Contraception, fecundity, and pregnancy in women with epilepsy: an update on recent literature

Seizure control and pregnancy outcomes in Chinese women with epilepsy: A prospective multicenter cohort study

OBJECTIVE

Data on seizure and pregnancy outcomes in Asian women with epilepsy are limited. We used a Chinese pregnancy registry to assess the impact of seizures and antiseizure medications (ASMs) on pregnant women with epilepsy and their children.

METHODS

This is an ongoing prospective multicenter study of pregnant women with epilepsy that has been running since 2012. Eligible participants were consecutively enrolled and had multiple follow-ups up to one year after delivery. We assessed ASM use and seizure frequency during pregnancy to establish potential effects on the mothers and infants and to identify relevant correlations. Descriptive analysis was used to estimate proportions. Logistic regression was used to identify the relevant risk factors and correlations.

RESULTS

Of 1907 potentially eligible pregnancies, we included 1763 in 1483 women with known outcomes from January 2012 to February 2022. There were 1278 completed pregnancies, resulting in 1270 live births. Tonic-clonic seizures occurred in fewer than one-third of pregnancies in each trimester. Compared with baseline, seizure frequency remained relatively stable throughout approximately two-thirds of the pregnancies. The majority were on ASM, with levetiracetam (39%), oxcarbazepine (19%), and lamotrigine (17.5%) being the most commonly used. In contrast, only 14.2% of pregnancies were exposed to valproate (VPA). There was a declining trend in treatment adjustments over the course of the pregnancy, with most changes occurring in the first trimester. The incidence of major congenital malformation (MCM) was 4.4%, with cardiogenic and orofacial anomalies being the most common. VPA use (p < .001), lack of folic acid use (p = .009), positive family history of MCM (p = .006), and topiramate (TPM) use (p = .04) were the most important predictors of MCM.

SIGNIFICANCE

Seizure control remained stable for the majority of women with epilepsy throughout pregnancy. Family history of MCM, VPA use, TPM use, and not taking folic acid were strong predictors of MCM in infants born to women with epilepsy.

Effect of antiepileptic drug monotherapy on endogenous sex hormonal profile in men and women with epilepsy

OBJECTIVE

To assess the alterations of endogenous sex hormone profiles in patients with epilepsy (PWE) on different antiepileptic drug (AED) monotherapies compared to healthy controls and drug naïve PWE (DNPWE).

METHODS

Four databases MEDLINE, EMBASE, SCOPUS, and CENTRAL were searched for analytical observational/intervention studies on the assessment of endogenous sex hormones in PWE compared to healthy controls and DNPWE. Two researchers reviewed the title/abstract, and full-text articles for the selection of the studies independently. Extracted data included information on study details, participant demographics, interventions, method of assessment and study results. The study outcomes were used to calculate the standard mean differences (SMD) and 95% confidence interval (CI) as effect size for assessing differences in the endogenous sex hormone levels between the treatment group and control/DNPWE.

RESULTS

Among 5888 publications retrieved, 33 studies were included. Enzyme-inducing AEDs (EIAEDs) such as phenytoin (men: SMD = 1.36; 95%CI = 1.06,1.66) and carbamazepine (men: SMD = 0.71; 95%CI = 0.39, 1.04 and women: SMD = 0.54; 95%CI = 0.25, 0.83) and weak-EIAED oxcarbazepine (men: SMD = 0.62; 95%CI = 0.26,0.99) increased the SHBG levels in PWE compared to control. The same trend was observed when comparing it to DNPWE. No significant changes in SHBG were observed for non-EIAEDs valproic acid, lamotrigine and levetiracetam in men. Lamotrigine significantly reduced SHBG in women (SMD = -0.50; 95%CI = -0.85, -0.16) compared to controls. Testosterone (T) levels were significantly reduced for both carbamazepine (SMD = -0.39; 95%CI = -0.67, -0.11) and valproic acid (SMD = -0.48; 95%CI = -0.74, -0.21) treated men compared to control.

SIGNIFICANCE

Our findings emphasize the importance of screening the endogenous sex hormonal profile in PWE on AED monotherapies to evaluate the associated endocrine-related perturbations which may impact reproductive functions.

Transition from pediatric to adult care system in patients with complex epilepsies: Necker model for transition evaluated on 70 consecutive patients

OBJECTIVE

Complex epilepsies such as epileptic and developmental encephalopathies require multidisciplinary care throughout life. A coordinated transition program is therefore essential to provide optimal support for patients leaving pediatric for adult care. The aim of this study is to describe and evaluate our transition program for complex epilepsies, focusing on the last step in this program, that is, the multidisciplinary transition day hospital (MTDH).

METHODS

We performed a retrospective observational study including patients with complex epilepsies who underwent the full steps of the transition program at Necker-Enfants Malades Hospital between May 2021 and June 2023, with a follow-up until February 2024. We described the cohort and detailed the interventions performed during the MTDH including medical, medicosocial, educational, daily life abilities, and laboratory and imaging assessments with the participation of one member of the adult team. We evaluated two indicators of our program: (1) the "adult first clinic attendance rate," defined by the percentage of patients attending their first adult clinic; and (2) the "return rate," defined by the percentage of patients who requested a pediatric encounter after their transfer.

