Malformation Rates in Children of Women with Untreated Epilepsy

[Epilepsy and pregnancy]

BACKGROUND

Regarding treatment of women of childbearing potential with epilepsy, several aspects of family planning and desire to have children have to be taken into account.

OBJECTIVE

Overview of current data on mutual implications of epileptic seizures, antiseizure medication (ASM), pregnancy and child development.

METHOD

Review of the current literature, discussion and presentation of resulting treatment recommendations.

RESULTS

Many ASMs bear the potential for clinically relevant interactions with both contraceptives and altered concentrations of sexual hormones and modified pharmacokinetics during pregnancy. All ASMs show an increased risk for congenital malformations; however, due to seizure-related risks for the mother and child effective ASM treatment during pregnancy is crucial.

CONCLUSION

When considering the special aspects of consultation and treatment of women of childbearing potential with epilepsy most pregnancies are uncomplicated.

Valproic Acid in Pregnancy Revisited: Neurobehavioral, Biochemical and Molecular Changes Affecting the Embryo and Fetus in Humans and in Animals: A Narrative Review

Valproic acid (VPA) is a very effective anticonvulsant and mood stabilizer with relatively few side effects. Being an epigenetic modulator, it undergoes clinical trials for the treatment of advanced prostatic and breast cancer. However, in pregnancy, it seems to be the most teratogenic antiepileptic drug. Among the proven effects are congenital malformations in about 10%. The more common congenital malformations are neural tube defects, cardiac anomalies, urogenital malformations including hypospadias, skeletal malformations and orofacial clefts. These effects are dose related; daily doses below 600 mg have a limited teratogenic potential. VPA, when added to other anti-seizure medications, increases the malformations rate. It induces malformations even when taken for indications other than epilepsy, adding to the data that epilepsy is not responsible for the teratogenic effects. VPA increases the rate of neurodevelopmental problems causing reduced cognitive abilities and language impairment. It also increases the prevalence of specific neurodevelopmental syndromes like autism (ASD) and Attention Deficit Hyperactivity Disorder (ADHD). High doses of folic acid administered prior to and during pregnancy might alleviate some of the teratogenic effect of VPA and other AEDs. Several teratogenic mechanisms are proposed for VPA, but the most important mechanisms seem to be its effects on the metabolism of folate, SAMe and histones, thus affecting DNA methylation. VPA crosses the human placenta and was found at higher concentrations in fetal blood. Its concentrations in milk are low, therefore nursing is permitted. Animal studies generally recapitulate human data.

Developmental Toxicity Studies: The Path towards Humanized 3D Stem Cell-Based Models

Today, it is recognized that medicines will eventually be needed during pregnancy to help prevent to, ameliorate or treat an illness, either due to gestation-related medical conditions or pre-existing diseases. Adding to that, the rate of drug prescription to pregnant women has increased over the past few years, in accordance with the increasing trend to postpone childbirth to a later age. However, in spite of these trends, information regarding teratogenic risk in humans is often missing for most of the purchased drugs. So far, animal models have been the gold standard to obtain teratogenic data, but inter-species differences have limited the suitability of those models to predict human-specific outcomes, contributing to misidentified human teratogenicity. Therefore, the development of physiologically relevant in vitro humanized models can be the key to surpassing this limitation. In this context, this review describes the pathway towards the introduction of human pluripotent stem cell-derived models in developmental toxicity studies. Moreover, as an illustration of their relevance, a particular emphasis will be placed on those models that recapitulate two very important early developmental stages, namely gastrulation and cardiac specification.

The Use of Antiepileptic Drugs During Pregnancy and Fetal Outcomes

Epilepsy affects approximately 1 percent of the population and roughly 1 million women of childbearing age. Estimates suggest that 0.3-0.7 percent of pregnancies occur in women with epilepsy. Epilepsy itself increases the risk of congenital malformation and medications add to this risk. Also, approximately one-half of the use of medications for epilepsy are used for other indications, possibly increasing exposure in some women. As controlled trials with these medications are not performed during pregnancy, data has been accumulated primarily through databases and case studies. This review is intended to update the practitioner about the use and concerns of antiepileptic medications in the presnant woman and the potential effects on the fetus and neonate.

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.

Levetiracetam, lamotrigine and carbamazepine: which monotherapy during pregnancy?

OBJECTIVE

Epilepsy treatment during pregnancy is still challenging. The study is aimed at comparing the efficacy and safety of carbamazepine (CBZ), lamotrigine (LTG) and levetiracetam (LEV) monotherapies during pregnancy in women with focal (FE) or generalized (GE) epilepsy.

