Makindo Medical Notes.com

Related Subjects: |Status Epilepticus (Epilepsy) |Coma management |Lorazepam |Phenytoin |Levetiracetam |Epilepsy - General Management |First Seizure |Epilepsy in Pregnancy |Febrile seizures

About

• Issues are optimising control and reducing seizures
• Avoiding teratogenic drugs

Aetiology

• Pregnancy + epilepsy increases maternal mortality
• Increased obstetric haemorrhage
• Increased hypertensive disorders of pregnancy
• Fetal growth issues

Issues

• Seizure frequency rate rarely affected with pregnancy
• Risk of physical defects in babies whose mothers take sodium valproate in pregnancy is around 11%, compared with 2-3% for children in the general population. This means that out of 100 women with epilepsy who take sodium valproate in pregnancy, 11 will have a baby with a physical defect. Early preferable pre pregnancy support and specialist neurological involvement in terms of choice of anticonvulsant.
• Plan pregnancies pre conception
• Start Folate, optimise Anticonvulsants
• Healthy living advice to reduce seizures

RCOG Recommendations 2016

Diagnosis of epilepsy

• The diagnosis of epilepsy and epileptiform seizures should be made by a medical practitioner with expertise in epilepsy, usually a neurologist.
• Women with a history of epilepsy who are not considered to have a high risk of unprovoked seizures can be managed as low-risk women in pregnancy.
• Women with epilepsy (WWE), their families and healthcare professionals should be aware of the different types of epilepsy and their presentation to assess the specific risks to the mother and baby.
• In pregnant women presenting with seizures in the second half of pregnancy which cannot be clearly attributed to epilepsy, immediate treatment should follow existing protocols for eclampsia management until a definitive diagnosis is made by a full neurological assessment. Other cardiac, metabolic and intracranial conditions should be considered in the differential diagnosis. Neuropsychiatric conditions including non-epileptic attack disorder should also be considered.

Planning

• WWE who are planning their pregnancy should have a clinician competent in the management of epilepsy take responsibility for sharing decisions around choice and dose of AEDs, based on the risk to the fetus and control of seizures.
• WWE should be reassured that most mothers have normal healthy babies and the risk of congenital malformations is low if they are not exposed to AEDs in the preconception period.
• Women should be informed that the risk of congenital abnormalities in the fetus is dependent on the type, number and dose of AEDs.

Exposure to AEDs and maternal seizure in infants born to WWE?

• WWE and their partners need to be informed about the possible adverse impact on long-term neurodevelopment of the newborn following in utero exposure to sodium valproate. Based on limited evidence, in utero exposure to carbamazepine and lamotrigine does not appear to adversely affects the neurodevelopment of the offspring. There is very little evidence for Levetiracetam and phenytoin. Parents should be informed that evidence on long-term outcomes is based on small numbers of children.
• All WWE should be advised to take 5 mg/day of folic acid prior to conception and to continue the intake until at least the end of the first trimester to reduce the incidence of major congenital malformation.
• Pre-pregnancy folic acid 5 mg/day may be helpful in reducing the risk of AED-related cognitive deficits.
• The lowest effective dose of the most appropriate AED should be used.
• Exposure to sodium valproate and other AED polytherapy should be minimised by changing the medication prior to conception, as recommended by an epilepsy specialist after a careful evaluation of the potential risks and benefits.

What is the effect of pregnancy on seizures in WWE?

• WWE should be informed that two-thirds will not have seizure deterioration in pregnancy.
• Pregnant women who have experienced seizures in the year prior to conception require close monitoring for their epilepsy.

How should risks be communicated to WWE?

• WWE should be provided with verbal and written information on prenatal screening and its implications, the risks of self-discontinuation of AEDs and the effects of seizures and AEDs on the fetus and on pregnancy, breastfeeding and contraception.
• WWE should be informed that the introduction of a few safety precautions may significantly reduce the risk of accidents and minimise anxiety.
• Healthcare professionals should acknowledge the concerns of WWE and be aware of the effect of such concerns on their adherence to AEDs.

