2. Introduction
• Prevalence 0.5%-1% & 0.5% expose to AEDs in pregnancy
• 33% of epileptic females in reproductive age
• Risk of death significantly increase in pregnancy (10 Fold)
• Use of anti-epileptics increase fetal anomalies & affect CNS
development
• Discontinuation or reduction of doses increase seizures
3. Diagnosis
Should be done by medical expert, usually neurologist
Previous epileptic patients with non high risk for
unprovoked seizures can be manage as low risk
women in ANC
Women who are seizure free for least 10 yrs and was
not on medication in last 5 years are no longer
epileptic patients
Childhood seizure patients who are free of seizure in
adulthood and not on AED are also consider as above
4. Value of
classifying
seizure type
& epilepsy
syndromes
Clinical manifestation are highly varied
Rate of seizure deterioration associated
with types/syndromes
So need to choose useful AED depend on
syndrome
Used to identify & avoid triggers that
deteriorate seizure
for this purpose-documentation of type &
frequency of seizures important
5.
6. SUDEP
• Sudden , unexpected , witnessed or unwitnessed , nontraumatic &
nondrowning deaths in epileptic patients
• There may be evidence for seizures & but no documented status
epilepticus
• Postmortem does not reveal anatomical or toxicological causes for
death
• Uncontrolled GTCS is the strongest risk factor for this
7. Differential diagnosis
• If a woman present with fits in 2nd half of
pregnancy which can not be described with
epilepsy , immediately assess & manage as
Eclampsia until definitive diagnosis is made
with full neurological assessment
• Cardiac, metabolic & Intracranial conditions
should be considered together with
Neuropsychiatric conditions
8.
9. Pre-pregnancy counselling.
1.Educate on risk of congenital anomalies when women is on
AED or not on AED
Most will have normal healthy babies
Risk is low if not exposed to AED in periconceptional period
Risk depend on type , number & dose of AED
If not exposed to AED, risk resembles to background risk of
general population (3%)
If exposed 2-3 times increase major malformations compare
to general population
10. • Least risk of anomalies were observed in Levitracetam
(0.7%) Lamotrigine (2%) , CBZ (4%) monotherapy with
low doses
• Risk is highest with Valproate (10%) and AED
polytherapy (17%)
• Risk of anomaly recurrence is high as (16%) if previous
child was affected
• No significant association observed between epilepsy
type & GTCS in first trimester with regard to anomalies
11.
12.
13. 2.Long tern neurodevelopmental outcome
• Obvious with in utero exposure to valproate (Intelligence Quotient )
• Non verbal , verbal abilities , memory , executive function are
declined with high doses of valproate
• In utero valproate use increases Autism
• Limited evidence of safety with Lamotrigine , CBZ & Phenytoin use
when compared with no AED use (2014 Cochrane)
• Very limited data available on Levetiracetam and those are reassuring
14. 3. Can we reduce
cong.anomalies
• Folic acid 5mg daily from
pre conceptional period up
to T1 completion
• This reduces incidence of
major malformations & AED
related cognitive defects
• Select the most safe agents
& avoid poly therapy as
much as possible
15. 4.How pregnancy affects seizures?
• There is no test to predict the risk of seizure deterioration in
pregnancy
• 2/3rd will not have deterioration in pregnancy
• If last seizure is within a year from conception, need to have a close
look
• Women who are seizure free for 9-12 months before conception,
75%-90% of them will be seizure free in pregnancy.
• This is the most important factor.
• 75% of generalized epilepsy pts remain seizure free in pregnancy in
contrast to focal epilepsy pts. (60%)
16. 5.Other factors to be considered
• Educate on safety precautions
• Advise to continue medicines as physician recommend & avoid
discontinuation
• Prenatal screening & implications
• Effects of seizures & AED on pregnancy , fetus , lactation &
contraception
• Both written & oral communication are vital
• Counselling sessions
17.
