EPILEPSY IN PREGNANCY
A 24-year-old woman attends for
pre-pregnancy counselling. Her general practitioner (GP) referral letter is
shown.
Dear Doctor
Please could you see and advise this young woman
who wishes to start a family in the near future?
She was diagnosed with grand mal epilepsy when she was 12 and
has been on medication since then. She was initially under a paediatric
neurologist but for the last 6 years has been under
my care at the practice. Her current treatment regime includes
sodium valproate, phenytoin and lamotrigine. She last had a fit around 1 month ago.
She recently married and is keen to start a family as soon as possible.
I would be grateful if you could see her to discuss the management of any pregnancy. She has
never been pregnant before.
Yours sincerely
·
What specific risks are there in pregnancy for this woman?
·
How should she be managed?
·
The incidence of epilepsy in women
of child-bearing age is approximately 1 in 150.
·
The
risks of epilepsy
in pregnancy can be divided
into risks to the mother
and to the fetus.
Increased plasma volume causes
reduced drug levels
and a possible increase in fits. Other causes of increased fit frequency
include excessive tiredness and hyperemesis. Some women also decide to stop their
medication because of fears of adverse effects
on the baby, although this may actually
increase the risk to the baby as a result
of a higher like- lihood
of prolonged fits.
There is an increased risk of congenital abnormality due to antiepileptic drugs
(7 per cent risk for one drug,
with risk increasing with multiple drugs).
The risk probably applies simi-
larly to all antiepileptic medications used.
There is also an intrinsic increased risk of epilepsy
in the offspring of an epileptic mother, and during the pregnancy the fetus is also at risk of fetal hypoxia
from uncontrolled maternal epilepsy.
·
Refer for neurology opinion
and minimize the number of drugs, aiming
for a single drug regime.
·
If
no fits have occurred for at least
2 years consider
stopping all medication.
·
Advise the woman to continue her medication during pregnancy, as having an increased number of fits is likely to increase
the risk of fetal hypoxia.
·
Prescribe preconceptual folic acid (5 mg daily rather
than 400 μg) to minimize
the risk of neural
tube defects and
prevent folate deficiency seen with antiepileptic regimes.
·
Plan for joint medical and obstetric care.
·
Monitor plasma levels of anticonvulsant regime
(levels are likely
to diminish due to
increased plasma volume).
·
Advise the woman to take showers
instead of baths
to minimize the risk of drowning
if a fit occurs in the bath.
·
Arrange detailed anomaly scan and a fetal echocardiography at around 18–20
weeks for cardiac abnormalities.
·
Start vitamin K from 36 weeks’
gestation, to correct
any potential clotting
deficiency from the inhibition of clotting factor
production by anticonvulsants and thus reduce the chance of fetal
bleeding (e.g. intraventricular haemorrhage). The baby should also receive intramuscular (rather than oral) vitamin
K at birth.
·
There are no specific differences in labour
management from non-epileptic women.
·
Anticonvulsant therapy
is not a contraindication to breast-feeding.
·
Decrease medication doses as maternal physiology returns to normal.
·
Adequate social support is vital and plans need to be made for safe care of the infant
(due to the risk of fits in the mother).
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