Antiepileptic drug exposure in pregnancy and pregnancy outcome from national drug usage data

First-trimester use of antiseizure medications and the risk of miscarriage: a population-based cohort study

BACKGROUND

Antiseizure medications (ASMs) during the first trimester of pregnancy have been associated with an increased risk of miscarriage.

METHODS

We carried out a population-based cohort study using routinely collected healthcare data from the UK, 1995-2018. Pregnancies were identified in the Clinical Practice Research Datalink and we estimated the HR of miscarriage associated with prescriptions of ASMs during the first trimester of pregnancy, using Cox regression, adjusting for potential confounders, including ASM indications.

RESULTS

ASMs were prescribed during the first trimester in 7832 (0.8%) of 1 023 787 included pregnancies. 14.5% of pregnancies with first-trimester exposure to ASMs ended in miscarriage, while 12.2% without ASM exposure in the first trimester ended in miscarriage; after adjustment, there was a 1.06-fold relative hazard of miscarriage (95% CI 1.00 to 1.13) in women with first-trimester ASM use. After restricting to women with specific ASM indications, this association was not evident in women with epilepsy (adjusted HR 0.98, 95% CI 0.89 to 1.08), but was observed in women with bipolar or other psychiatric conditions (1.08, 95% CI 1.00 to 1.16) although CIs overlapped. Compared with discontinuation of ASMs prior to pregnancy, there was no evidence of increased risk of miscarriage for first-trimester ASM use in women with bipolar or other psychiatric conditions (1.02, 95% CI 0.87 to 1.20).

CONCLUSION

We found no clear evidence to suggest that first-trimester ASM use increased the risk of miscarriage. Taken together, our analyses suggest that apparent associations between first-trimester ASM use and miscarriage may be the result of confounding by the presence of a bipolar disorder or associated unmeasured variables.

Antiepileptic treatment with levetiracetam during the first trimester and pregnancy outcome: An observational study

OBJECTIVE

Levetiracetam is increasingly used in pregnant women with epilepsy. Although teratogenic effects have not been observed so far, data on the risks of spontaneous abortion and major birth defects are still limited, especially for the frequently used dual therapy of levetiracetam and lamotrigine. Our primary aim was to analyze rates of major birth defects and spontaneous abortion after maternal levetiracetam treatment.

METHODS

This was a cohort study based on pregnancies recorded by the Embryotox Center from 2000 to 2017. Outcomes of prospectively ascertained pregnancies with first trimester levetiracetam monotherapy (n = 221) were compared to pregnancies with lamotrigine monotherapy for epilepsy (n = 469). In addition, all pregnancies with levetiracetam (n = 364) exposure during the first trimester were analyzed in comparison to a nonexposed cohort (n = 729). Pregnancies with the most frequently used combination therapy comprising levetiracetam and lamotrigine (n = 80) were evaluated separately.

RESULTS

There was no significantly increased risk of major birth defects or of spontaneous abortions after first trimester exposure to levetiracetam. Birth weight of male neonates was significantly lower after levetiracetam monotherapy compared to lamotrigine monotherapy. Dual therapy with levetiracetam and lamotrigine resulted in a significantly increased risk of spontaneous abortion (adjusted hazard ratio = 3.01, 95% confidence interval [CI] = 1.43-6.33) and a nonsignificant effect estimate for major birth defects (7.7%, n = 5/65, adjusted odds ratio = 1.47, 95% CI = .48-4.47) compared to a nonexposed cohort.

SIGNIFICANCE

Our study confirms the use of levetiracetam as a suitable antiepileptic drug in pregnancy. The lower birth weight of male neonates after maternal levetiracetam monotherapy and the unexpectedly high risk of spontaneous abortion and birth defects after dual therapy with levetiracetam and lamotrigine require further investigation.

Comparative analysis of three decades' experience in the management of pregnant women with epilepsy: a real-life scenario

Introduction

People with epilepsy have to face many challenges, including regular follow-ups, the need to take antiseizure medications (ASMs), and the fear of seizures. Pregnant women with epilepsy (PWWE) are a special group with even more challenges because they are responsible for the fetus. We aimed to evaluate the change in the frequency of pregnancies over the years and the possible role of newer types of ASMs concerning this change, the shift in medication use over three decades, and their possible impact on the outcome of the observed pregnancies.