18. Antepartum management
• 1.Recommended models of ANC & benefits of joint Obs/Neuro
clinics
• regular ANC visits + Epilepsy clinic visits
• Never recommend to stop or change AED abruptly without neuro op.
• Local clinic registration & midwife visits
20. 3.Monitoring
to avoid
worsening of
seizures
Most AED level will fall in pregnancy (Eg- lamotrigine
70%)
Some clinicians tend to increase doses prophylactically
while some refuse to do as side effects profile increases
Routine AED level monitoring in pregnancy is not
recommended
Clinical response also used as a tool to monitor AED
response
Currently no data to say what is superior method
21. 4.Advesre
effects of AED
on mother &
how to reduce
those?
Alert on signs of depression ,
anxiety ,neuro-psychiatric
symptoms
High dose poly-therapy affects
cognition
Early identification and referral to
mental health team is important
22. 5. Risk of obstetric complications
• Increased spontaneous miscarriage , APH , Hypertensive dx , Labour
Induction , LSCS , PTL , FGR , PPH in WWE compare to no epilepsy. No
difference in GDM or Perinatal deaths found. (metanalysis conducted
in 2015)
• Those who are on AEDs are even at high risk of Induction of Labour ,
FGR , PPH , Neonatal ICU requirement
• When on Polytherapy LSCS rate is higher than mono therapy group
23. 6. Monitoring of WWE in pregnancy
• Routine assessment for provoking factors like lack of sleep , stress ,
compliance to medication , seizure types/frequency
• AED side effects assessment
• Arrange caregivers or arrange accommodations in an environment
where continuous observation is there.
• Joint clinic assessments to avoid /address provoking factors
24. 7.Antepartum fetal surveillance
• Serial growth scans to find FGR
• No role of routine CTGs
• Fetal HR changes such as bradycardia & reduce variability has been
reported due to possible hypoxia with seizures
• CTG heart rate patterns are generally not differ from non epileptics.so
no evidence for routine CTG as ApFS.
25. 8.Role of Vit K
• Enzyme inducing AED (CBZ,Phenytoin,Barbiturates) competitively
inhibit precursors of clotting factors & affect fetal microsomal enzyme
that destroy Vit K . Thus Increase risk of bleeding.
• All babies born to WWE taking enzyme inducing AEDs should have IM
Vit K 1mg to overcome Hemorrhagic Dx of newborn
• There is insufficient data of routine oral vit K for this purpose
• There is insufficient data for maternal Vit k therapy to lower PPH
26. 9.Optimal TOD/MOD
• There is no such
• Most will have uncomplicated labour & delivery
• Diagnosis of epilepsy per se is not an indication for CS or IOL
• Provided no other obstetric risk factors , if seizure were well
controlled –no need to early induce
• Recurrent , prolonged seizures with risk of status epilepticus, EL/CS
may be considered.
27. 10.Do we need to double the Dexa dose?
• Even with enzyme inducing AEDs, it is not recommended.
• But they may enhance drug catabolism & reduce efficacy
• Currently no studies to address this . Better to attach same doses.
28. Intrapartum care
• 1.what are the risks & risk factors for seizures during labour?
• Risk of seizure during labour is low (3.5%)
• GTCS 1-2% during labour& 1-2% In immediate postpartum 24hrs may
occur
• Fits in labour can cause maternal hypoxia due to apnea during seizure
• Uterine hypertonus associated with seizure can cause fetal hypoxia &
acidosis
• Fits are provoked by pain,fatigue,stress,dehydration,lack of
sleep,avoidance of AEDs
29. How to minimize?
• AED should continue during labour (even as IV agents if need)
• Hydrate well
• Pain relief with epidural
• Overcome avoidable delays related to decision of Early IOL /ELCS
• Long acting Benzodiazepine (Clobazam) can consider around
peripartum period
• Clobazam may cause neonatal respiratory depression-Alert Neonatal
team
• Prophylactic clobazam use if recent convulsions, fits provoked by
above factors , previous history exists
30. 2.What to do if a seizure developed in LR?
