Epilepsy in pregnancy

Obstetrics

Clinicals - History

Fact Explanation
Known personal history of epilepsy The aetiology is usually idiopathic while rarely a secondary aetiology predisposing seizure development may exist. Epilepsy affects about 0.5% of pregnant women. Known personal history of epilepsy
The aetiology is usually idiopathic while rarely a secondary aetiology predisposing seizure development may exist. Epilepsy affects about 0.5% of pregnant women.
A diagnosed patient with epilepsy may present with a seizure episode. During the antenatal period the seizure frequency may increase/decrease or remain unchanged. The patient may experience an alteration in the seizure frequency due to the physiological changes associated with pregnancy. Reduced drug absorption (due to nausea & vomiting), increase in plasma volume, changes in renal & hepatic metabolism may precipitate seizure attacks. A diagnosed patient with epilepsy may present with a seizure episode.
During the antenatal period the seizure frequency may increase/decrease or remain unchanged. The patient may experience an alteration in the seizure frequency due to the physiological changes associated with pregnancy. Reduced drug absorption (due to nausea & vomiting), increase in plasma volume, changes in renal & hepatic metabolism may precipitate seizure attacks.
Newly diagnosed with epilepsy during pregnancy Majority of women have being diagnosed prior to conception. A wide differential diagnosis including Eclampsia, central nervous system infection, metabolic disturbances, epilepsy, stroke etc needs to be considered if the first seizure episode develops during pregnancy. Newly diagnosed with epilepsy during pregnancy
Majority of women have being diagnosed prior to conception. A wide differential diagnosis including Eclampsia, central nervous system infection, metabolic disturbances, epilepsy, stroke etc needs to be considered if the first seizure episode develops during pregnancy.

Clinicals - Examination

Fact Explanation
Usually unremarkable. Examination is usually normal in patients with idiopathic epilepsy. Patients with secondary epilepsy may exhibit neurological signs in accordance to the underlying aetiology. Usually unremarkable.
Examination is usually normal in patients with idiopathic epilepsy. Patients with secondary epilepsy may exhibit neurological signs in accordance to the underlying aetiology.

Investigations - Diagnosis

Fact Explanation
The diagnosis of epilepsy is primarily based on history & an account of an eye witness. Patients presenting with their first seizure during pregnancy need to be evaluated with a thorough history. An eye witness account is essential to exclude other differential diagnoses. To exclude a secondary aetiology, brain imaging with CT scan, MRI etc may be required. The diagnosis of epilepsy is primarily based on history & an account of an eye witness.
Patients presenting with their first seizure during pregnancy need to be evaluated with a thorough history. An eye witness account is essential to exclude other differential diagnoses. To exclude a secondary aetiology, brain imaging with CT scan, MRI etc may be required.
Urine protein assessment Significant proteinuria (>300mg protein/ 24 hours) is seen in severe pre-eclampsia. Urine protein assessment
Significant proteinuria (>300mg protein/ 24 hours) is seen in severe pre-eclampsia.
Full blood count A full blood count is performed to help exclude eclampsia. Haemoconcentration, thrombocytopenia, haemolytic anemia may be seen in the presence of severe pre-eclampsia. Full blood count
A full blood count is performed to help exclude eclampsia. Haemoconcentration, thrombocytopenia, haemolytic anemia may be seen in the presence of severe pre-eclampsia.
Coagulation profile ( Prothrombin time test, APTT) Disseminated intravascular coagulopathy is a complication of severe pre-eclampsia. Coagulation profile ( Prothrombin time test, APTT)
Disseminated intravascular coagulopathy is a complication of severe pre-eclampsia.

Investigations - Management

Fact Explanation
Full blood count Anticonvulsants such as carbamazepine, sodium valproate may lead to blood disorders. Full blood count
Anticonvulsants such as carbamazepine, sodium valproate may lead to blood disorders.
Liver function tests Anticonvulsants such as sodium valproate, carbamazepine etc have hepatotoxic properties & need periodical liver function assessment. Liver function tests
Anticonvulsants such as sodium valproate, carbamazepine etc have hepatotoxic properties & need periodical liver function assessment.
Serum anticonvulsant levels Monitoring of drug levels is not recommended routinely and is performed in circumstances such as increased seizure frequency, polypharmacy, concern over drug side effects etc. Serum anticonvulsant levels
Monitoring of drug levels is not recommended routinely and is performed in circumstances such as increased seizure frequency, polypharmacy, concern over drug side effects etc.
Ultrasound scan A detailed anomaly scan needs to be performed since a majority of anticonvulsants are teratogenic. Common congenital anomalies seen are neural tube defects, facial clefts, cardiac anomalies & genitourinary anomalies. Ultrasound scan
A detailed anomaly scan needs to be performed since a majority of anticonvulsants are teratogenic. Common congenital anomalies seen are neural tube defects, facial clefts, cardiac anomalies & genitourinary anomalies.
Fetal echocardiography Fetal echocardiography is considered at 22-24 weeks. Use of sodium valproate, carbamazepine and phenytoin during pregnancy has being linked with fetal cardiac anomalies. Fetal echocardiography
Fetal echocardiography is considered at 22-24 weeks. Use of sodium valproate, carbamazepine and phenytoin during pregnancy has being linked with fetal cardiac anomalies.
α fetoprotein Prenatal screening for neural tube defects. α fetoprotein
Prenatal screening for neural tube defects.

