseizure medication treatment. SUMMARY Women with epilepsy should be counseled early and regularly about reproductive health. Practitioners should discuss the risks of various obstetric complications; potential anatomic teratogenicity and neurodevelopmental dysfunction related to fetal antiseizure medication exposure; and a plan of care during pregnancy, delivery, and postpartum. Women with epilepsy should also be reassured that the majority of pregnancies are uneventful.
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Affiliation(s)
- Yi Li
- Clinical Assistant Professor of Neurology and Neurological Sciences, Stanford University, Palo Alto, California
| | - Kimford J. Meador
- Stanford, University School of Medicine, Stanford Neuroscience Health, Center, 213 Quarry Rd, MC 5979, Palo Alto, CA 94304
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18
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Jędrzejczak J, Majkowska-Zwolińska B. Clinical predictors for breastfeeding initiation among women with epilepsy. Seizure 2022; 96:59-65. [DOI: 10.1016/j.seizure.2022.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 01/17/2022] [Accepted: 01/19/2022] [Indexed: 10/19/2022] Open
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19
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Scime NV, Lee S, Jain M, Metcalfe A, Chaput KH. A Scoping Review of Breastfeeding in Women with Chronic Diseases. Breastfeed Med 2021; 16:851-862. [PMID: 34319788 DOI: 10.1089/bfm.2021.0129] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Background: Approximately 10-20% of mothers have a chronic disease. Studies on breastfeeding in women with chronic disease span multiple disciplines, and these have not been collated to synthesize knowledge and identify gaps. The objective of this review was to summarize published literature on breastfeeding in women with chronic disease. Methods: We conducted a scoping review of original research and systematic reviews identified in Medline, EMBASE, and CINAHL (1990-2019) and by hand searching on women with chronic diseases reporting on at least one breastfeeding-related topic. Conference abstracts, case-studies, and studies on pregnancy-induced conditions or lactation pharmacology were excluded. Content analysis and narrative synthesis were used to analyze findings. Results: We identified 128 articles that were predominantly quantitative (80.5%), conducted in Europe or North America (65.6%), analyzed sample sizes of <200 (57.0%), and published from 2010 onward (68.8%). Diabetes (42.2%), multiple sclerosis (MS; 19.5%), and epilepsy (13.3%) were the most common diseases studied. Breastfeeding was a primary focus in approximately half (53.1%) of the articles, though definitions were infrequently reported (32.8%). The most-studied topics were breastfeeding duration/exclusivity (55.7%), reasons for feeding behavior (19.1%), and knowledge and attitudes about breastfeeding (18.3%). Less studied topics (<10% of articles each) included milk expression behaviors, breastfeeding difficulties, and feeding supports. Conclusions: Existing literature focuses primarily on diabetes or MS, and breastfeeding behaviors and outcomes. Further research examining a broader range of chronic diseases, with large sample sizes, and sufficient breastfeeding measurement detail can improve our understanding of breastfeeding disparities in this population.
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Affiliation(s)
- Natalie V Scime
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Sangmin Lee
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Mandakini Jain
- Undergraduate Medical Education Program, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Amy Metcalfe
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada.,Undergraduate Medical Education Program, Cumming School of Medicine, University of Calgary, Calgary, Canada.,Department of Obstetrics and Gynaecology, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Kathleen H Chaput
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada.,Department of Obstetrics and Gynaecology, Cumming School of Medicine, University of Calgary, Calgary, Canada
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20
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Meador KJ, Cohen MJ, Loring DW, May RC, Brown C, Robalino CP, Matthews AG, Kalayjian LA, Gerard EE, Gedzelman ER, Penovich PE, Cavitt J, Hwang S, Sam M, Pack AM, French J, Tsai JJ, Pennell PB. Two-Year-Old Cognitive Outcomes in Children of Pregnant Women With Epilepsy in the Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs Study. JAMA Neurol 2021; 78:927-936. [PMID: 34096986 DOI: 10.1001/jamaneurol.2021.1583] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Importance The neurodevelopmental risks of fetal exposure are uncertain for many antiseizure medications (ASMs). Objective To compare children at 2 years of age who were born to women with epilepsy (WWE) vs healthy women and assess the association of maximum ASM exposure in the third trimester and subsequent cognitive abilities among children of WWE. Design, Setting, and Participants The Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs (MONEAD) study is a prospective, observational, multicenter investigation of pregnancy outcomes that enrolled women from December 19, 2012, to January 13, 2016, at 20 US epilepsy centers. Children are followed up from birth to 6 years of age, with assessment at 2 years of age for this study. Of 1123 pregnant women assessed, 456 were enrolled; 426 did not meet criteria, and 241 chose not to participate. Data were analyzed from February 20 to December 4, 2020. Main Outcomes and Measures Language domain score according to the Bayley Scales of Infant and Toddler Development, Third Edition (BSID-III), which incorporates 5 domain scores (language, motor, cognitive, social-emotional, and general adaptive), and association between BSID-III language domain and ASM blood levels in the third trimester in children of WWE. Analyses were adjusted for multiple potential confounding factors, and measures of ASM exposure were assessed. Results The BSID-III assessments were analyzed in 292 children of WWE (median age, 2.1 [range, 1.9-2.5] years; 155 female [53.1%] and 137 male [46.9%]) and 90 children of healthy women (median age, 2.1 [range, 2.0-2.4] years; 43 female [47.8%] and 47 male [52.2%]). No differences were found between groups on the primary outcome of language domain (-0.5; 95% CI, -4.1 to 3.2). None of the other 4 BSID-III domains differed between children of WWE vs healthy women. Most WWE were taking lamotrigine and/or levetiracetam. Exposure to ASMs in children of WWE showed no association with the language domain. However, secondary analyses revealed that higher maximum observed ASM levels in the third trimester were associated with lower BSID-III scores for the motor domain (-5.6; 95% CI, -10.7 to -0.5), and higher maximum ASM doses in the third trimester were associated with lower scores in the general adaptive domain (-1.4; 95% CI, -2.8 to -0.05). Conclusions and Relevance Outcomes of children at 2 years of age did not differ between children of WWE taking ASMs and children of healthy women. Trial Registration ClinicalTrials.gov Identifier: NCT01730170.