METHODS

A multicentre retrospective study was conducted to evaluate seizures frequency and seizure freedom (SF) rate during 3 months before pregnancy, each trimester of gestation and post-partum period in women on monotherapy with CBZ, LTG and LEV.

RESULTS

Fifty-seven pregnancies (45 FE, 12 GE) on monotherapy (29 CBZ, 11 LTG, 17 LEV) were included. A significant reduction of seizure frequency was found in the first trimester of pregnancy as compared with that one before pregnancy (p = 0.004), more evident in GE (p = 0.003) and in LEV group (p = 0.004). The SF rate significantly increased in the first trimester in comparison to that one before pregnancy and persisted in the post-partum period in the whole sample (p < 0.001) and in women on LEV (p = 0.004). Besides, 88.57% of SF women before pregnancy remained unchanged during gestation and the post-partum period. One major heart malformation in CBZ and no major malformations in LTG and LEV groups were found.

CONCLUSIONS

A better clinical outcome during pregnancy emerged since the first trimester in comparison to the before-pregnancy period, mostly evident in women with GE and LEV therapy, reinforcing the hypothesis of a protective role of pregnancy versus seizures. SF before pregnancy represents a significant predictive factor of good clinical outcome during gestation and the post-partum period. Compared to CBZ, LTG and LEV showed a better safety profile.

Dynamic placenta-on-a-chip model for fetal risk assessment of nanoparticles intended to treat pregnancy-associated diseases

Pregnant women often have to take medication either for pregnancy-related diseases or for previously existing medical conditions. Current maternal medications pose fetal risks due to off target accumulation in the fetus. Nanoparticles, engineered particles in the nanometer scale, have been used for targeted drug delivery to the site of action without off-target effects. This has opened new avenues for treatment of pregnancy-associated diseases while minimizing risks on the fetus. It is therefore instrumental to study the potential transfer of nanoparticles from the mother to the fetus. Due to limitations of in vivo and ex vivo models, an in vitro model mimicking the in vivo situation is essential. Placenta-on-a-chip provides a microphysiological recapitulation of the human placenta. Here, we reviewed the fetal risks associated with current therapeutic approaches during pregnancy, analyzed the advantages and limitations of current models used for nanoparticle assessment, and highlighted the current need for using dynamic placenta-on-a-chip models for assessing the safety of novel nanoparticle-based therapies during pregnancy.

Effects of antiepileptic drugs' administration during pregnancy on the nerve cell proliferation and axonal outgrowth of human neuroblastoma SH-SY5Y nerve cells

It has been suggested that the intelligence quotient of children born to pregnant women taking 1000 mg or more of valproic acid per day is lower than that of children born to pregnant women taking other antiepileptic drugs. However, the mechanism whereby intelligence quotient is decreased in children exposed to valproic acid during the fetal period has not yet been elucidated. Therefore, we used the human neuroblastoma cell line SH-SY5Y to evaluate the effects of antiepileptic drugs containing valproic acid on nerve cells. We assessed the anti-proliferative effects of drugs in these cells via WST-8 colorimetric assay, using the Cell Counting Kit-8. We also quantified drug effects on axonal elongation from images using ImageJ software. We also evaluated drug effects on mRNA expression levels on molecules implicated in nervous system development and folic acid uptake using real-time PCR. We observed that carbamazepine and lamotrigen were toxic to SH-SY5Y cells at concentrations >500 μM. In contrast, phenytoin and valproic acid were not toxic to these cells. Carbamazepine, lamotrigen, phenytoin, and valproic acid did not affect axonal outgrowth in SH-SY5Y cells. Sodium channel neuronal type 1a (SCN1A) mRNA expression-level ratios increased when valproic acid was supplemented to cells. The overexpression of SCN1A mRNA due to high valproic acid concentrations during the fetal period may affect neurodevelopment. However, since detailed mechanisms have not yet been elucidated, it is necessary to evaluate it by comparing cell axon elongation and SCN1A protein expression due to high-concentration valproic acid exposure.

Obstetric outcomes in pregnant women with seizure disorder: A hospital-based, longitudinal study

Objective:

To study the association of seizure disorder with adverse obstetric outcome in terms of maternal and perinatal complications.

Materials and Methods:

This longitudinal study was conducted at Maulana Azad Medical College, New Delhi over 15 months among women attending the antenatal clinic (ANC) outpatient department. Fifty pregnant women with seizure disorder with their first ANC visit before 28 weeks were recruited as the case group, excluding patients with eclampsia. The control group included 120 matched healthy pregnant women. After obtaining informed consent, subjects were recruited and followed till one week postpartum and obstetric outcomes were analyzed.