RESULTS

Our cohort included 70 patients with a mean age of 19.1 years (interquartile range = 16.3-19.5). Eighty percent had an epilepsy syndrome diagnosis; 72.8% were treated with three or more antiseizure medications. All patients had their appointment at the adult clinic within 6 months of the day hospital, and only two families requested a pediatric encounter after the transfer.

SIGNIFICANCE

The transition program is key for an optimal transfer of patients with complex epilepsies to adult care. It requires a comprehensive multidisciplinary approach and provides a complete summary of the medical record. Our program secures a smooth landing in adult care and is a promising model to better manage the challenging transition process, especially in patients with complex epilepsy.

Investigation of spontaneous abortion and stillbirth adverse events in epilepsy patients treated with levetiracetam: A pharmacovigilance study

BACKGROUND

The prescription of levetiracetam during pregnancy has become more common due to its lower teratogenic risk profile. However, due to a lack of data about its association with stillbirth and spontaneous abortion, worries remain.

OBJECTIVE

To investigate information on any possible association of spontaneous abortion and stillbirth adverse events with levetiracetam in women with epilepsy.

METHODS

This retrospective pharmacovigilance study used disproportionality analysis to detect signals of adverse reaction of interest reported with Levetiracetam in FAERS, the FDA Adverse Event Reporting System. The ratio of reporting odds (ROR) and information component (IC) indices were used to undertake disproportionality analyses, and change point analyses were carried out to identify variations in the frequency of reporting of relevant adverse events. Sensitivity analyses included subgroup analyses by indication, treatment regimen, and reporting region.

RESULTS

Overall, 2870 cases of spontaneous abortion and stillbirth with commonly used antiseizure medications were analyzed. A total of 65.5 % of these cases had epilepsy as the indication. In the entire dataset, we observed disproportionality signals of spontaneous abortion for 6 ASMs (levetiracetam, carbamazepine, lamotrigine, oxcarbazepine, topiramate, valproic acid) and disproportionality signals of stillbirth for 4 ASMs (levetiracetam, carbamazepine, lamotrigine, oxcarbazepine). In the epileptic population, disproportionality signals for stillbirth (ROR0.25 = 4.60; IC0.25 = 1.30) and spontaneous abortion (ROR0.25 = 3.98; IC0.25 = 1.20) in levetiracetam was identified. These disproportionality signals have been consistently robust over the past years, according to a temporal assessment of them. Sensitivity studies proved how reliable the findings were.

CONCLUSION

Using validated pharmacovigilance methods, we found significant disproportional signals for spontaneous abortion and stillbirth associated with levetiracetam. Of these, the signals for spontaneous abortion were observed after 2011 and for stillbirth after 2014, which may be related to the rise in levetiracetam prescriptions during pregnancy in recent years. The association of spontaneous abortion and stillbirth adverse events with levetiracetam and potential biases confounding this association merit further investigation.

Assisted reproductive technology outcomes and management considerations for people with epilepsy

PURPOSE OF REVIEW

Epilepsy is a common neurologic condition amongst people with reproductive capacity, and assisted reproductive technology (ART) is being increasingly utilized. A recent population-based study described favorable outcomes of ART in this population, but other work shows how fluctuating sex hormones may influence medication concentrations and seizures.

RECENT FINDINGS

This review discusses hormonal influences on epilepsy and catamenial epilepsy, considerations regarding fertility in women with epilepsy, emerging ART outcomes, and management considerations for people with epilepsy undergoing ART.

SUMMARY

Utilizing ART is an effective treatment for people with epilepsy desiring pregnancy, but closer monitoring and antiseizure medication adjustments may be needed to ensure the best outcomes. More research is needed to better guide epilepsy care during ART.

Epilepsy and Issues Related to Reproductive Health

Sexual disorders are prevalent and vary in men and women with epilepsy (WWE). Infertility and reproductive abnormalities are twice as common in females with epilepsy. Antiepileptic medications and seizures can both have an impact on sexual health in people with epilepsy. Seizures can alter the release of pituitary and hypothalamic hormones, and some antiepileptic drugs (AEDs) can alter sex steroid hormones (gonadal steroids and gonad corticoids). Females with epilepsy are more susceptible to menstrual cycle irregularity and polycystic ovary syndrome. Females and males had lower reproductive rates, and the causes are likely psychological and physiological, with epilepsy and AEDs again playing a role. Sexual disorders are common in WWE and men with epilepsy and can be caused by psychological, physical, or social factors. Specialists must address the gender-based biology of epilepsy and the impact of AEDs on sexual well-being to offer the best treatment possible for patients with epilepsy, particularly women of sexual maturity.

Contemporary management of epilepsy in pregnancy

PURPOSE OF REVIEW

The number of reproductive aged people with epilepsy in the United States is increasing, making epilepsy during pregnancy more prevalent. Simultaneously, more people are using newer generations of antiseizure medications before, during and after pregnancy. Here, we review current evidence on contemporary management and outcomes of pregnancies among people with epilepsy.