Antepartum management

• Pregnant WWE should have access to regular planned antenatal care with a designated epilepsy care team.
• WWE taking AEDs who become unexpectedly pregnant should be able to discuss therapy with an epilepsy specialist on an urgent basis. It is never recommended to stop or change AEDs abruptly without an informed discussion.
• All pregnant WWE should be provided with information about the UK Epilepsy and Pregnancy Register and invited to register.
• What is the optimum method and timing of screening for the detection of fetal abnormalities?
• Early pregnancy can be an opportunity to screen for structural abnormalities. The fetal anomaly scan at 18+0â??20+6 weeks of gestation can identify major cardiac defects in addition to neural tube defects.
• All WWE should be offered a detailed ultrasound in line with the national health Service Fetal Anomaly

Screening Programme standards.

• Based on current evidence, routine monitoring of serum AED levels in pregnancy is not recommended although individual circumstances may be taken into account.
• Healthcare professionals should be alert to signs of depression, anxiety and any neuropsychiatric symptoms in mothers exposed to AEDs.
• Healthcare professionals need to be aware of the small but significant increase in obstetric risks to WWE and those exposed to AEDs, and to incorporate this in the counselling of women and the planning of management.

How should WWE be monitored in pregnancy?

• In the antenatal period, WWE should be regularly assessed for the following: risk factors for seizures, such as sleep deprivation and stress; adherence to AEDs; and seizure type and frequency.
• If admission is required antenatally, WWE at reasonable risk of seizures should be accommodated in an environment that allows for continuous observation by a carer, partner or nursing staff.
• Serial growth scans are required for detection of small-for-gestational-age babies and to plan further management in WWE exposed to AEDs.
• There is no role for routine antepartum fetal surveillance with cardiotocography in WWE taking AEDs.

What is the role of Vitamin K in preventing haemorrhagic disease of the newborn and maternal haemorrhage in WWE taking AEDs?

• All babies born to WWE taking enzyme-inducing AEDs should be offered 1 mg of intramuscular Vitamin K to prevent haemorrhagic disease of the newborn.
• There is insufficient evidence to recommend routine maternal use of oral Vitamin K to prevent haemorrhagic disease of the newborn in WWE taking enzyme-inducing AEDs.
• There is insufficient evidence to recommend giving Vitamin K to WWE to prevent postpartum haemorrhage.
• WWE should be reassured that most will have uncomplicated labour and delivery.
• The diagnosis of epilepsy per se is not an indication for planned caesarean section or induction of labour.
• Inappropriate medical intervention, including AED administration and iatrogenic early delivery, should be avoided when there is a firm diagnosis of non-epileptic attack disorder.
• In WWE taking enzyme-inducing AEDs who are at risk of preterm delivery, doubling of the antenatal corticosteroid dose for prophylaxis against respiratory distress syndrome in the newborn is not recommended.

Intrapartum care

• What are the risks and risk factors for seizures in labour in WWE and how can they be minimised?
• Pregnant WWE should be counselled that the risk of seizures in labour is low.
• Adequate analgesia and appropriate care in labour should be provided to minimise risk factors for seizures such as insomnia, stress and dehydration.
• Long-acting benzodiazepines such as clobazam can be considered if there is a very high risk of seizures in the peripartum period.
• AED intake should be continued during labour. If this cannot be tolerated orally, a parenteral alternative should be administered.

What is the optimum management of epileptic seizures in labour?

• Every obstetric unit should have written guidelines on the management of seizures in labour.
• Seizures in labour should be terminated as soon as possible to avoid maternal and fetal hypoxia and fetal acidosis. Benzodiazepines are the drugs of choice.
• Continuous fetal monitoring is recommended in women at high risk of a seizure in labour and following an intrapartum seizure.

What are the recommended methods of analgesia in labour for WWE?

