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epilepsy during pregnancy

Epidemiology: a) 0.5% of children are born to women with a seizure disorder b) 33% of women with epilepsy sustain seizure during pregnancy -> risk of seizure greater if history of seizures within 2 years (54% vs 9%) Laboratory: - anticonvulsant monitoring Complications: 1) 20% of women with epilepsy experience an increased frequency of seizures during pregnancy 2) fetal anomalies a) fetal anticonvulsant syndrome b) fetal cardiovascular malformation c) higher rates of major congenital malformations in children of women taking multiple antieleptic drugs vs those taking a single agent (9.1% vs 6.2%)* 4) antenatal hypertension (not preeclampsia) 5) modestly increased risk of obstetrical complications (induced labor) * corresponding rate for non-epileptics reported as 4.5% seems high Management: 1) administer anticonvulsants only to patients with well-documented epilepsy 2) monotherapy at the lowest possible dose should be used - risk of congenital malformation is dose-dependent [4] 3) the medication dose is likely to increase during pregnancy 4) levetiracetam, lamotrigine & oxcarbazepine are the preferred anticonvulsants [1,8] - levetiracetam does not seem to effect language or developmental scores [6] 5) phenytoin & valproic acid are pregnany category D - increased risk of neural tube defects [8] 6) topiramate, carbamazepine, & multiple anticonvulsants associated with congenital malformations [1,8] 7) administration of folate 0.4 mg QD decreases the risk of neural tube defects in the fetus [8] 8) vitamin K should be administered to avoid neonatal bleeding before & during delivery

Related

seizure; epileptic seizure

General

pregnancy disorder; obstetric disorder; pregnancy complication epilepsy

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 11, 16, 18 American College of Physicians, Philadelphia 1998, 2012, 2018
  2. Journal Watch 24(8):67, 2004 Richmond JR et al Am J Obstet Gynecol 190:371 2004 PMID: 14981376
  3. Prescriber's Letter 17(1): 2010 Antiepileptics in Pregnancy COMMENTARY: Antiepileptics in Pregnancy GUIDELINES: Managing Epilepsy During Pregnancy Detail-Document#: 260107 (subscription needed) http://www.prescribersletter.com
  4. Tomson T et al Dose-dependent risk of malformations with antiepileptic drugs: an analysis of data from the EURAP epilepsy and pregnancy registry The Lancet Neurology, Early Online Publication, 6 June 2011 PMID: 21652013 http://www.thelancet.com/journals/laneur/article/PIIS1474-4422(11)70107-7/abstract
  5. Harden CL, Meador KJ, Pennell PB et al Practice parameter update: management issues for women with epilepsy--focus on pregnancy (an evidence-based review): teratogenesis and perinatal outcomes: report of the Quality Standards Subcommittee and Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology and American Epilepsy Society. Neurology. 2009 Jul 14;73(2):133-41. PMID: 19398681
  6. Shallcross R et al In utero exposure to levetiracetam vs valproate. Development and language at 3 years of age. Neurology. Jan 8, 2014 PMID: 24401687 http://www.neurology.org/content/early/2014/01/08/WNL.0000000000000030.short - Klein P, Mathews GC Antiepileptic drugs and neurocognitive development. Neurology. Jan 8, 2014 PMID: 24401684 http://www.neurology.org/content/early/2014/01/08/WNL.0000000000000044.extract
  7. Meador KJ, Baker GA, Browning N et al Fetal antiepileptic drug exposure and cognitive outcomes at age 6 years (NEAD study): a prospective observational study. Lancet Neurol. 2013 Mar;12(3):244-52 PMID: 23352199
  8. Pack AM, Oskoui M, Williams Roberson S et al Teratogenesis, Perinatal, and Neurodevelopmental Outcomes After In Utero Exposure to Antiseizure Medication: Practice Guideline From the AAN, AES, and SMFM. Neurology. 2024 Jun;102(11):e209279. PMID: 38748979