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Affiliation(s)
- Kimford J Meador
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Palo Alto, California
| | - Morris J Cohen
- Pediatric Neuropsychology International, Augusta, Georgia
| | - David W Loring
- Department of Neurology, Emory University, Atlanta, Georgia
| | | | | | | | | | - Laura A Kalayjian
- Department of Neurology, University of Southern California, Los Angeles
| | | | | | | | - Jennifer Cavitt
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio
| | | | - Maria Sam
- Department of Neurology, Wake Forest University, Winston-Salem, North Carolina
| | - Alison M Pack
- Department of Neurology, Columbia University, New York, New York
| | | | - Jeffrey J Tsai
- Department of Neurology, University of Washington, Seattle
| | - Page B Pennell
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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21
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Al-Faraj AO, Pandey S, Herlihy MM, Pang TD. Factors affecting breastfeeding in women with epilepsy. Epilepsia 2021; 62:2171-2179. [PMID: 34289107 DOI: 10.1111/epi.17003] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 06/24/2021] [Accepted: 06/28/2021] [Indexed: 01/16/2023]
Abstract
OBJECTIVE This study aimed to compare rates of breastfeeding initiation and maintenance in women with epilepsy (WWE) with those of the general population and to identify factors affecting breastfeeding patterns in WWE. METHODS We retrospectively reviewed data for the following variables in pregnant WWE (n = 102) and healthy women without epilepsy (n = 112): demographic characteristics (age, race, ethnicity), epilepsy type (focal or generalized onset), antiseizure medication(s), psychiatric comorbidities, postpartum seizure control, breastfeeding counseling, and lactation consultation. Fisher exact test and logistic regression analyses were performed to compare the rates of breastfeeding initiation and continuation in pregnant WWE with those of healthy pregnant women and to determine factors associated with rates of breastfeeding initiation and maintenance. RESULTS The rate of breastfeeding initiation in WWE was significantly lower than in healthy women without epilepsy (50.9% vs. 87.6%), and WWE were less likely to maintain breastfeeding at 6 weeks (38.2%) and 3 months (36%) postpartum. Nearly half (53%) of WWE received antepartum breastfeeding counseling by their neurologists, and these women had higher odds of breastfeeding initiation and continuation (odds ratio [OR] = 2.53, 95% confidence interval [CI] = 1.14-5.72, p = .02). Postpartum consultation with a board-certified lactation consultant was associated with higher odds of breastfeeding continuation at 6 weeks (OR = 5.43, 95% CI = 1.39-27.23, p = .02) and at 3 months (OR = 4.9, 95% CI = 1.34-20.87, p = .019). Women taking levetiracetam were more likely to initiate and continue breastfeeding than those taking lamotrigine (OR = 6.22, 95% CI = 2.15-20.20, p = .001). SIGNIFICANCE The initiation rate and duration of breastfeeding were significantly lower in WWE than in healthy women without epilepsy and were significantly associated with several factors. Identification of potential barriers to breastfeeding in WWE may lead to development of intervention strategies that can improve breastfeeding rates in WWE to maximize positive health outcomes for WWE and their infants.
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Affiliation(s)
- Abrar O Al-Faraj
- Department of Neurology, Boston Medical Center, Boston, Massachusetts, USA.,Boston University School of Medicine, Boston, Massachusetts, USA
| | - Samiksha Pandey
- Boston University School of Medicine, Boston, Massachusetts, USA.,Beaumont Health-Royal Oak, Royal Oak, Michigan, USA
| | - Mary M Herlihy
- Department of Obstetrics & Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Trudy D Pang
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Abstract
Special considerations are required for women with epilepsy. These include issues such as catamenial exacerbation, concerns for contraception, teratogenesis (including both anatomical and neurodevelopmental effects), and other concerns for pregnancy complications such as increased seizures or adverse obstetric outcomes. In this manuscript, several cases are presented and discussed addressing some of the important issues in the management of women with epilepsy.
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Govindan K, Mandadi GD. Alopecia in Breastfed Infant Possibly Due to Mother Getting Valproate. Indian J Pediatr 2021; 88:519-520. [PMID: 32557138 DOI: 10.1007/s12098-020-03390-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 06/05/2020] [Indexed: 01/16/2023]
Affiliation(s)
- Karthika Govindan
- Department of Child and Adolescent Psychiatry, Asha Hospital, Hyderabad, India.
| | - Gowri Devi Mandadi
- Department of Child and Adolescent Psychiatry, Asha Hospital, Hyderabad, India
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Jędrzejczak J, Wilińska M, Kamińska E, Lauterbach R, Helwich E, Jackowska T, Nagańska E, Jacyna N, Majkowska-Zwolińska B. A position paper on breastfeeding by women with epilepsy – working group report. JOURNAL OF EPILEPTOLOGY 2020. [DOI: 10.21307/jepil-2020-005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Noe K. Further Evidence Breastfeeding by Women With Epilepsy Is Safe: Are Mothers Getting the Message? Epilepsy Curr 2020; 20:141-143. [PMID: 32550833 PMCID: PMC7281906 DOI: 10.1177/1535759720917997] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Antiepileptic Drug Exposure in Infants of Breastfeeding Mothers With
Epilepsy Birnbaum AK, Meador KJ, Karanam A, Brown C, et al. JAMA Neurology,
2019; epub. doi:10.1001/jamaneurol.2019.4443. There is limited information on infant drug exposure via breastfeeding by mothers who
are receiving antiepileptic drug therapy. Objective: To provide direct, objective information on antiepileptic drug exposure through
breast milk. Design, Setting, and Participants: This prospective cohort study was conducted between December 2012 and October 2016,
with follow-up in children until 6 years of age at 20 sites across the United
States. Data were collected via an observational multicenter investigation (Maternal
Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs) of outcomes in
pregnant mothers with epilepsy and their children. Pregnant women with epilepsy who
were aged 14 to 45 years, had pregnancies that had progressed to less than 20 weeks’
gestational age, and had measured intelligence quotient (IQ) scores of more than 70
points were enrolled and followed up through pregnancy and 9 postpartum months.