RECENT FINDINGS

This review evaluates recent literature to summarize current practices in preconception counselling, contraception, antiseizure medications before, during and after pregnancy, and peri-partum and postpartum risks in people with epilepsy.

SUMMARY

With the introduction of newer generation antiseizure medications being used during pregnancy, current literature shows that there may be decreased risk in adverse foetal and maternal outcomes. In the peri-partum and postpartum period, recent literature shows that people with epilepsy have an increased risk of severe maternal morbidity and hospital readmission. Given this, as well as considerations for dosing of antiseizure medications, close surveillance of people with epilepsy during pregnancy is warranted.

Construction of nursing-sensitive quality indicators for epilepsy in China: A Delphi consensus study

OBJECTIVE

The quality and safety of epilepsy care are of great importance because seizures are unpredictable. The aim of this study was to develop a set of nursing-sensitive quality indicators (NSQIs) for assessing and improving the quality of epilepsy nursing care in China.

METHODS

An international literature review, a cross-sectional survey and a qualitative study were conducted to identify candidate NSQIs for epilepsy care and compile a questionnaire. Then, two rounds of electronic Delphi studies were conducted with a panel of 27 independent experts to identify the final NSQIs for epilepsy.

RESULTS

Thirty-nine candidate NSQIs were extracted for the Delphi process. The recovery rates in the first and second rounds of expert consultations were 92.6% and 96.2%, respectively. The experts' authority coefficients of the two rounds were 0.876 and 0.878, respectively. The Kendall W value of the two rounds ranged between 0.094 and 0.200 (p<0.001). Eight structure indicators, 9 process indicators and 7 outcome indicators that represented the following three domains were included in the set of NSQIs for epilepsy: nursing resource allocation, implementation of nursing care, and outcomes of patients with epilepsy.

CONCLUSION

These NSQIs for epilepsy provide a primary foundation for monitoring and improving the quality of epilepsy nursing care in China. However, the effects of these indicators on improvements in epilepsy care and outcomes in patients need to be verified in clinical practice.

Reproduction and genetic causal attribution of epilepsy

OBJECTIVE

This study addresses the contribution of genetics-related concerns to reduced childbearing among people with epilepsy.

METHODS

Surveys were completed by 606 adult patients with epilepsy of unknown cause at our medical center. Poisson regression analysis was used to assess the relations of number of offspring to: (1) genetic attribution (GA: participants' belief that genetics was a cause of their epilepsy), assessed via a novel scale developed from four survey items (Cronbach's alpha = .89), (2) participants' estimates of epilepsy risk in the child of a parent with epilepsy (1%, 5%-10%, 25%, and 50%-100%), and (3) participants' reports of the influence on their reproductive decisions of "the chance of having a child with epilepsy" (none/weak/moderate, strong/very strong). Analyses were adjusted for age, education, race/ethnicity, religion, type of epilepsy (generalized, focal, and both/unclassifiable), and age at epilepsy onset (<10, 10-19, and ≥20 years).

RESULTS

Among participants 18-45 years of age, the number of offspring decreased significantly with increasing GA (highest vs lowest GA quartile rate ratio [RR] = .5, p < .001), and increasing estimated epilepsy risk in offspring (with 5%-10% as referent because it is closest to the true value, RR for 25%: .7, p = .05; RR for 50%-100%: .6, p = .03). Number of offspring was not related to the reported influence of "the chance of having a child with epilepsy" on reproductive decisions. Among participants >45 years of age, the number of offspring did not differ significantly according to GA quartile or estimated offspring epilepsy risk. However, those reporting a strong/very strong influence on their reproductive decisions of "the chance of having a child with epilepsy" had only 60% as many offspring as others.

SIGNIFICANCE

These findings suggest that overestimating the risk of epilepsy in offspring can have important consequences for people with epilepsy. Patient and provider education about recurrence risks and genetic testing options to clarify risks are critical, given their potential influence on reproductive decisions.

Seizure medication and planned pregnancy: balancing the risks and outcomes

INTRODUCTION

The therapeutic management of women with epilepsy (WWE) of childbearing age can be complicated by the need to balance maternal/fetal risks related to seizure occurrence during gestation with the potential teratogenic risks related to the use of anti-seizure medications (ASMs).

AREAS COVERED

The authors review clinical evidence on seizure-related and ASM-related risks during pregnancy. Current regulatory indications are discussed, evaluating their impact on clinical practice, and ethical implications of pharmacological decisions are debated.

EXPERT OPINION

If properly informed about the maternal/fetal risks carried by different pharmacological choices, WWE can become the final decision makers regarding their care in every phase of their life. Over the coming years, analysis of aggregated pregnancy registry data on the structural impact, on the fetus, of low doses of valproate and of newer ASMs, together with analysis of the main population study data on functional (cognitive and behavioral) outcomes, could lead to huge advances, making choosing an ASM a less complex process for the clinician and a less painful decision for the woman. Future objectives should include identification of the potential role of the pharmacogenomic profile of WWE in determining the risk of fetal malformations.