Combining adverse pregnancy and perinatal outcomes for women exposed to antiepileptic drugs during pregnancy, using a latent trait model

[Guidelines for the management of adverse effects of anti-seizure medications (2023)]

Epilepsy is a prevalent neurological disorder with a complex etiology and an unclear pathogenesis. In order to standardize the management of adverse effects caused by anti-seizure medications (ASMs), the Youth Committee of the Chinese Association Against Epilepsy (CAAE), in collaboration with the CAAE Precision Medicines and Adverse Effect Monitoring Committee, has developed a guideline: guidelines for the management of adverse effects of anti-seizure medications (2023). This guideline addresses 13 clinical questions related to the management of adverse effects of ASMs in the nervous system, cardiovascular system, and fetus. Its primary objective is to provide guidance to medical professionals specializing in pediatric neurology, neurology, and neurosurgery in China, and to facilitate their clinical practice.

Developmental toxicity and programming alterations of multiple organs in offspring induced by medication during pregnancy

Medication during pregnancy is widespread, but there are few reports on its fetal safety. Recent studies suggest that medication during pregnancy can affect fetal morphological and functional development through multiple pathways, multiple organs, and multiple targets. Its mechanisms involve direct ways such as oxidative stress, epigenetic modification, and metabolic activation, and it may also be indirectly caused by placental dysfunction. Further studies have found that medication during pregnancy may also indirectly lead to multi-organ developmental programming, functional homeostasis changes, and susceptibility to related diseases in offspring by inducing fetal intrauterine exposure to too high or too low levels of maternal-derived glucocorticoids. The organ developmental toxicity and programming alterations caused by medication during pregnancy may also have gender differences and multi-generational genetic effects mediated by abnormal epigenetic modification. Combined with the latest research results of our laboratory, this paper reviews the latest research progress on the developmental toxicity and functional programming alterations of multiple organs in offspring induced by medication during pregnancy, which can provide a theoretical and experimental basis for rational medication during pregnancy and effective prevention and treatment of drug-related multiple fetal-originated diseases.

Relation of in-utero exposure to antiepileptic drugs to pregnancy duration and size at birth

Background

The associations of individual antiepileptic drugs (AEDs) with pregnancy duration and size at birth, and potential dose relations, are not well characterized.

Methods

This cohort study used nationwide Swedish register data (1996–2013). Adjusting for smoking, epilepsy and other AED indications, we used linear and quantile regression to explore associations with pregnancy duration, and birth weight, length, and head circumference (the last three operationalized as z-scores). We used logistic regression for preterm delivery, small for gestational age, and microcephaly. Lamotrigine was the reference drug.

Results

6,720 infants were exposed to AEDs in utero; AED exposure increased over the study period. Relative to lamotrigine-exposed infants, carbamazepine-exposed infants were born, on average, 1.3 days earlier (mean [95% confidence interval]: -1.3 [-2.3 to -0.3]); were 0.1 standard deviations (SDs) lighter (-0.1 [-0.2 to 0.0]); and had a head circumference that was 0.2 SDs smaller (-0.2 [-0.3 to -0.1]). Pregabalin-exposed infants were born, on average, 1.1 days earlier (-1.1 [-3.0 to 0.8]); were 0.1 SDs lighter (-0.1 [-0.3 to 0.0]); and had the same head circumference as lamotrigine-exposed infants. Levetiracetam-exposed infants were born, on average, 0.5 days earlier (-0.5 [-2.6 to 1.6]); were 0.1 SDs lighter (-0.1 [-0.3 to 0.0]); and had a head circumference 0.1 SDs smaller (-0.1 [-0.3 to 0.1]). Valproic acid–exposed infants had, on average, the same duration of gestation and birth weight z-score as lamotrigine-exposed infants, but had a head circumference 0.2 SDs smaller (-0.2 [-0.2 to -0.1]). Associations between carbamazepine exposure and pregnancy duration and between valproic acid exposure and pregnancy duration and birth weight z-score were more negative at the left than at the right tails of the outcome distributions. Effect-measure modification and dose-response relations were noted for some of the associations.

Conclusions

Relative to lamotrigine, valproic acid and carbamazepine were associated with smaller head circumference.

Maternal carbamazepine alters fetal neuroendocrine-cytokines axis

This study detected the impact of maternal carbamazepine (CBZ) on the fetal neuroendocrine-cytokines axis. 25 or 50mg/kg of CBZ was intraperitoneally administrated to pregnant albino rats from the gestation day (GD) 1 to 20. Both administrations of CBZ caused a hypothyroidism in dams and fetuses whereas the decreases in serum thyroxine (T4) and triiodothyronine (T3) and increases in serum thyrotropin (TSH) levels were highly significant (LSD; P <0.01) at GD 20 compared to untreated control dams. Also, both administrations had undesirable impacts on the maternofetal body weight, litter weight, survival of dams and fetuses, and their food consumption in comparison to the corresponding control. These administrations also elicited a reduction in fetal serum growth hormone (GH), interferon-γ (IFNγ), interleukins (IL-2 & 4) and prostaglandin E2 (PGE2) levels. Also, the elevation in fetal serum tumor necrosis factor-alpha (TNFα), transforming growth factor-beta (TGFβ), and interleukins (IL-1β & 17) levels was observed at embryonic day (ED) 20. Moreover, there were a cellular fragmentation, distortion, hyperemia, oedema and vacuolation in the fetal cerebellar cortex due to both maternal administrations. These developmental changes were dose-dependent. These novel results suggest that CBZ may act as a developmental immunoneuroendocrine disruptor.