Their infants were enrolled at birth. Data were analyzed from May 2014 to August
2019. Exposures: Antiepileptic drug exposure in infants who were breastfed. Main Outcomes and Measures: The percentage of infant-to-mother concentration of antiepileptic drugs.
Antiepileptic drug concentrations were quantified from blood samples collected from
infants and mothers at the same visit, 5 to 20 weeks after birth. Concentrations of
antiepileptic drugs in infants at less than the lower limit of quantification were
assessed as half of the lower limit. Additional measures collected were the total
duration of all daily breastfeeding sessions and/or the volume of pumped breast milk
ingested from a bottle. Results: A total of 351 women (of 865 screened and 503 eligible individuals) were enrolled,
along with their 345 infants (179 female children [51.9%]; median [range] age, 13
[5-20] weeks). Of the 345 infants, 222 (64.3%) were breastfed; the data collection
yielded 164 matching infant–mother concentration pairs from 138 infants.
Approximately 49% of all antiepileptic drug concentrations in nursing infants were
less than the lower limit of quantification. The median percentage of
infant-to-mother concentration for all 7 antiepileptic drugs and 1 metabolite
(carbamazepine, carbamazepine-10,11-epoxide, levetiracetam, lamotrigine,
oxcarbazepine, topiramate, valproate, and zonisamide) ranged from 0.3% (range:
0.2%-0.9%) to 44.2% (range: 35.2%-125.3%). In multiple linear regression models,
maternal concentration was a significant factor associated with lamotrigine
concentration in infants (Pearson correlation coefficient, 0.58; P
< .001) but not levetiracetam concentration in infants. Conclusions and Relevance: Overall, antiepileptic drug concentrations in blood samples of infants who were
breastfed were substantially lower than maternal blood concentrations. Given the
well-known benefits of breastfeeding and the prior studies demonstrating no ill
effects when the mother was receiving antiepileptic drugs, these findings support
the breastfeeding of infants by mothers with epilepsy who are taking antiepileptic
drug therapy.
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Sprague J, Wisner KL, Bogen DL. Pharmacotherapy for depression and bipolar disorder during lactation: A framework to aid decision making. Semin Perinatol 2020; 44:151224. [PMID: 32199600 PMCID: PMC7214126 DOI: 10.1016/j.semperi.2020.151224] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVE Breastmilk is recommended as the exclusive source of nutrition for infants younger than 6 months due to the numerous health benefits for both infants and mothers. Although many women are prescribed medications during pregnancy and postpartum, limited data are available to assist women in weighing the benefits compared to the risks of peripartum medication use. The goals of this paper are to discuss the importance of breastmilk for the health of both the mother and infant, evaluate the impact of medication use on women's infant feeding choice, describe the transfer of drugs to breastmilk and infants, and provide a framework for clinicians to support evidence-based counseling for women treated for mood disorders. RECOMMENDATIONS We recommend early pregnancy counseling to discuss the benefits and risks of medications during breastfeeding. The Surgeon General's Call to Action (2011) highlights the short and long-term negative health effects of not providing breastmilk. Integrating recommendations from the pediatric and obstetric teams allows patients to make decisions based on evidence and reach their infant feeding goals. Databases containing summaries of research findings and pharmacologic properties of the drug of interest are an essential resource for clinicians.
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Affiliation(s)
- Jennifer Sprague
- Perinatal and Women's Mental Health Fellow, Instructor, Department of Psychiatry, Northwestern University Feinberg School of Medicine, 676N St. Clair St. Suite 1000, Chicago, IL 60611, USA
| | - Katherine L Wisner
- Norman and Helen Asher Professor of Psychiatry and Behavioral Sciences and Obstetrics and Gynecology, Director, Asher Center for the Study and Treatment of Depressive Disorders, Northwestern University Feinberg School of Medicine, 676 North Saint Clair St. Suite 1000, Chicago, IL 60611, USA
| | - Debra L Bogen
- Professor of Pediatrics, Psychiatry and Clinical and Translational Sciences, University of Pittsburgh School of Medicine, Vice Chair of Education, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Co-director of Quality and Safety, Children's Community Pediatrics, 3414 Fifth Ave, CHOB 320, Pittsburgh, PA 15213, USA.
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Bogen DL, Whalen BL. Breastmilk feeding for mothers and infants with opioid exposure: What is best? Semin Fetal Neonatal Med 2019; 24:95-104. [PMID: 30922811 DOI: 10.1016/j.siny.2019.01.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
With rare exception, breastfeeding is the optimal way to feed infants, and has special benefits for women and infants with perinatal opioid exposure. Infants breastfed and/or fed their mother's own breastmilk experience less severe opioid withdrawal symptoms, have shorter hospital stays, and are less likely to be treated with medication for withdrawal. The specific impact of mothers' milk feeding on opioid withdrawal may be related to the act of breastfeeding and associated skin-to-skin contact, qualities of breastmilk, healthier microbiome, small amounts of opioid drug in breastmilk, or a combination of these. Women with opioid use disorder face significant breastfeeding obstacles, including psychosocial, behavioral, concomitant medications, and tobacco use and thus may require high levels of support to achieve their breastfeeding goals. They often don't receive information to make informed infant feeding decisions. Hospital practices such as prenatal education, rooming-in and having a policy that minimizes barriers to breastfeeding are associated with increased breastfeeding rates.
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Affiliation(s)
- Debra L Bogen
- University of Pittsburgh School of Medicine, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, 3414 Fifth Ave, Pittsburgh, PA, 15213, USA.
| | - Bonny L Whalen
- Geisel School of Medicine at Dartmouth, Children's Hospital at Dartmouth-Hitchcock, Dartmouth-Hitchcock Medical Center, DHMC Pediatrics, One Medical Center Drive, Lebanon, NH, 03756, USA.