Methods

Data were retrieved from the prospective Epilepsy Database of the Outpatient Clinic at our tertiary center between 1 January 1992 and 31 December 2020. Groups were formed for comparison in time and depending on whether regular care consultation was our task. Statistical analysis was carried out using Microsoft Office Excel 2021. Basic statistics and categorical variables were assessed using Pearson's χ2 test with Yates' correction. Differences were considered significant if the p-value was <0.05. The odds ratio and 95% confidence intervals were calculated wherever needed.

Results

Altogether, 181 pregnancies were studied, mostly after 2002. The regular follow-up group consisted of 101 patients, with 44.5% presenting in the first trimester. The majority of seizures were either generalized or focal to bilateral tonic-clonic seizure types (85.6%). Pregnancies ended in live births in 91.7%, which gradually improved over time, while spontaneous abortion did not differ significantly in the time interval groups. Mostly, monotherapy was provided. PWWEs had higher chances for seizure freedom in the regular-care group I: OR = 2.9 (2.15-3.65) p < 0.0001. A shift toward newer-type ASMs was found as time passed. Levetiracetam and lamotrigine were more commonly used in the regular care group I than by those patients who were sent to consultation only and not treated at our center [OR = 3.18 (2.49-3.87)] p < 0.0001.

Conclusion

This is the first study in our region to evaluate experience in the treatment and outcome of PWWE. Having received reliable care and safer ASMs, the number of pregnancies among PWWEs grew. Data suggested that specialized centers' care offered cooperation with obstetricians is important. Moreover, professional care can also enable PWWEs to have uneventful pregnancies.

Changes in antiepileptic drug prescriptions over a decade in childbearing women in Lombardy region, Italy

AIMS

To describe the antiepileptic drug (AED) prescription pattern in pregnant women and women of childbearing age in the 2010-2019 period in the Lombardy region, Italy.

METHODS

The Lombardy region administrative healthcare databases (2010-2019) were analysed. AEDs were classified as drugs belonging to the N03A subgroup of the Anatomical Therapeutic Chemical Classification System. Women aged 15-49 years were considered as being of childbearing age, while exposure during pregnancy was estimated taking into account the 12 months before delivery (International Classification of Diseases, Ninth Revision, Clinical Modification, ICD-9-CM codes in the diagnosis record from 650 to 659).

RESULTS

During 2019, 16 605 women of childbearing age (prevalence: 14.8‰) received at least 1 AED prescription. Pregabalin was the most widely used antiepileptic in women of childbearing age (22.3%), followed by valproic acid (20.0%). In 2010, the prevalence of valproic acid prescription to women of childbearing age was 30.2%; in 2019 this was 20.0%. In pregnant women, this prevalence was 24.9% in 2010 and 14.1% in 2019. Starting from 2017, levetiracetam and lamotrigine were the most commonly drugs prescribed to pregnant women.

CONCLUSION

Despite the decrease in valproic acid prescription over time, this drug is still among the most used AEDs, in particular in women of childbearing age. Educational interventions for healthcare professionals and women are needed in order to reduce the risk of unplanned pregnancy.

Therapeutic termination of pregnancy and women’s mental health: Determinants and consequences

The therapeutic termination of pregnancy (TToP) is an induced abortion following a diagnosis of medical necessity. TToP is applied to avoid the risk of substantial harm to the mother or in cases of fetal unviability. This type of induced abortion is provided after the second semester of gestation if fetal illness or the pregnancy cause physical danger or pathological mental distress to the mother. Socio-cultural and economic determinants could influence the desire for children and family planning in couples, as well as the use of effective contraception and the choice to perform an induced abortion. Also, pre-existing mental health problems could affect the decision between carrying on a problematic pregnancy or having TToP. Furthermore, the TToP is a reproductive event with an important traumatic burden, but also with an intrinsic therapeutic effect and it can produce different psychological and psychopathological effects on women and couples. The aim of this review is to evaluate what demographic, reproductive and psychopathological determinants are involved in the choice of undergoing a TToP in women. Also, we will examine both positive and negative consequences of this procedure on women’s mental health, underlying which factors are related to a worse outcome in order to provide the best clinical support to vulnerable groups.