• Any seizure lasing >5min is unusual & represent high risk of status
epilepticus (1% of pregnancies in WWE)
• Immediately control/terminate seizure using Benzodiazepines before
status occurs & treatment resistance develops
• Continuous CTG monitoring of fetus
• Left lateral tilt with airway + O2 supply
• doses- IV Lorazepam 4mg stat + further dose after 20min
• IV Diazepam 5-10mg slow infusion
• PR Diazepam 10-20mg stat + further dose after 15 min
• Buccal Midazolam 10mg stat
31. Cont.
• If seizures not settling , IV Phenytoin 10-15mg/Kg loading dose
(1000mg stat) infuse
• Meantime get the help of VP / Anesthetist & Neurologist
• If evidence of persistent uterine hypertonia exists, Tocolysis need & if
FHS fails to recover in 5 min or seizures continues/recurrent expedite
delivery by AVD or CS
• Keep inform neonatal team to attend as there is a risk of neonatal
withdrawal syndromes with AEDs
32. 3.What are the suitable analgesia methods in
labour?
• TENS , Entonox & Regional analgesia suitable & safe
• Epidural is better
• Diamorphine is better than Pethidine (since its norpethidine
metabolite is epileptogenic)
• If GA requires avoid Pethidine & ketamine as they reduce seizure
threshold and also Sevoflurane which is epileptogenic
33. 4.Will AEDs affect Induction Agents? Methods?
• No contraindication for any induction agents
• No evidence that AEDs affect induction agents
• Anyhow WWE are at high risk of inductions than normal pts.
34. 5.Ideal setting for delivery
• Consultant lead units with 1 to 1 care
• Maternal + neonatal resuscitation teams should be available
• Water birth offer if seizure free for long period + not on AEDs
• For high risk of seizure pts-CTG monitoring need
• So In SL-Tertiary care center
35. Postpartum period (PPP)
• 1.what is the risk of seizure deterioration in PPP & how to minimize?
• Overall chance is low but relatively higher than APP
• Risk is highest on PP 3rd day and when last seizure occurred 1 month
prior to delivery
• Continue AED
• Avoid provoking factors
• Supportive staff ( aid feeding with expressed milk during night )
36. 2.Is it necessary to modify AED doses?
• Yes if doses increased during APP , it should be R/V within 10days of
delivery to avoid drug toxicity
37. 3. Impact to fetus by AED
• Rate of AED transfer via placenta & BF vary
• Many AED cross placenta freely
• Fetal accumulation is slightly high with Gabapentin, valproate &
levetiracetam .
• Babies may shows toxicity & withdrawal symptoms
• Magnitude of AED transfer in Breast milk unknown
• But pts should encouraged to continue Breast feeding
• Valproate , CBZ , phenytoin are the least transferring agents via milk
• BF has not affected cognitive functions in studies
38. 4.Safety precautions in PPP
• Nursing baby on the floor
• Shallow baby baths
• Keep baby down if warning symptoms appear
• Bath baby with help of a someone
• Avoid sleep deprivation , alcohol
• Identification tags
• First aid & emergency contact details display
• Keep a companion as much as possible
41. • Promote Cu-IUD / LNG-IUS / IM DMPA as reliable methods which are not
affected by enzyme inducers
• Efficacy of COCP & Progesterone implants affected by enzyme inducers
(COCP failure rate is 3 times higher)
• All methods of contraceptive can offer for non enzyme inducers
• When emergency contraception requires , Cu-IUD is the choice for enzyme
inducers
• Lamotrigine & COCP cross react to reduce Lamotrigine level thus seizures
may increase
42. Cont.
• If a women on enzyme inducing AEDs request COCP , contraceptive
efficacy may improved by High dose estradiol pills , reduce pill free
interval to 4 days & Tricycling by taking 3 back to back packs
• But there are no data for success rates
• They should be on backup methods- barrier methods on top of COCP