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Hao N, Jiang H, Wu M, Pan T, Yan B, Liu J, Mu J, Liu W, Li J, O’Brien TJ, Chen Z, Vajda F, Zhou D. Breastfeeding initiation, duration and exclusivity in mothers with epilepsy from South West China. Epilepsy Res 2017; 135:168-175. [DOI: 10.1016/j.eplepsyres.2017.06.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 06/23/2017] [Accepted: 06/29/2017] [Indexed: 01/16/2023]
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Morales Ríos O, Jasso Gutiérrez L, Talavera JO, Téllez-Rojo MM, Olivar López V, Garduño Espinosa J, Muñoz Hernández O. A comprehensive intervention for adverse drug reactions identification and reporting in a Pediatric Emergency Department. Int J Clin Pharm 2016; 38:80-7. [PMID: 26499501 DOI: 10.1007/s11096-015-0209-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 10/06/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND Physicians identify from 45.7 to 96.2 % of Adverse Drug Reactions (ADRs) in their patients, with under-reporting ranging from 6 to 100 %. In order to improve ADR reporting, several interventions have been evaluated in different studies, but not with regard to ADR identification. In addition, it is not known whether some patient characteristics might influence on ADR identification and reporting by physicians. OBJECTIVES (a) To assess the effectiveness of a comprehensive intervention directed to Emergency Department physicians and coordinated by a pharmacist in a tertiary care pediatric hospital on ADR identification and reporting. (b) To assess if some of the children’s characteristics might influence on ADR identification and reporting. Setting The Emergency Department of the Hospital Infantil de México “Federico Gómez”, which is a national pediatric institute of health in México. METHODS A Quasi-experimental, pre-post test trial was designed. During the intervention, the pharmacist gave talks on Pharmacovigilance and on the program for electronic capture of data, took part in patient visits, left reminders, improved accessibility to ADR report format and performed feedback activities. To classify and quantify correctly identified ADRs and ADRs reported to the Institutional Pharmacovigilance Center (IPC), 1136 clinical records were reviewed. The models were adjusted for patient variables. MAIN OUTCOME MEASURES Total ADRs, ADRs correctly identified by physicians, ADRs reported to the IPC by physicians. Results Before the intervention, 97 % of ADRs were correctly identified and 6.1 % reported by physicians. During the intervention, 99.6 % were correctly identified and 41.2 % were reported, and after the intervention, 99.6 and 41.7 %, respectively. Identification during the intervention showed a sevenfold increase with regard to preintervention and was maintained post-intervention. ADR reporting during the intervention showed a 14-fold increase with regard to pre-intervention and was maintained during post-intervention. CONCLUSION Physicians do identify ADRs, but fail to report them. The intervention increased ADR correct identification and reporting. The effect was maintained after the intervention.
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Mood stabilizers and antipsychotics during breastfeeding: Focus on bipolar disorder. Eur Neuropsychopharmacol 2016; 26:1562-78. [PMID: 27568278 DOI: 10.1016/j.euroneuro.2016.08.008] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 07/27/2016] [Accepted: 08/05/2016] [Indexed: 01/16/2023]
Abstract
Breast milk is considered the best source of nutrients and provides much better protection than immune modified milk. However, the postpartum period is a phase of increased risk for all women to experience psychiatric symptoms and recurrences or new episodes of bipolar disorder (BD), especially in those who have discontinued treatment. This is a systematic review of the risks and benefits of mood stabilizers and antipsychotics during breastfeeding as they relate to the health and well-being of mothers and their infants. Evidence-based treatment advice for women with BD during lactation is also provided. This systematic review has been conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. We included studies examining the exposure and the effects of antipsychotics and mood stabilizers used to treat BD on infants during breastfeeding clearly reporting the estimated amount of drug or effects on infants. The final selection included 56 studies. The available data supports the use of lithium as a possible treatment option during breastfeeding. Carbamazepine and valproic acid are also considered relatively safe. Lamotrigine can be used but at the lowest doses and considered for individual cases. Among the antipsychotics, quetiapine and olanzapine should be considered as first-line treatment options. Risperidone may be compatible with breastfeeding under medical supervision. Clozapine and amisulpiride are currently contraindicated. Long-term outcome studies evaluating the infant׳s health and psychosocial and cognitive functioning are needed.
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Altalib H, Cavazos J, Pugh MJ, Hussain A, Kelly-Foxworth P, Tran T, Krumholz A, LaFrance WC, Lopez MR, Rutecki P, Van Cott A. Providing Quality Epilepsy Care for Veterans. Fed Pract 2016; 33:26-32. [PMID: 30930614 PMCID: PMC6430519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Quality epilepsy care depends on balancing seizure control with medication adverse effects and on understanding a patient's medical history and anxieties related to the illness.
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33
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Uguz F, Sharma V. Mood stabilizers during breastfeeding: a systematic review of the recent literature. Bipolar Disord 2016; 18:325-33. [PMID: 27297617 DOI: 10.1111/bdi.12398] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 03/11/2016] [Accepted: 04/22/2016] [Indexed: 01/16/2023]
Abstract
OBJECTIVE This review examined the safety of mood stabilizers in exposed breastfed infants. METHODS PubMed was searched for English language reports between 1 January 1995 and 30 August 2015 by using combinations of key words breastfeeding, lactation, postpartum period, puerperium, mood stabilizers, lithium, lamotrigine, valproate, carbamazepine, and oxcarbazepine. Case reports, case series, and prospective or cross-sectional studies including relevant data such as relative infant dose, milk-to-plasma ratio, infant drug plasma levels, and adverse events were identified. RESULTS A total of 26 of 604 relevant reports in PubMed were included in the study. These reports included lamotrigine (122 cases in 12 reports), lithium (26 cases in five reports), carbamazepine (64 cases in five reports), valproate (nine cases in three reports), and oxcarbazepine (two cases in two reports). Of 26 reports, one report included both carbamazepine and valproate. The reports suggest that a considerable amount of lithium and lamotrigine are excreted into breast milk. There is a paucity of data on valproate and oxcarbazepine; however, the infant/maternal ratio of serum drug concentration seems to be lower in valproate exposure compared to other mood stabilizers. The incidence of adverse events in infants exposed to mood stabilizers is reported to be very low. CONCLUSIONS The current data suggest that mood stabilizers can be prescribed without any adverse events in most infants in lactating women. The available reports also suggest a low prevalence rate of laboratory abnormalities including hepatic, kidney, and thyroid functions in the infants. Additional studies examining short-term and especially long-term effects of mood stabilizers on breastfed infants are required.
