Epilepsy in pregnancy GTG

Question 1

Prevalence of epilepsy?

Answer 1

0.6-1%

Question 2

What proportion of women with epilepsy have good pregnancy outcome

Answer 2

96%

Question 3

How much is the risk of death in pregnancy of a woman with epilepsy vs those who do not?

Answer 3

10 fold

Question 4

Which women with epilepsy can be considered low risk?

Answer 4

Women who have been seizure free for 10 years (5 years off AEDs) and those with a childhood epilepsy syndrome who have reached adulthood.

Question 5

Who with which type of seizures are most likely to suffer sudden unexpected death in epilpsy?

Answer 5

Uncontrolled tonic clonic seizures

Associated with variable period of fetal hypoxia

Question 6

In juvenile myoclonic epilpsy when are the Myoclonic jerks most often to happen?

What are some risk associated with this?

Answer 6

Sudden, unpredictable but occurs more frequently when sleep deprivation.

Sudden jerks can lead to falls, dropping objects or baby.

Can develop into tonic-clonic.

Question 7

An aura is typical of which type of epilepsy?

Answer 7

Focal seizure - primary focal seizure then can undergo secondary generalisation.

Question 8

If 1st seizure in 2nd/3rd trimester, what is the main DD and how should be managed?

Answer 8

Eclampsia
MgSu

Question 9

Are MRI head/CT head safe in pregnancy?

Answer 9

Yes - minimal exposure to fetus

Question 10

What is the background risk of congenital malformations? (No AED)

Answer 10

2.8/100

Question 11

What is the risk of congenital malformation with lamotrigene?

Answer 11

2/100

Question 12

What is the risk of congenital malformation with carbamazepine?

Answer 12

3.4/100

Question 13

What is the risk of congenital malformation with sodium valproate?

Answer 13

10/100

Question 14

What is the risk of congenital malformation with poly therapy?

Answer 14

16/100

Question 15

What is the risk of congenital malformation with previous congenital malformation?

Answer 15

16.8/100

Question 16

Sodium valproate is associated with which congenital malformations?

Answer 16

spina bida/neural tube defects
Facial cleft
Hypospadias
Neurodevelopment - lower IQ, risk autism

Question 17

What % of women taking sodium valproate will neurodevelopment disorders?

Answer 17

30-40%

Question 18

Phenobarbital and phenytoin are associated with which congenital malformations?

Answer 18

cardiac malformations

Question 19

Phenytoin and carbamazepine are associated with which congenital malformations?

Answer 19

cleft palate

Question 20

Which medication should be offered to women with epilepsy in pre-conception period?

Answer 20

5mg folic acid until end of 1st trimester

Question 21

How to optimise AED pre-conceptionall

Answer 21

Aim mono therapy with lowest effective AED dose
If SV consider weaning off to alternative AED, if SV change to moderate realise or increase daily frequency doses >800mg/day higher teratogenicity

Question 22

When to advise to avoid pregnancy

Answer 22

Uncontrolled seizures (particularly tonic clonic)

Taking high doses of AEDs
Polytherapy: multiple AEDs
Drug resistant epilepsy/uncontrolled epilepsy
Non-compliance with medication

Poor general health or other medical comorbidities

Question 23

What Qs to ask at 1st ANC with a women with epilepsy>

Answer 23

Who is the neurologist overseeing the care?

When was epilepsy diagnosed (childhood or teenage onset)?

What types of seizures are experienced? (e.g. a) focal, b) generalised, c) non-convulsive or d) unclassified)

What is the frequency of seizures?

When was the last seizure?

What AEDs are taken and at what dose?

What other features of seizures (triggers, aura, activity during seizure) occur?

Is there a history of status epilepticus or ITU admission?

Question 24

What proportion of women experience seizure deterioration in pregnancy?

Answer 24

1/3

Question 25

Main aspects of ANC for women with epilepsy

Answer 25

Regular ANC with designated epilepsy team 5mg folic acid Fetal anomaly USS + Cardiac USS Assess risk of seizures Serial growth USS - if AEDS Vit K 1 mg to baby if AED

Question 26

Women with epilepsy taking AED, risk of SGA?

Answer 26

3.5 x greater risk

Question 27

What is the risk of seizure in labour?

Answer 27

Overall 3.5% 1-2 % in labour 1-2% in 24 hours after labour

Question 28

How to prevent seizure in labour

Answer 28

Adequate analgesia 1 to 1 care Good hydration Continue AED in labour, consider IV if not tolerating PO

Question 29

If high risk of seizure in labour can consider which medication

Answer 29

Clobazam

Question 30

How to manage seizure in labour?

Answer 30

L lateral IV access - lorazepam 4mg bolus every 10-20mins or diazepam 10mg PR If not controlled consider phenytoin/fosphenytoin 10-15mg/kg IV If hypertonic consider tocolytics CTG after mother recovered, if FH not recovered after 5 mins of seizure, or seizure recurrent - expedite delivery

Question 31

What analgesia should not be given to women with epilepsy?

Answer 31

Pethadine

Question 32

If AED increased in pregnancy, when should this be review post partum?

Answer 32

Within 10 days

Question 33

Can women taking AED breastfeed?

Answer 33

Yes, is present in breast milk but not known to be harmful. Caution if preterm

Question 34

Any AED that says avoid in breast feeding?

Answer 34

Phenobarbital - causes drowsiness

Question 35

What post partum safety advise should be given?

Answer 35

Nurse baby on floor, shallow baths, lay baby down if aura, no bathing unaccompanied, wear ID tag, avoid triggers, family & friends know 1st aid, driving

Question 36

What is the risk of depressive disorders?

Answer 36

29% vs 11%

Question 37

Enzyme inducing AEDs have what impact on which contractraception?

Answer 37

Higher risk of failure rate (3/1000) using oral contraceptions, transdermal patch, vaginal mins, implants If choosing oral contraception increase the oestrogen dose = 50 micrograms and 4 days interval not 7.

Question 38

Which methods of contraception can be used with enzyme inducing AED

Answer 38

Cu, hormonal coil, Depot medroxyprogesterone

Question 39

Which AEDs dose if lowered with oestrogen based contraceptives/

Answer 39

Lamotrigene

Question 40

Which is the preferred form of emergency contraception in women taking AED

Answer 40

Cu IUD

Question 41

Which AEDs are enzyme inducing?

Answer 41

Phenobarbital Phenytoin Carbamazipine Topirmate Oxcarbazepine

Question 42

What number of women have no seizures during pregnancy?

Answer 42

64%

Question 43

What proportion of women with epilepsy have increased/decresed seizure acvitivty?

Answer 43

16% for both

Question 44

Risk status epileptics in pregnancy

Answer 44

<2%

Question 45

Factors contributing to deterioration of epilepsy during pregnancy

Answer 45

oorly controlled epilepsy prior to pregnancy Seizure frequency of >1 per month Multiple seizure types Drug-resistant epilepsy High-dose polytherapy Poor compliance with AEDs Reduced drug concentration in pregnancy due to increased renal clearance and metabolism Pregnancy specific triggers: nausea and vomiting (reduced AED concentration), sleep deprivation, labour (pain and hyperventilation)