Management - Supportive

Fact Explanation
Patient education & counseling Patient education is paramount and should cover the following aspects : About the disease process, importance of compliance to treatment, drugs & their side effects, implications to the fetus, first aid measures in a seizure & about high risk situations such as bathing, driving etc. She should be advised to avoid seizure provoking factors such as sleep deprivation, extreme exhaustion, hypoglyceamia etc. The pregnant women should be counseled about fetal implications due to the disease itself and the anticonvulsant therapy. There is a higher risk of congenital anomalies even without anticonvulsant treatment which is further aggravated with the use of teratogenic drugs. Sodium valproate is considered the most teratogenic anticonvulsant but is the most effective drug for seizure control. Valproate use can lead to development of neural tube defects, genitourinary anomalies etc. There is a 4% risk of epilepsy in the child if one parent is affected & 15% if both parents are affected. Patient education & counseling
Patient education is paramount and should cover the following aspects : About the disease process, importance of compliance to treatment, drugs & their side effects, implications to the fetus, first aid measures in a seizure & about high risk situations such as bathing, driving etc. She should be advised to avoid seizure provoking factors such as sleep deprivation, extreme exhaustion, hypoglyceamia etc. The pregnant women should be counseled about fetal implications due to the disease itself and the anticonvulsant therapy. There is a higher risk of congenital anomalies even without anticonvulsant treatment which is further aggravated with the use of teratogenic drugs. Sodium valproate is considered the most teratogenic anticonvulsant but is the most effective drug for seizure control. Valproate use can lead to development of neural tube defects, genitourinary anomalies etc. There is a 4% risk of epilepsy in the child if one parent is affected & 15% if both parents are affected.
Involvement of the general practitioners in the management plan Care for the pregnant women with epilepsy should start pre-conceptually. General practitioners should optimize the drug regime and refer the patient for specialist assessment. Involvement of the general practitioners in the management plan
Care for the pregnant women with epilepsy should start pre-conceptually. General practitioners should optimize the drug regime and refer the patient for specialist assessment.

Management - Specific

Fact Explanation
Pre-pregnancy management The main objectives during the preconceptual period are to optimization the treatment, achieve good seizure control and patient education. The obstetrician should liaise with a neurologist for optimal care. Efforts should be made to maximize seizure control on the least tetatogenic monotherapy. The lowest effective drug doses should be used in divided doses. Consider stopping the anticonvulsant therapy if the patient was seizure free for more than two years. All women should be advised to take folic acid 5mg daily for at least 12 weeks prior to conception and continue to do so until delivery. Pre-pregnancy management
The main objectives during the preconceptual period are to optimization the treatment, achieve good seizure control and patient education. The obstetrician should liaise with a neurologist for optimal care. Efforts should be made to maximize seizure control on the least tetatogenic monotherapy. The lowest effective drug doses should be used in divided doses. Consider stopping the anticonvulsant therapy if the patient was seizure free for more than two years. All women should be advised to take folic acid 5mg daily for at least 12 weeks prior to conception and continue to do so until delivery.
Antenatal management The patient's drug regime is continued if epilepsy is well controlled. The patient should be stressed about the importance of compliance to treatment during the antenatal period. If epilepsy is diagnosed during pregnancy lamotrigine and carbamazepine are the drugs of choice. To avoid neonatal coagulopathy due to administration of enzyme inducing drugs, vitamin K 10mg/day is administered for the last 4 weeks of pregnancy. Antenatal management
The patient's drug regime is continued if epilepsy is well controlled. The patient should be stressed about the importance of compliance to treatment during the antenatal period. If epilepsy is diagnosed during pregnancy lamotrigine and carbamazepine are the drugs of choice. To avoid neonatal coagulopathy due to administration of enzyme inducing drugs, vitamin K 10mg/day is administered for the last 4 weeks of pregnancy.
Intrapartum care A diagnosis of epilepsy alone is not a contraindication for vaginal delivery. Vaginal delivery may precipitate seizure attacks due to maternal dehydraion, electrolyte changes, hypoglycaemia, exhaustion and pain. Caesarian section is reserved for usual obstetric indications and in the circumstance of status epilepticus. Anticonvulsant treatment should be continued during the intrapartum period. Labor may precipitate seizure episodes due to sleep deprivation, poor drug absorption etc which should be controlled with benzodiazepines (diazepam/lorazepam). Monitor fetal parameters to identify fetal compromise. Intrapartum care
A diagnosis of epilepsy alone is not a contraindication for vaginal delivery. Vaginal delivery may precipitate seizure attacks due to maternal dehydraion, electrolyte changes, hypoglycaemia, exhaustion and pain. Caesarian section is reserved for usual obstetric indications and in the circumstance of status epilepticus. Anticonvulsant treatment should be continued during the intrapartum period. Labor may precipitate seizure episodes due to sleep deprivation, poor drug absorption etc which should be controlled with benzodiazepines (diazepam/lorazepam). Monitor fetal parameters to identify fetal compromise.
Postpartum management The neonate should receive intramuscular vitamin K to reduce the risk of neonatal coagulopathy. Breast feeding is not contraindicated since the dose passed over to the fetus is low. Drug dose changes made during the antenatal period are converted back to pre-pregnancy levels gradually. The women should be educated on an appropriate contraceptive method. Postpartum management
The neonate should receive intramuscular vitamin K to reduce the risk of neonatal coagulopathy. Breast feeding is not contraindicated since the dose passed over to the fetus is low. Drug dose changes made during the antenatal period are converted back to pre-pregnancy levels gradually. The women should be educated on an appropriate contraceptive method.

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