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Affiliation(s)
- Faruk Uguz
- Department of Psychiatry, Meram Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Verinder Sharma
- Department of Psychiatry and Obstetrics and Gynecology, Western University, Parkwood Institute, London, ON, Canada
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Antiepileptic Medications and Breastfeeding: Better News than Expected? Epilepsy Curr 2016; 16:84-6. [DOI: 10.5698/1535-7511-16.2.84] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Abstract
Pregnancy and postpartum represent times of increased vulnerability for women with bipolar disorder, yet this condition remains under-diagnosed and under-treated. As 50 % of pregnancies are unplanned, the risks associated with the illness and the potential risks associated with treatment should be considered when a woman of reproductive age first presents for evaluation. This article reviews the epidemiology of perinatal bipolar disorder, screening recommendations, and treatment with pharmacotherapy and electroconvulsive therapy (ECT). An overview of the data in pregnancy and lactation is presented for lithium, lamotrigine, valproic acid, newer antipsychotics, and ECT. General principles of management include close monitoring in pregnancy and postpartum, careful adjustment of the treatment regimen to attenuate the risk of relapse, and avoidance of valproic acid when possible. Thoughtful consideration of these issues will minimize the risks to the mother and baby.
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Abstract
The clinical management of women with epilepsy on antiepileptic drugs (AEDs) during pregnancy presents unique challenges. The goal of treatment is optimal seizure control with minimal in utero fetal exposure to AEDs in an effort to reduce the risk of structural and neurodevelopmental teratogenic effects. This paper reviews the following key issues pertaining to women with epilepsy during pregnancy: AED pharmacokinetics; clinical management of AEDs; seizure frequency; major congenital malformation; neurodevelopmental outcomes; perinatal complications; and breast feeding.
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Affiliation(s)
- Sima I Patel
- Department of Neurology, University of Minnesota Health/MINCEP Epilepsy Care, 5775 Wayzata Blvd, Minneapolis, MN 55416, USA
| | - Page B Pennell
- Department of Neurology, Divisions of Epilepsy and Women's Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Moussa HN, Ontiveros AE, Haidar ZA, Sibai BM. Safety of anticonvulsant agents in pregnancy. Expert Opin Drug Saf 2015; 14:1609-20. [DOI: 10.1517/14740338.2015.1085503] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Epilepsy and recommendations for breastfeeding. Seizure 2015; 28:57-65. [DOI: 10.1016/j.seizure.2015.02.013] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Revised: 01/27/2015] [Accepted: 02/10/2015] [Indexed: 02/08/2023] Open
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Powell EM. Breast is still best: no harmful effects of breastfeeding in women taking antiepileptic drugs. Epilepsy Curr 2015; 15:10-2. [PMID: 25678877 PMCID: PMC4320947 DOI: 10.5698/1535-7597-15.1.10] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
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Abstract
This article reviews the necessary skills required for clinicians to make informed decisions about the use of medications in breastfeeding women. Even without specific data on certain medications, this review of kinetic principles, mechanisms of medication entry into breast milk, and important infant factors can aid in clinical decision making. In addition, the article reviews common medical conditions (eg, depression, hypertension, infections) in breastfeeding women and their appropriate treatment.
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Affiliation(s)
- Hilary Rowe
- Department of Pharmacy, Fraser Health Authority, Surrey, British Columbia, Canada
| | - Teresa Baker
- Texas Tech University School of Medicine, 1400 Coulter Street, Amarillo, Texas 79106, USA
| | - Thomas W Hale
- Texas Tech University School of Medicine, 1400 Coulter Street, Amarillo, Texas 79106, USA.
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Ahmadzai H, Tee LBG, Crowe A. Pharmacological role of efflux transporters: Clinical implications for medication use during breastfeeding. World J Pharmacol 2014; 3:153-161. [DOI: 10.5497/wjp.v3.i4.153] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2014] [Revised: 09/03/2014] [Accepted: 09/24/2014] [Indexed: 02/06/2023] Open
Abstract
The World Health Organisation recommends exclusive breastfeeding for the first six months of an infant’s life and in combination with solid food thereafter. This recommendation was introduced based on research showing numerous health benefits of breastfeeding for both the mother and the infant. However, there is always concern regarding the transfer of medications from mother to their breastfed baby via milk. Pharmacokinetic properties of a drug are usually used to predict its transferability into breast milk. Although most drugs are compatible with breastfeeding, cases of toxic drug exposure have been reported. This is thought to be due to active transport mechanisms whereby efflux transporter proteins expressed in the epithelial cells of the mammary gland actively secrete drugs into milk. An example of such efflux transporters including the breast cancer resistance protein which is strongly induced during lactation and this could result in contamination of milk with the substrates of this transporter which may place the suckling infant at risk of toxicity. Furthermore, there is little known about the substrate specificity of most efflux transporters as we have highlighted in this review. There also exists some degree of contradiction between in vivo and in vitro studies which makes it difficult to conclusively predict outcomes and drug-drug interactions.