Results:

Women with seizure disorder had significantly increased incidence of severe preeclampsia (cases =8%, controls =0%, p<0.001), antepartum hemorrhage (cases =4%, controls =0%, p<0.001), babies with early neonatal complications such as asphyxia (cases =4.1%, controls =0.5%, p=0.04), respiratory distress (cases =14.5%, controls =5.1%, p=0.02), necrotizing enterocolitis (cases =2.0%, controls =0%, p=0.04), early neonatal death (cases =2.0%, controls =0%, p=0.04) and Neonatal Intensive Care Unit admission (cases =20.8%, controls =8.6%, p<0.001) when compared with women without seizure disorder. No significant difference was observed in rates of induction of labor, cesarean section, abortion, congenital anomalies in babies, still births. Conclusion: Women with seizure disorder are at higher risk of hypertensive disorders, antepartum hemorrhage, and early neonatal complications.

Conclusion:

Women with seizure disorder are at higher risk of hypertensive disorders, antepartum hemorrhage, and early neonatal complications. Appropriate obstetric, pediatric and neurology care is required during preconception, pregnancy, labor, delivery, and postpartum.

Prescribing for pregnancy: epilepsy

Topics for DTB review articles are selected by DTB's editorial board to provide concise overviews of medicines and other treatments to help patients get the best care. Articles include a summary of key points and a brief overview for patients. Articles may also have a series of multiple choice CME questions.

Therapeutic strategies for treating epilepsy during pregnancy

INTRODUCTION

Counseling for women with epilepsy of childbearing potential surrounding pregnancy issues is of the utmost importance and should be done when antiepileptic medications are prescribed and reviewed regularly at clinic visits. Physicians must be familiar with risks associated with antiepileptic medication, and endeavor to minimize risks to a fetus while selecting best medications for epilepsy type.

AREAS COVERED

The authors discuss the role of folic acid, updated evidence relating to the occurrence of major congenital malformations and neurocognitive risks associated with antiepileptic medication. They also examine the rationale for monitoring drug levels, optimum delivery strategies, and evidence for the safety of breastfeeding while taking antiepileptic medication.

EXPERT OPINION

Valproate carries the highest known teratogenic risk in pregnancy and should only be prescribed to women of child-bearing potential in a specialist setting. There is a need for the ongoing register collection of risks associated with newer AEDs which lack substantial (major) data. Choosing these newer medications can create a dilemma for physicians, particularly when seizures are not well controlled or where treatment options are limited. The authors advocate a multidisciplinary team approach to managing women with epilepsy so that pregnancies in such women can be well managed in an optimum and individualized fashion.

Maternal and neonatal complications during pregnancy in women with epilepsy

Epilepsy is the commonest serious neurological problem faced by obstetricians and gynaecologists. Epidemiological studies estimate epilepsy to complicate 0.3–0.7% of all pregnancies.1 2 The importance of epilepsy in pregnancy lies in the fact that many women with epilepsy (WWE) have to go through their pregnancy while taking antiepileptic (AED) drugs. Both the seizures and AEDs can have harmful effects on the mother as well the foetus. Thus, during pregnancy, the clinician faces dual challenge of controlling seizures as well as preventing teratogenicity of AEDs.1 In this review we discuss the possible impact of seizures as well as AEDs on mother as well as the child. We try to answer some of the commonest questions which are relevant to successful management of pregnancy and ensuring birth of a healthy baby.

Mood-Stabilizing Anticonvulsants, Spina Bifida, and Folate Supplementation: Commentary

PURPOSE/BACKGROUND

High risks of neural tube defects and other teratogenic effects are associated with exposure in early pregnancy to some anticonvulsants, including in women with bipolar disorder.

METHODS/PROCEDURES

Based on a semistructured review of recent literature, we summarized findings pertaining to this topic.

FINDINGS/RESULTS

Valproate and carbamazepine are commonly used empirically (off-label) for putative long-term mood-stabilizing effects. Both anticonvulsants have high risks of teratogenic effects during pregnancy. Risks of neural tube defects (especially spina bifida) and other major malformations are especially great with valproate and can arise even before pregnancy is diagnosed. Standard supplementation of folic acid during pregnancy can reduce risk of spontaneous spina bifida, but not that associated with valproate or carbamazepine. In contrast, lamotrigine has regulatory approval for long-term use in bipolar disorder and appears not to have teratogenic effects in humans.

