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Management of Seizures during Pregnancy

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15-32% of women with epilepsy will have a seizure during pregnancy ... Fingernail hypoplasia * Developmental delay. Fetal Hydantoin Syndrome. Prevention of Seizures ... – PowerPoint PPT presentation

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Title: Management of Seizures during Pregnancy


1
Management of Seizures during Pregnancy
  • Christopher R. Leon-Guerrero MS3

2
Epidemiology
  • Seizures are the most frequent major neurologic
    complication encountered in pregnancy
  • 15-32 of women with epilepsy will have a seizure
    during pregnancy
  • 4-8 chance of major fetal malformations compared
    to 2-3 in the general population
  • 10-15 chance of minor fetal malformation
    compared to 5-10 in the general population
  • 2-14 risk of fetal death compared to 2-7 in the
    general population

3
The Impact of Pregnancy of Seizures
Seizure frequency during pregnancy Increase in
24 Decrease in 23 Unchanged 53
4
Seizures vs. Antiepileptic Drugs
  • Uncertain as to which is worse during pregnancy
  • Women with epilepsy appear to have an increased
    baseline risk of fetal malformations
  • Seizures during pregnancy can lead to an
    increased risk of maternal trauma potentially
    leading to fetal injury e.g. abruption, hypoxia
  • Increased incidence of depressed APGAR scores,
    low birth weight, diminished head circumference,
    pre-eclampsia and still birth

5
Toxicity of Antiepileptic Drugs
6
Fetal Hydantoin Syndrome
  • Constellation of abnormal findings attributed to
    the use of Phenytoin or other anticonvulsants
    during early pregnancy
  • Incidence 10-30 of infants born to women taking
    these drugs
  • Findings include
  • Midline Craniofacial defects
  • - Hypertelorism
  • - Cleft palate
  • - Broad nasal bridge
  • Fingernail hypoplasia
  • Developmental delay

7
Goals of Management
  • Prevention of Seizures
  • Risk to Benefit Approach
  • Monotherapy
  • Prenatal Counseling
  • Screening throughout Pregnancy

8
Prenatal Management
  • Ideally, management should begin prior to
    conception.
  • If a patient has been seizure-free for 2 years
    consider discontinuing antiepileptic treatment
  • If treatment is continued, the woman should use
    the most effective AED for her epilepsy type at
    the lowest possible dose to control seizures
  • Patients should be counseled on the potential
    teratogenicity of antiepileptic medications
  • A minimum of 4 mg daily of folic acid
    supplementation is important prior to conception
    and during pregnancy in women

9
Antenatal Management
  • Levels of antiepileptics should be monitored
    throughout pregnancy
  • Avoid changing/adding medications during
    pregnancy
  • Comprehensive Level II Ultrasound at 18-22 weeks
    is recommended to check for congenital and
    cardiac malformations
  • Amniocentesis should be offered
  • Vitamin-K 10 mg QDay starting at the 36th week of
    gestation until delivery

10
Seizure Disorder vs. Eclampsia
  • New onset seizures may occur during the third
    trimester of pregnancy
  • Important to consider eclampsia on the
    differential diagnosis
  • Management for eclampsia includes
  • -blood pressure control with hydralazine or
    labetalol
  • -seizure prophylaxis with MgSO4
  • -immediate delivery

11
Intrapartum Care
  • 5 of women with epilepsy will have a seizure
    during labor and delivery
  • Monitor antiepileptic drug levels
  • Consider seizure prophylaxis with IV
    benzodiazepines or phenytoin
  • Manage seizures acutely with 1-2 mg of
    intravenous diazepam then load phenytoin 1 g/1 h.
  • Multidisciplinary Approach Maternal Fetal
    Medicine, Neurology, Pediatrics, Anesthesiology…

12
Post-Partum Care
  • Increased risk of neonatal hemorrhage secondary
    to decreased levels of Vitamin K in mothers
    taking phenytoin, phenobarbital and primidone
  • Give the newborn Vitamin-K 1 mg IM x1
  • Levels of anticonvulsants will rise abruptly in
    the post-partum period
  • Newborn is 4x more likely to develop an
    idiopathic epilepsy compared to the general
    population
  • Breastfeeding is not contraindicated in patients
    taking anticonvulsants but caution should be
    taken due to sedation of the newborn

13
Future Studies
  • Genetic Studies to determine which patients are
    at risk
  • Algorithmic approach to drug selection
  • Better understanding of the pathophysiology of
    seizures
  • Long-term outcomes of patients taking
    anti-epileptic medications during pregnancy

14
Summary
  • Patients should be informed about the pros and
    cons of antiepileptic medications during
    pregnancy
  • Additional monitor and screening should be
    considered
  • Multidisciplinary approach is essential
  • Future studies are needed

15
References
  • Seizure Disorders in Pregnancy ACOG Educational
    Bulletin. International Journal of Obstetrics
    and Gynecology. 1997(56). 279-286.
  • Holmes LB, Harvey EA, Coull BA, et al. The
    Teratogenicity of Anticonvulsant Drugs. The New
    England Journal of Medicine. 2001344(15)1132-113
    8.
  • Practice parameter management issues for women
    with epilepsy (summary statement). Report of the
    Quality Standards Subcommittee of the American
    Academy of Neurology. Neurology. 199851944-8.
  • Kalviainen R and Tomson T. Optimizing Treatment
    of Epilepsy During Pregnancy. Neurology.
    200667(Suppl 4)S59-S63.
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