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Bromley R, Weston J, Adab N, Greenhalgh J, Sanniti A, McKay AJ, Tudur Smith C, Marson AG. Treatment for epilepsy in pregnancy: neurodevelopmental outcomes in the child. Cochrane Database Syst Rev 2014; 2014:CD010236. [PMID: 25354543 PMCID: PMC7390020 DOI: 10.1002/14651858.cd010236.pub2] [Citation(s) in RCA: 102] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Accumulating evidence suggests an association between prenatal exposure to antiepileptic drugs (AEDs) and increased risk of both physical anomalies and neurodevelopmental impairment. Neurodevelopmental impairment is characterised by either a specific deficit or a constellation of deficits across cognitive, motor and social skills and can be transient or continuous into adulthood. It is of paramount importance that these potential risks are identified, minimised and communicated clearly to women with epilepsy. OBJECTIVES To assess the effects of prenatal exposure to commonly prescribed AEDs on neurodevelopmental outcomes in the child and to assess the methodological quality of the evidence. SEARCH METHODS We searched the Cochrane Epilepsy Group Specialized Register (May 2014), Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (2014, Issue 4), MEDLINE (via Ovid) (1946 to May 2014), EMBASE (May 2014), Pharmline (May 2014) and Reprotox (May 2014). No language restrictions were imposed. Conference abstracts from the last five years were reviewed along with reference lists from the included studies. SELECTION CRITERIA Prospective cohort controlled studies, cohort studies set within pregnancy registers and randomised controlled trials were selected for inclusion. Participants were women with epilepsy taking AED treatment; the two control groups were women without epilepsy and women with epilepsy who were not taking AEDs during pregnancy. DATA COLLECTION AND ANALYSIS Three authors (RB, JW and JG) independently selected studies for inclusion. Data extraction and risk of bias assessments were completed by five authors (RB, JW, AS, NA, AJM). The primary outcome was global cognitive functioning. Secondary outcomes included deficits in specific cognitive domains or prevalence of neurodevelopmental disorders. Due to substantial variation in study design and outcome reporting only limited data synthesis was possible. MAIN RESULTS Twenty-two prospective cohort studies were included and six registry based studies. Study quality varied. More recent studies tended to be larger and to report individual AED outcomes from blinded assessments, which indicate improved methodological quality.The developmental quotient (DQ) was lower in children exposed to carbamazepine (CBZ) (n = 50) than in children born to women without epilepsy (n = 79); mean difference (MD) of -5.58 (95% confidence interval (CI) -10.83 to -0.34, P = 0.04). The DQ of children exposed to CBZ (n = 163) was also lower compared to children of women with untreated epilepsy (n = 58) (MD -7.22, 95% CI -12.76 to - 1.67, P = 0.01). Further analysis using a random-effects model indicated that these results were due to variability within the studies and that there was no significant association with CBZ. The intelligence quotient (IQ) of older children exposed to CBZ (n = 150) was not lower than that of children born to women without epilepsy (n = 552) (MD -0.03, 95% CI -3.08 to 3.01, P = 0.98). Similarly, children exposed to CBZ (n = 163) were not poorer in terms of IQ in comparison to the children of women with untreated epilepsy (n = 87) (MD 1.84, 95% CI -2.13 to 5.80, P = 0.36). The DQ in children exposed to sodium valproate (VPA) (n = 123) was lower than the DQ in children of women with untreated epilepsy (n = 58) (MD -8.72, 95% -14.31 to -3.14, P = 0.002). The IQ of children exposed to VPA (n = 76) was lower than for children born to women without epilepsy (n = 552) (MD -8.94, 95% CI -11.96 to -5.92, P < 0.00001). Children exposed to VPA (n = 89) also had lower IQ than children born to women with untreated epilepsy (n = 87) (MD -8.17, 95% CI -12.80 to -3.55, P = 0.0005).In terms of drug comparisons, in younger children there was no significant difference in the DQ of children exposed to CBZ (n = 210) versus VPA (n=160) (MD 4.16, 95% CI -0.21 to 8.54, P = 0.06). However, the IQ of children exposed to VPA (n = 112) was significantly lower than for those exposed to CBZ (n = 191) (MD 8.69, 95% CI 5.51 to 11.87, P < 0.00001). The IQ of children exposed to CBZ (n = 78) versus lamotrigine (LTG) (n = 84) was not significantly different (MD -1.62, 95% CI -5.44 to 2.21, P = 0.41). There was no significant difference in the DQ of children exposed to CBZ (n = 172) versus phenytoin (PHT) (n = 87) (MD 3.02, 95% CI -2.41 to 8.46, P = 0.28). The IQ abilities of children exposed to CBZ (n = 75) were not different from the abilities of children exposed to PHT (n = 45) (MD -3.30, 95% CI -7.91 to 1.30, P = 0.16). IQ was significantly lower for children exposed to VPA (n = 74) versus LTG (n = 84) (MD -10.80, 95% CI -14.42 to -7.17, P < 0.00001). DQ was higher in children exposed to PHT (n = 80) versus VPA (n = 108) (MD 7.04, 95% CI 0.44 to 13.65, P = 0.04). Similarly IQ was higher in children exposed to PHT (n = 45) versus VPA (n = 61) (MD 9.25, 95% CI 4.78 to 13.72, P < 0.0001). A dose effect for VPA was reported in six studies, with higher doses (800 to 1000 mg daily or above) associated with a poorer cognitive outcome in the child. We identified no convincing evidence of a dose effect for CBZ, PHT or LTG. Studies not included in the meta-analysis were reported narratively, the majority of which supported the findings of the meta-analyses. AUTHORS' CONCLUSIONS The most important finding is the reduction in IQ in the VPA exposed group, which are sufficient to affect education and occupational outcomes in later life. However, for some women VPA is the most effective drug at controlling seizures. Informed treatment decisions require detailed counselling about these risks at treatment initiation and at pre-conceptual counselling. We have insufficient data about newer AEDs, some of which are commonly prescribed, and further research is required. Most women with epilepsy should continue their medication during pregnancy as uncontrolled seizures also carries a maternal risk.