NRF2 activation inhibits valproic acid-induced neural tube defects in mice

Valproic acid (VPA) is a widely prescribed medication that has traditionally been used to treat epilepsy, yet embryonic exposure to VPA increases the risk of the fetus developing neural tube defects (NTDs). While the mechanism by which VPA causes NTDs is unknown, we hypothesize that VPA causes dysmorphogenesis through the disruption of redox-sensitive signaling pathways that are critical for proper embryonic development, and that protection from the redox disruption may decrease the prevalence of NTDs. Time-bred CD-1 mice were treated with 3H-1,2-dithiole-3-thione (D3T), an inducer of nuclear factor erythroid 2-related factor 2 (NRF2)-a transcription factor that activates the intracellular antioxidant response to prevent redox disruptions. Embryos were then collected for whole embryo culture and subsequently treated with VPA in vitro. The glutathione (GSH)/glutathione disulfide (GSSG) redox potential (E_h), a measure of the intracellular redox environment, was measured in the developing mouse embryos. Embryos treated with VPA exhibited a transiently oxidizing GSH/GSSG E_h, while those that received D3T pretreatment prior to VPA exposure showed no differences compared to controls. Moving to an in utero mouse model, time-bred C57BL/6 J dams were pretreated with or without D3T and then exposed to VPA, after which all embryos were collected for morphological analyses. The prevalence of open neural tubes in embryos treated with VPA significantly decreased with D3T pretreatment, as did the severity of the observed defects evaluated by a morphological assessment. These data show that NRF2 induction via D3T pretreatment protects against VPA-induced redox dysregulation and decreases the prevalence of NTDs in developing mouse embryos.

The role of xenobiotic-metabolizing enzymes in the placenta: a growing research field

Introduction: The placenta is a temporary and unique organ that allows for the physical connection between a mother and fetus; this organ regulates the transport of gases and nutrients mediating the elimination of waste products contained in the fetal circulation. The placenta performs metabolic and excretion functions, on the basis of multiple enzymatic systems responsible for the oxidation, reduction, hydrolysis, and conjugation of xenobiotics. These mechanisms give the placenta a protective role that limits the fetal exposure to harmful compounds. During pregnancy, some diseases require uninterrupted treatment even if it is detrimental to the fetus. Drugs and other xenobiotics alter gene expression in the placenta with repercussions for the fetus and mother's well-being.Areas covered: This review provides a brief description of the human placental structure and function, the main drug and xenobiotic transporters and metabolizing enzymes, placenta-metabolized substrates, and alterations in gene expression that the exposure to xenobiotics may cause.Expert opinion: Research should be focused on the identification and validation of biological markers for the assessment of the harmful effects of some drugs in pregnancy, including the evaluation of polymorphisms and methylation patterns in chorionic villous samples and/or amniotic fluid.

Pregnancy and Childbirth Experiences of Women with Epilepsy: A Phenomenological Approach

PURPOSE

This study sought to understand and describe the pregnancy and childbirth experiences of women with epilepsy (WWE).

METHODS

Data were collected from 2016-2017 through in-depth individual interviews with 12 WWE who experienced childbirth within 36 months. Verbatim transcripts were analyzed following Colaizzi's phenomenological analysis to uncover the meaning of the experiences of the participants.

RESULTS

The pregnancy and childbirth experiences of WWE were clustered into four theme clusters and 8 themes from 20 meaning units: 1) Feeling anxious due to unplanned pregnancy and unexpected changes; 2) Standing at crossroads that never guarantee satisfaction; 3) Carrying a burden of fearful expectation and daily routines; 4) Enjoying rewards of pregnancy and childbirth as a woman with epilepsy.

CONCLUSION

WWE had strong anxiety about the possible abnormality of their babies during pregnancy. They had mixed feelings about delivery and had to make a tough decision about breastfeeding because of antiepileptic drugs use. After childbirth, they had increased fear about the possible inheritance of the illness and had a hard time managing the burden of childcare and seizure control. However, pregnancy allows these women to gain disease awareness and further appreciate the importance of their health. The study results indicate the need for multidisciplinary intervention for WWE, before, during, and after pregnancy to increase communication with health professionals. Especially, preconception counselling and education led by nurses are required.