Prevalence of highly effective contraception use by women with epilepsy

Screening to understand pregnancy preferences and offer referrals and treatment (SUPPORT): Results of a pilot quality improvement initiative

OBJECTIVE

To assess the feasibility of integrating a pregnancy intention assessment screening algorithm into the electronic medical record (EMR) at a multispecialty clinic focused on the health of women and people assigned female at birth (AFAB).

STUDY DESIGN

This pilot quality improvement project implemented a series of clinician reminders, new data fields in the patient record, and templated clinical notes to prompt care providers across specialties to ask AFAB reproductive age individuals about their desire for future pregnancies. Investigators created a novel screening question based on prior literature and expert input. Prospective observational study of one year of during-intervention EMR data on screening uptake and documentation, contraceptive use, and referrals to obstetrics and gynecology (OBGYN) for preconception care, contraceptive care, and related services.

RESULTS

SUPPORT launched in February 2020 and was paused for 6 months due to the COVID-19 pandemic. During the intervention period through July 2021, 18% of patients for whom the automated screening reminder was activated had a documented pregnancy intention. Patients were screened in OBGYN, internal medicine, and eight subspecialty medical clinics. Among those screened, individuals who reported they did not desire pregnancy in the next year were more likely to use contraception (aOR 1.8, 95% CI 1.1, 3.1). Individuals that did desire pregnancy in the next year were more likely to be subsequently referred to OBGYN (aOR 2.7, 95% CI 1.2, 6.0).

CONCLUSIONS

Despite the competing demands of the COVID-19 pandemic, the SUPPORT intervention was utilized at higher rates than prior similar interventions and across multiple disease specialties.

IMPLICATIONS

Results from the SUPPORT pilot suggest that pregnancy intention screening of reproductive age AFAB individuals with an EMR-based screening prompt is feasible at scale.

Issues of Women with Epilepsy and Suitable Antiseizure Drugs

Seizure aggravation in women with epilepsy (WWE) tends to occur at two specific times during the menstrual cycle: the perimenstrual phase and the ovulation period. Antiseizure drugs (ASDs), especially those that induce enzymes, can accelerate the metabolism of hormones in oral contraceptives, rendering them less effective. Estrogen in contraceptive pills increases the metabolism of lamotrigine. Physiological changes during pregnancy can significantly impact the pharmacokinetics of ASDs, potentially necessitating adjustments in dosage for women with epilepsy to maintain seizure control. The use of valproate in pregnant women is associated with the highest risk of major congenital malformations among ASDs. Risks of major congenital malformations associated with lamotrigine, levetiracetam, and oxcarbazepine were within the range reported in the general population. Exposure to valproate can lead to lower IQ in offspring. Reduced folic acid levels are linked to orofacial clefts, cardiovascular malformations, and urogenital and limb anomalies in WWE. Decreased folate levels are expected with the use of enzyme-inducing ASDs. However, a high dose of folate was associated with an increased risk of cancer in children of mothers with epilepsy. Most ASDs are generally considered safe for breastfeeding and should be encouraged. However, no single ASD is considered ideal for childbearing WWE. Lamotrigine and levetiracetam are relatively more suitable options for this situation.

Counseling on the Need for Folic Acid in Adolescents With Epilepsy

Background and Objectives

Folic acid is an important supplement to take for women with epilepsy on antiseizure medications (ASMs). Determination of baseline counseling given to women with epilepsy and the association with folic acid being recommended were evaluated. Factors surrounding the association were reviewed.

Methods

An exploratory retrospective review of women with epilepsy seen at a large Midwestern pediatric institution was performed between January 2018 and January 2020.

Results

Patients who received preconception counseling were more likely to be given a recommendation to take folic acid. Patients on more than 1 ASM were likely to receive counseling. Patient age and race were associated with having folic acid recommended.

Discussion

Providing preconception counseling for women with epilepsy is associated with an increased recommendation and prescription of folic acid. Further evaluation into possible disparities to receiving a folic acid recommendation is needed.

Reproductive Health Counseling in Adolescent Women With Epilepsy: A Single-Center Study

BACKGROUND

Counseling adolescent women with epilepsy (WWE) about reproductive health (contraception, sexual activity, and menstruation) is important given the teratogenicity of many antiseizure medications and high rates of contraception failure. Only a third of adolescent WWE report discussing contraception with their epileptologists, demonstrating a significant gap in counseling.

METHODS

We assessed factors associated with reproductive health counseling by pediatric neurologists via a retrospective chart review of adolescent (aged 12-18 years) WWE seen at a pediatric neurology clinic from 2018 to 2020.

RESULTS

We analyzed 219 visits among 89 unique WWE. There were 23 documented discussions on contraception (11% of visits), 8 on sexual activity (4%), and 127 on menstruation (58%). When contraception was discussed, sexual activity and menstruation were more frequently discussed. Female providers were more likely to document a discussion of menstruation (OR = 3.2, 95% CI = [1.6, 6.4]). WWE who were older at the time of visit or who had their first seizure at an older age were more likely to have documented discussions of contraception and sexual activity. Neither details of treatment regimen nor epilepsy type was associated with documentation of counseling.