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Affiliation(s)
- Rebecca Bromley
- Institute of Human Development, University of Manchester, 6th Floor, Genetic Medicine, St Mary's Hospital, Oxford Road, Manchester, UK, M13 9WL
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Davanzo R, Bua J, Paloni G, Facchina G. Breastfeeding and migraine drugs. Eur J Clin Pharmacol 2014; 70:1313-24. [PMID: 25217187 DOI: 10.1007/s00228-014-1748-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 08/31/2014] [Indexed: 01/16/2023]
Abstract
PURPOSE Breastfeeding women may suffer from migraine. While we have many drugs for its treatment and prophylaxis, the majority are poorly studied in breastfeeding women. We conducted a review of the most common anti-migraine drugs (AMDs) and we determined their lactation risk. METHODS For each AMD, we collected all retrievable data from Hale's Medications and Mother Milk (2012), from the LactMed database (2014) of the National Library of Medicine, and from a MedLine Search of relevant studies published in the last 10 years. RESULTS According to our review, AMDs safe during breastfeeding are as follows: low-dose acetylsalicylic acid (ASA), ibuprofen, sumatriptan, metoprolol, propranolol, verapamil, amitriptyline, escitalopram, paroxetine, sertraline, acetaminophen, caffeine, and metoclopramide. AMDs compatible with breastfeeding but warranting caution are as follows: diclofenac, ketoprofen, naproxen, most new triptans, topiramate, valproate, venlafaxine, and cyproheptadine. Finally, high-dose ASA, atenolol, nadolol, cinnarizine, flunarizine, ergotamine, methysergide, and pizotifen are contraindicated. CONCLUSIONS According to our review, the majority of the revised AMDs were assessed to be compatible with breastfeeding.
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Affiliation(s)
- Riccardo Davanzo
- Division of Neonatology, Institute for Maternal and Child Health, IRCCS "BurloGarofolo", Trieste, Italy
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New antiepileptic drugs and women. Seizure 2014; 23:585-91. [DOI: 10.1016/j.seizure.2014.05.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Revised: 05/08/2014] [Accepted: 05/10/2014] [Indexed: 12/26/2022] Open
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Meador KJ, Baker GA, Browning N, Cohen MJ, Bromley RL, Clayton-Smith J, Kalayjian LA, Kanner A, Liporace JD, Pennell PB, Privitera M, Loring DW. Breastfeeding in children of women taking antiepileptic drugs: cognitive outcomes at age 6 years. JAMA Pediatr 2014; 168:729-36. [PMID: 24934501 PMCID: PMC4122685 DOI: 10.1001/jamapediatrics.2014.118] [Citation(s) in RCA: 114] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
IMPORTANCE Breastfeeding is known to have beneficial effects, but concern exists that breastfeeding during maternal antiepileptic drug (AED) therapy may be harmful. We previously noted no adverse effects of breastfeeding associated with AED use on IQ at age 3 years, but IQ at age 6 years is more predictive of school performance and adult abilities. OBJECTIVES To examine the effects of AED exposure via breastfeeding on cognitive functions at age 6 years. DESIGN, SETTING, AND PARTICIPANTS Prospective observational multicenter study of long-term neurodevelopmental effects of AED use. Pregnant women with epilepsy receiving monotherapy (ie, carbamazepine, lamotrigine, phenytoin, or valproate) were enrolled from October 14, 1999, through April 14, 2004, in the United States and the United Kingdom. At age 6 years, 181 children were assessed for whom we had both breastfeeding and IQ data. All mothers in this analysis continued taking the drug after delivery. MAIN OUTCOMES AND MEASURES Differential Ability Scales IQ was the primary outcome. Secondary measures included measures of verbal, nonverbal, memory, and executive functions. For our primary analysis, we used a linear regression model with IQ at age 6 years as the dependent variable, comparing children who breastfed with those who did not. Similar secondary analyses were performed for the other cognitive measures. RESULTS In total, 42.9% of children were breastfed a mean of 7.2 months. Breastfeeding rates and duration did not differ across drug groups. The IQ at age 6 years was related to drug group (P < .001 [adjusted IQ worse by 7-13 IQ points for valproate compared to other drugs]), drug dosage (regression coefficient, -0.1; 95% CI, -0.2 to 0.0; P = .01 [higher dosage worse]), maternal IQ (regression coefficient, 0.2; 95% CI, 0.0 to 0.4; P = .01 [higher child IQ with higher maternal IQ]), periconception folate use (adjusted IQ 6 [95% CI, 2-10] points higher for folate, P = .005), and breastfeeding (adjusted IQ 4 [95% CI, 0-8] points higher for breastfeeding, P = .045). For the other cognitive domains, only verbal abilities differed between the breastfed and nonbreastfed groups (adjusted verbal index 4 [95% CI, 0-7] points higher for breastfed children, P = .03). CONCLUSIONS AND RELEVANCE No adverse effects of AED exposure via breast milk were observed at age 6 years, consistent with another recent study at age 3 years. In our study, breastfed children exhibited higher IQ and enhanced verbal abilities. Additional studies are needed to fully delineate the effects of all AEDs. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00021866.