IMPLICATIONS/CONCLUSIONS

Lack of protective effects against anticonvulsant-associated neural tube defects by folic acid supplements in anticipation of and during pregnancy is not widely recognized. This limitation and high risks of neural tube and other major teratogenic effects, especially of valproate, indicate the need for great caution in the use of valproate and carbamazepine to treat bipolar disorder in women of child-bearing age.

Topiramate use early in pregnancy and the risk of oral clefts: A pregnancy cohort study

OBJECTIVE

To assess the relative risk of oral clefts associated with maternal use of high and low doses of topiramate during the first trimester for epilepsy and nonepilepsy indications.

METHODS

This population-based study nested in the US 2000-2010 Medicaid Analytic eXtract included a cohort of 1,360,101 pregnant women with a live-born infant enrolled in Medicaid from 3 months before conception through 1 month after delivery. Oral clefts were defined as the presence of a recorded diagnosis in claims during the first 90 days after birth. Women with a topiramate dispensing during the first trimester were compared with those without any dispensing and with an active reference group of women with a lamotrigine dispensing during the first trimester. Risk ratios (RRs) were estimated with generalized linear models with fine stratification on the propensity score of treatment to control for potential confounders. Stratified analyses by indication of use and dose were conducted.

RESULTS

The risk of oral clefts at birth was 4.1 per 1,000 in the 2,425 infants born to women exposed to topiramate compared with 1.1 per 1,000 in the unexposed group (RR 2.90, 95% confidence interval [CI] 1.56-5.40). The RR among women with epilepsy was 8.30 (95% CI 2.65-26.07); among women with other indications such as bipolar disorder, it was 1.45 (95% CI 0.54-3.86). The median daily dose for the first prescription filled during the first trimester was 200 mg for women with epilepsy and 100 mg for women without epilepsy. For topiramate monotherapy, the RR for oral clefts associated with doses ≤100 mg was 1.64 (95% CI 0.53-5.07) and for doses >100 mg it was 5.16 (95% CI 1.94-13.73). Results were similar when lamotrigine was used as a reference group.

CONCLUSION

The increased risk of oral clefts associated with use of topiramate early in pregnancy was more pronounced in women with epilepsy, who used higher doses.

Pregnancy outcome in women with epilepsy in Western China: A prospective hospital based study

OBJECTIVE

Gaps exist in the diagnosis and treatment of women with epilepsy (WWE) between China and Euro-American countries. We aim to find out and share our experience of the multidisciplinary integrated treatment for WWE.

METHODS

We prospectively registered WWE who were diagnosed by both epileptologists and obstetrician in our green way system for the past 5years (2009-2015). Registration information include years of education, epilepsy history, seizure type and frequency, pregnancy and delivery complications, delivery mode, and Apgar score of newborn. All data were analyzed by SAS 9.3 version.

RESULTS

We included 137 cases of maternal epilepsy (155 pregnancies with average maternal age of 26years old). 18 cases underwent epilepsy surgery before pregnancy. 103 pregnancies (66.45%) were cesarean section, 52 (33.55%) were natural childbirth, only 10 pregnancies have pregnancy complications, 2 have delivery complication, and 15 have seizures during delivery process. Most offspring were healthy when they were born (only 11 newborn got Apgar score<7). For drug treatment, patients never took AEDs or withdrew AEDs in 55 (35.48%) pregnancies. For folic acid supplementation, only 9 (5.81%) achieved the dose recommended by ILAE guideline (5mg/day). For the seizure frequency, 108 pregnancies (69.68%) did not changed, 3 (1.94%) reduced, 44(28.39%) increased and mainly increased in the first and last trimesters. For feeding way, 90 (58.06%) chose artificial feeding, followed by 39 (16.77%) of mixed feeding and 26 of breastfeeding.

CONCLUSION

Clinical features and perinatal outcome of Chinese WWE are similar to western WWE. For mode of delivery, even suggested by our epileptologists and obstetrician to deliver naturally, more patients selected cesarean section. Moreover, withdrawal of AEDs during pregnancy is common. Therefore, it is necessary to pay more attention to standard management of WWE and establish a more practical green way for WWE in China, to keep up with developed countries and improve the health level of birth in China.

Pentylenetetrazole-induced seizures in developing rats prenatally exposed to valproic acid

BACKGROUND

Epidemiological evidence indicates epilepsy is more common in patients with autism spectrum disorders (ASD) (20-25%) than in the general population. The aim of this project was to analyze seizure susceptibility in developing rats prenatally exposed to valproic acid (VPA) as autism model.