• Pain relief in labour should be prioritised in WWE, with options including transcutaneous electrical nerve stimulation (TENS), nitrous oxide and oxygen (Entonox), and regional analgesia.
• Pethidine should be used with caution in WWE for analgesia in labour.
• Diamorphine should be used in preference to pethidine.

What are the effects of induction of labour on WWE and do AEDs affect induction agents?

• There are no known contraindications to the use of any induction agents in WWE taking AEDs.
• For WWE at risk of peripartum seizures delivery should be in a consultant-led unit with facilities for one-to-one midwifery care and maternal and neonatal resuscitation.
• The decision to use water for analgesia and birth should be made on an individual basis.
• WWE who are not taking AEDs and who have been seizure-free for a significant period may be offered a water birth after discussion with their epilepsy specialist.

Postpartum management

• WWE and their caregivers need to be aware that although the overall chance of seizures during and immediately after delivery is low, it is relatively higher than during pregnancy. WWE should be advised to continue their AEDs postnatally.
• Mothers should be well supported in the postnatal period to ensure that triggers of seizure deterioration such as sleep deprivation, stress and pain are minimised.
• If the AED dose was increased in pregnancy, it should be reviewed within 10 days of delivery to avoid postpartum toxicity.
• Neonates born to WWE taking AEDs should be monitored for adverse effects associated with AED exposure in utero.
• WWE who are taking AEDs in pregnancy should be encouraged to breastfeed.
• Based on current evidence, mothers should be informed that the risk of adverse cognitive outcomes is not increased in children exposed to AEDs through breast milk.

What advice should be given regarding safety strategies and care of the baby?

• Postpartum safety advice and strategies should be part of the antenatal and postnatal discussions with the mother alongside breastfeeding, seizure deterioration and AED intake.
• Postnatal mothers with epilepsy at reasonable risk of seizures should be accommodated in single rooms only when there is provision for continuous observation by a carer, partner or nursing staff.
• WWE should be screened for depressive disorder in the puerperium. Mothers should be informed about the symptoms and provided with contact details for any assistance.

Contraception

• WWE should be offered effective contraception to avoid unplanned pregnancies. Copper intrauterine devices (IUDs), the levonorgestrel-releasing intrauterine system (LNG-IUS) and medroxyprogesterone acetate injections should be promoted as reliable methods of contraception that are not affected by enzyme-inducing AEDs.
• Women taking enzyme-inducing AEDs (carbamazepine, phenytoin, phenobarbital, primidone, oxcarbazepine, topiramate and eslicarbazepine) should be counselled about the risk of failure with some hormonal contraceptives.
• Women should be counselled that the efficacy of oral contraceptives (combined hormonal contraception, progestogen-only pills), transdermal patches, vaginal ring and progestogen-only implants may be affected if they are taking enzyme-inducing AEDs (e.g. carbamazepine, phenytoin, phenobarbital, primidone, oxcarbazepine and eslicarbazepine).
• All methods of contraception may be offered to women taking non-enzyme-inducing AEDs (e.g. sodium valproate, Levetiracetam, gabapentin, vigabatrin, tiagabine and pregabalin). WWE taking enzyme-inducing AEDs should be informed that a copper IUD is a preferred choice for emergency contraception.
• Emergency contraception pills with levonorgestrel and ulipristal acetate are affected by enzyme-inducing AEDs.
• Women taking lamotrigine monotherapy and oestrogen-containing contraceptives should be informed of the potential increase in seizures due to a fall in the levels of lamotrigine.
• The risks of contraceptive failure and the short- and long-term adverse effects of each contraceptive the method should be carefully explained to the woman.
• Effective contraception is extremely important with regard to stabilisation of epilepsy and planning of pregnancy to optimise outcomes.

Other implications

• WWE should be informed of the effect of changing the dose of AED on seizures and its impact on driving privileges.
• What are the implications of disability legislation for WWE and health service providers?
• Healthcare providers need to be aware of equality legislation in the UK that protects individuals with a disability from discrimination.

References

• Epilepsy in Pregnancy RCOG