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Affiliation(s)
- Kimford J. Meador
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, California
| | - Gus A. Baker
- Walton Centre for Neurology and Neurosurgery, University of Liverpool, Merseyside, England
| | | | - Morris J. Cohen
- Departments of Neurology, Pediatrics, and Psychiatry, Georgia Regents University, Augusta
| | - Rebecca L. Bromley
- Institute of Human Development, University of Manchester, and Central Manchester University Hospitals National Health Service Foundation Trust, Manchester, England
| | - Jill Clayton-Smith
- Institute of Human Development, University of Manchester, and Central Manchester University Hospitals National Health Service Foundation Trust, Manchester, England
| | | | - Andres Kanner
- Department of Neurology, University of Miami, Miami, Florida
| | | | - Page B. Pennell
- Department of Neurology, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - David W. Loring
- Departments of Neurology and Pediatrics, Emory University, Atlanta, Georgia
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Abstract
IMPORTANCE Exposure to antiepileptic drugs during pregnancy is associated with adverse effects on psychomotor development. OBJECTIVES To determine whether signs of impaired development appear already during the first months of life in children exposed prenatally to antiepileptic drugs, and to explore potential adverse effects of antiepileptic drug exposure through breastfeeding. DESIGN, SETTING, AND PARTICIPANTS Mothers at 13 to 17 weeks of pregnancy were recruited in the population-based, prospective Norwegian Mother and Child Cohort Study from 1999 to 2009. The mothers reported on their child’s motor and social skills, language, and behavior using items from standardized screening tools at 6 months (n = 78 744), 18 months (n = 61 351), and 36 months (n = 44 147) of age. The mothers also provided detailed information on breastfeeding during the first year. MAIN OUTCOMES AND MEASURES The risk of adverse development in children according to maternal or paternal epilepsy was estimated as the odds ratio with corresponding 95% confidence interval, adjusted for maternal age, parity, education, smoking, breastfeeding, depression/anxiety, folate supplementation, and congenital malformation in the child. RESULTS At age 6 months, infants of mothers using antiepileptic drugs (n = 223) had a higher risk of impaired fine motor skills compared with the reference group (11.5% vs 4.8%, respectively; odds ratio = 2.1; 95% CI, 1.3–3.2). Use of multiple antiepileptic drugs compared with the reference group was associated with adverse outcome for both fine motor skills (25.0% vs 4.8%, respectively; odds ratio = 4.3; 95% CI, 2.0–9.1) and social skills (22.5% vs 10.2%, respectively; odds ratio = 2.6; 95% CI, 1.2–5.5). Continuous breastfeeding in children of women using antiepileptic drugs was associated with less impaired development at ages 6 and 18 months compared with those with no breastfeeding or breastfeeding for less than 6 months. At 36 months, prenatal antiepileptic drug exposure was associated with adverse development regardless of breastfeeding status during the first year. Children of women with epilepsy who did not use antiepileptic drugs and children of fathers with epilepsy had normal development at 6 months. CONCLUSIONS AND RELEVANCE Prenatal exposure to antiepileptic drugs was associated with impaired fine motor skills already at age 6 months, especially when the child was exposed to multiple drugs. There were no harmful effects of breastfeeding. Women with epilepsy should be encouraged to breastfeed their children irrespective of antiepileptic drug treatment.
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Affiliation(s)
- Kimford J Meador
- Department of Neurology and Neurological Sciences, Stanford Comprehensive Epilepsy Center, Stanford University School of Medicine, Stanford, California
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Saramma PP, Sarma PS, Thomas SV. Effect of a self-instructional module on the child rearing knowledge and practice of women with epilepsy. Seizure 2014; 23:424-8. [PMID: 24647345 DOI: 10.1016/j.seizure.2014.02.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Revised: 02/12/2014] [Accepted: 02/14/2014] [Indexed: 01/16/2023] Open
Abstract
UNLABELLED Women with epilepsy (WWE) have poorer knowledge and skill in child rearing than women without epilepsy. PURPOSE To evaluate the effect of a self-instructional module (SIM) on the child rearing knowledge (CRK) and practice (CRP) of WWE and developmental outcome of their babies. METHODS One hundred women in first trimester of pregnancy that were enrolled in to the Kerala Registry of Epilepsy and Pregnancy and consenting to participate were given a self instructional module (SIM) or a comparator booklet by random concealed allocation. Their child rearing knowledge (CRK) was assessed by a standardized protocol at entry (first trimester) and at 3-4 months postpartum. Their child rearing practice (CRP) was evaluated in third postpartum month. The developmental outcome of babies was assessed at 1 year of age as per registry protocol. RESULTS Eighty eight women completed this 1 year study. The CRK score was significantly higher (p=.034) for the intervention group (32.91±5) when compared to the comparator group (30.61±5) However, a corresponding improvement in CRP score was not observed for the former. Developmental outcome of 68 babies showed a positive weak correlation between CRP and developmental quotient both mental and motor. The intervention group demonstrated significant increase in their CRK. Nevertheless the results did not indicate a significant improvement in the CRP. CONCLUSION The SIM improved the CRK of WWE. Nevertheless, the child rearing practices did not show corresponding improvement.
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Affiliation(s)
- P P Saramma
- Kerala Registry of Epilepsy and Pregnancy, Comprehensive Epilepsy Care Program, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum 695011, Kerala, India
| | - P S Sarma
- Kerala Registry of Epilepsy and Pregnancy, Comprehensive Epilepsy Care Program, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum 695011, Kerala, India
| | - Sanjeev V Thomas
- Kerala Registry of Epilepsy and Pregnancy, Comprehensive Epilepsy Care Program, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum 695011, Kerala, India.
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Davanzo R, Dal Bo S, Bua J, Copertino M, Zanelli E, Matarazzo L. Antiepileptic drugs and breastfeeding. Ital J Pediatr 2013; 39:50. [PMID: 23985170 PMCID: PMC3844381 DOI: 10.1186/1824-7288-39-50] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Accepted: 08/10/2013] [Indexed: 01/16/2023] Open
Abstract
INTRODUCTION This review provides a synopsis for clinicians on the use of antiepileptic drugs (AEDs) in the breastfeeding mother. METHODS For each AED, we collected all retrievable data from Hale's "Medications and Mother Milk" (2012), from the LactMed database (2013) of the National Library of Medicine, and from a MedLine Search of relevant studies in the past 10 years. RESULTS Older AEDs, such as carbamazepine, valproic acid, phenytoin, phenobarbital, primidone are considered to have a good level of safety during lactation, due to the long term clinical experience and the consequent amount of available data from the scientific literature. On the contrary, fewer data are available on the use of new AEDs. Therefore, gabapentin, lamotrigine, oxcarbazepine, vigabatrin, tiagabine, pregabalin, leviracetam and topiramate are compatible with breastfeeding with a less documented safety profile. Ethosuximide, zonisamide and the continue use of clonazepam and diazepam are contraindicated during breastfeeding. CONCLUSIONS Although the current available advice on the use of AEDs during breastfeeding, given by different accredited sources, present some contradictions, most AEDs can be considered safe according to our review.
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Affiliation(s)
- Riccardo Davanzo
- Division of Neonatology, Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", Via dell'Istria 65/1, Trieste 34100, Italy.
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