CONCLUSIONS

A minority of adolescent WWE have documented reproductive health discussions, demonstrating a need for quality improvement projects to address this gap in care.

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

PURPOSE OF REVIEW

Caring for women with epilepsy requires specialized knowledge about potential teratogenicity of antiseizure medications, interactions with hormonal contraception, and pregnancy outcomes.

RECENT FINDINGS

There has been an improvement in understanding the cognitive outcomes of infants exposed in utero in recent years. Folic acid supplementation helps mitigate the cognitive teratogenicity of antiseizure medications. Recent updates provide reassurance that seizure frequency tends to remain stable throughout pregnancy. There is conflicting evidence about the fecundity impact of epilepsy and antiseizure medications in women with epilepsy.

SUMMARY

Recent research highlights the importance of early counseling about the risks and interactions of contraception, pregnancy, and antiseizure medications. More research is needed to understand fertility in women with epilepsy.

Differential risks of changes in seizure frequency with transitions between hormonal and non-hormonal contraception in women with epilepsy: A prospective cohort study

This prospective, observational, cohort study of 101 women with epilepsy (WWE) assesses the seizure safety of systemic hormonal contraception (HC) versus non-HC (NHC). It reports risks of changes in seizure frequency associated with transition from NHC to HC relative to HC to NHC for (1) proportions of WWE with ≥50% increase and decrease in seizure frequency, (2) changes in seizure frequency, (3) changes in seizure severity, and 4) changes in AED regimen during the study. In comparing NHC to HC versus HC to NHC, NHC to HC had greater risk of ≥50% increase in seizure frequency: RR = 1.98 (1.07-3.64), p = 0.03 and lower risk of ≥50% decrease in seizure frequency: RR = 0.42 (0.22 = 0.83), p = 0.01. These risks were particularly notable for oral contraceptive pill: RR = 2.91 (1.26-6.72), p = 0.01 and RR = 0.54 (0.30-0.97), p = 0.04, respectively. Median monthly seizure frequency (MMSF) increased 302.0% (p = 0.0019) with transition from NHC to HC. MMSF decreased 81.9% with change from HC to NHC (p = 0.001). RR for change in seizure type from milder to more severe type was greater for NHC to HC: RR = 3.32 (1.07-10.27), p = 0.04. Change in AED regimen was not a significant factor. The findings suggest further prospective study to assess whether HC, especially oral contraceptive pill, poses a greater risk of increased seizures than NHC.

Managing Transition of Care in Adolescent Females with Epilepsy

Transition of care from pediatric epilepsy clinics to adult health care is often a challenging process, especially due to limited availability of relevant guidelines. It carries even more significant implications in specific population subsets such as adolescent females, given a myriad of physiological as well as psychosocial changes seen in this age group. Women with epilepsy face distinct challenges because of hormonal variations on seizures (catamenial epilepsy). Furthermore, seizures and antiepileptic drugs impact menstruation, pregnancy, and lactation. These patients are at a higher risk for developing mental health problems, and a close follow-up with appropriate screening for psychiatric disorders is prudent.

Several factors contributing to poor transition of care include limited availability of a multidisciplinary set-up and social-support services, delayed referral to specialist(s), and tendency for treatment nonadherence. In this review, we discuss the current scenario of transition of care in adolescent females with epilepsy and explore avenues for improvement based on our subspecialty clinic experiences. We illustrate the value of interdisciplinary care proactively involving neurologists/epileptologists, primary care physicians, obstetricians–gynecologists, and relevant social services and emphasize shared decision-making, effective contraceptive methods, preconceptual counseling, maintenance of bone-health, and enhanced quality of life.

Effect of cinnamaldehyde on Cav-1 and Survivin expression in epilepsy: A protocol of systematic review and meta-analysis

BACKGROUND

This systematic review aims to assess the effect of cinnamaldehyde on Cav-1 and Survivin expression in epilepsy.

METHODS

We will search Cochrane Library, PUBMED, EMBASE, CINAHL, Web of Science, Google Scholar, PsycINFO, WANGFANG, VIP, CBM, and CNKI from their inceptions to the March 31, 2020, without language restrictions. Two authors will independently carry out searching literature records, scanning titles and abstracts, full texts, collecting data, and assessing risk of bias. RevMan 5.3 software will be used for statistical analysis.

RESULTS

This systematic review will investigate whether cinnamaldehyde is effective on Cav-1 and Survivin expression in epilepsy.

CONCLUSION

Its findings will provide helpful evidence for the effect of cinnamaldehyde on Cav-1 and Survivin expression in epilepsy.Systematic review registration: INPLASY202040152.