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Pregnancy monitoring - t he management of pregnant women with epilepsy -

Pregnancy monitoring - t he management of pregnant women with epilepsy -. Doina Vanghelie, Ionela Codita, Cristina Panea Elias University Emergency Hospital Bucharest. Pregnancy and epilepsy.

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Pregnancy monitoring - t he management of pregnant women with epilepsy -

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  1. Pregnancy monitoring- the management of pregnant women with epilepsy - Doina Vanghelie, Ionela Codita, Cristina Panea Elias University EmergencyHospital Bucharest

  2. Pregnancyandepilepsy • Pregnancies in women with epilepsy are considered at high risk for adverse outcomesbecause can be complicated by various maternal and fetal issues • careful management by both neurological and obstetrician specialist • Assesriskandbenefitswith individual drugs Limited data aboutnewestdrugs

  3. Pregnancyandepilepsy Objectives • seizure control (theoccurence of seizure / increasing of seizure frequency) • monitor thedevelopment of the fetus(congenital abnormalities, cognitive anddevelopment delay) • preventbirthcomplications for mother/child (miscarriage, premature labor, perinatal death, hemorrhage)

  4. Increase in seizurefrequency Mainlylastquarterdueto: • lowerplasma level of AEDs • increase hepatic / renal clearance • increasethe volume distributionby fluid retention • reducedproteinbinding • an increasedlevel of estrogen (epileptogenicbydecreasingtheseizurethresold) • sleepdeprivation • stress, anxiety • decreasedcompliance in takingAEDs ( dueto nausea or concernsregardingtheeffect on their fetus)  • Lowrisk for recurrenceof seizures ifthepatient is seizure-free for 9 month prior to pregnancy (levelB) (Gjerde et al, 1988, Tomson et al, 1994)

  5. ChangedAEDs plasma concentration • Pregnancycause an increase in theclearanceanddecrease in theconcentrations of: • lamotrigine • phenitoine • lesser for carbamazepine (9% in 2nd trimand 12% in 3rd trim) • Decreaselevel of levetiracetam, oxicarbamazepine (active metabolite MHD) • Recommendation: monitoring of total andfreelevel of plasma AEDsmonthly

  6. Acute seizuresduringpregnancy As the result of: • gestational epilepsy (idiopathic onset) • symptomatic epilepsy: • vascular malformations or meningioma with receptors for estrogen (exacerbatedby pregnancy) • cerebrovascular disease (cerebral thrombophlebitis, or paradoxical amnioticembolism) • Eclampsia • Hyponatremia- due to oxytocin which promotes water retention • Syncope • In response to the used anesthetic lidocaine • Psychogenicseizure (especially peripartum)

  7. Seizuresrelatedrisks for foetus • Duringpregnancy it isessentialto continue thetreatmenttoavoidtherisksassociatedwithseizures • High: tonic-clonic seizures • Injury • miscarriage • fetal bradycardia thelevel of risk dependsalsoon seizure frequency (definitive data islacking) • Low: focalseizure, absence and myoclonic seizure

  8. Seizuresrelatedrisks for mother Discusswiththosewho plan to stop AED theraphy! • SUDEP • Status epilepticus

  9. Status epilepticus • Exclude preeclamsiaand eclampsia • Check maternal vital signs • Assesthe fetal heart rate and fetal status • Laboratoryfindings (AED levels, electrolytes, glucose, toxicology) • Benzodiazepine iv, phenitoinwith cardiac monitoring • Monitor the fetus • Emergencydeliveryifnecessary

  10. Seizurescontrol must be balanced with the teratogenicrisk

  11. The AEDscrossthe placenta • in clinically important amounts: Phenobarbital, primidone, phenytoin , carbamazepine, levetiracetam and valproat • potentialyclinically important amounts: Gabapentin, lamotrigine, oxcarbamazepineandtopiramat • inssufficientdata for ethosuximide Symptomatic effects in newborns: lethargy, excessive somnolence, fussiness

  12. Teratogenicrisk Risk of major congenital malformationsis 4-9% in womenreceivingAEDs Specific malformations: • PHT: risk of cleft palate (class II) • CBZ: posterior cleft palate (classII) • VPA: neural tube defects, facial clefts (class I), hypospadias (class II); more than 800mg andpolytherapyincluded VPA are associatedwithhigherrisk • PB: cardiac malformations (classII) EURAP epilepsyandpregnancyregister

  13. BUT It isrecommendedthat do notchangethe AED duringpregnancy

  14. The teratogenicrisk must beevaluatedbeforepregnancy ! • CBZ probablydoesnotsubstantllyincreasetherisk (class I evidence) • LTG – best option • Close monitoring of childdevelopment • Fetal surveybyultrasonography at 19-20 weekwithcarefulattentiontothe face, central nervoussystemandheart • Possiblyamniocentesis UK EpilepsyandPregnancyRegister

  15. Folic acid • Folic acid supplementation is possibly effective in preventing or reduction the rate of neural tube defects (level C) • Startedbeforepregnancy • At least 0.4mg (0.5-4mg) per day • At leastuntilthe end of firsttrimester

  16. Delivery • Epilepsyandantiepileptictreatmentincreasetherisk of maternal and fetal complications: • preeclampsia • hypertension • Miscarriage • prematurity • neonatal asphyxia • Cesarean delivery: moderately increased risk is possible (level C) compared with women with no epilepsy • Insufficient evidence for preeclampsia, hypertension premature contractionsor premature labor and delivery • Increased risks for the smokers pregnant women with epilepsy • Possiblyan increased risk (level C) forbleeding complications andspontaneous abortion(lack of statical data) Viinikainen et al, 2006; Richmond et al, 2004

  17. Laboranddelivery • Preparationandclose monitoring • Inform all care providers (obstreticians, neurologist, anesthesiologist, pediatricians, nurses) thatthepatienthasepilepsy • CheckAEDs plasma level at admission • Extra doses of AED if it is necessary or switch to i.v. benzodiasepine or phenytoin (seizure prophylaxis)

  18. AEDsandnewborns • Newbornsexposedtoenzyme-inducingAED receivedvitamin K at delivery • inadequateevidenceto determine ifthenewbornshavesubstantiallyincreasedrisk of hemorrhagiccomplications.

  19. AEDsandnewborns Transfer intobreastmilk • Possiblyin clinically important amounts: primididoneandlevetiracetam; probablygabapentine, lamotrigine, topiramat • Notin clinically important amounts: valproate, phenobarbital, phenitoinandcarbamazepine

  20. Conclusions • Monitor total andfreelevel of AEDsmonthly, EEG monitoring • Manage acute seizureand status epilepticus • Continue folatesupplementation • Check maternal serumalphafetoproteinlevels • Fetal surveybyultrasonography at 19-20 week • It isnotclearprophylacticeffect of bleedingbyadministeringvitamin K prepartum • Prepare delivery • Breastfeeding

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