METHODS

Pregnant females were injected with VPA during the twelfth embryonic day. Seizures were induced in fourteen-days-old rat pups using two models of convulsions: pentylenetetrazole (PTZ) and lithium-pilocarpine (Li-Pilo).

RESULTS

Two subgroups with different PTZ-induced seizure susceptibility in rats exposed to VPA were found: a high susceptibility (VPA+) (28/42, seizure severity 5) and a low susceptibility (VPA-) (14/42, seizure severity 2). The VPA+ subgroup exhibited an increased duration of the generalized tonic-clonic seizure (GTCS; 45 ± 2.7 min), a higher number of rats showed several GTCS (14/28) and developed status epilepticus (SE) after PTZ injection (19/27) compared with control animals (36.6 ± 1.9 min; 10/39; 15/39, respectively). No differences in seizure severity, latency or duration of SE induced by Li-Pilo were detected between VPA and control animals.

DISCUSSION

Prenatal VPA modifies the susceptibility to PTZ-induced seizures in developing rats, which may be linked to an alteration in the GABAergic transmission. These findings contribute to a better understanding of the comorbidity between autism and epilepsy.

The treatment of epilepsy in pregnancy: The neurodevelopmental risks associated with exposure to antiepileptic drugs

A number of antiepileptic drugs (AEDs) have been confirmed as teratogens due to their association with an increased malformation rate. The majority of research to date does not find an association between prenatal exposure to monotherapy carbamazepine, lamotrigine or phenytoin and neurodevelopmental outcome in comparison to control children and noted higher abilities in comparison to children exposed to valproate; but further work is needed before conclusions can be drawn. Data for levetiracetam was limited to one study, as was the evidence for topiramate. Sodium valproate exposure appeared to carry a dose dependent risk to the developing brain, with evidence of reduced levels of IQ, poorer verbal abilities and increased rate of autistic spectrum disorder both in comparison to control children and children exposed to other AEDs. The severity of the neurodevelopmental deficits associated with prenatal exposure to valproate highlight the critical need to consider neurodevelopmental outcomes as a central aspect of teratological research.

Prescription patterns of antiepileptic drugs in young women: development of a tool to distinguish between epilepsy and psychiatric disorders

BACKGROUND

Antiepileptic drugs (AEDs) are also prescribed for therapeutic indications other than epilepsy (EPI), namely, psychiatric disorders (PSY). Our aim was to develop an algorithm able to distinguish between EPI and PSY among childbearing age women based on differences in AED exposure in these patient groups.

METHODS

Two groups of women (18-45 years) with EPI or PSY treated with AEDs in the first semester of 2010 or 2011 were extracted from paper or electronic medical charts of specialized centers. Through the prescription database of Bologna Local Health Authority (Italy), AEDs, treatment schedule and co-treatments were collected for each patient. A prescription-based hierarchical classification system was developed. The algorithm obtained was subsequently validated on internal and external data.

RESULTS

Eighty-one EPI and 94 PSY subjects were recruited. AED monotherapy was the most common choice in both groups (69% EPI vs 79% PSY). Some AEDs were used only in EPI, others exclusively in PSY. Co-treatments with antipsychotics (6% vs 67%), lithium (0% vs 9%), and antidepressants (7% vs 70%) were fewer in EPI than in PSY. The hierarchical classification system identified antipsychotics, SSRIs (Selective Serotonin Reuptake Inhibitors), and number of AEDs as variables to discriminate EPI and PSY, with an overall error rate estimate of 9.7% (95%CI: 5.3% to 14.1%).

CONCLUSION

Among the differences between EPI and PSY, prescription data alone allowed an algorithm to be developed to diagnose each childbearing age woman receiving AEDs. This approach will be useful to stratify patients for risk estimates of AED-treated patients based on administrative databases. Copyright © 2016 John Wiley & Sons, Ltd.

Teratogenic medications and concurrent contraceptive use in women of childbearing ability with epilepsy

BACKGROUND

Many antiepileptic drugs (AEDs) have the potential to cause teratogenicity. We evaluated eight antiepileptic drugs (AEDs) classified as Federal Drug Administration (FDA) pregnancy category D, X, or N designations and having documented teratogenic effects. These include carbamazepine, ethosuximide, fosphenytoin, phenobarbital, phenytoin, primidone, topiramate, and valproate. Women with epilepsy (WWE) may need one or more of these AEDs for seizure control but may be unaware of the potential teratogenicity associated with their use. In utero exposure to AEDs increases the risks for both congenital malformations and other teratogenic defects. Given that approximately 50% of pregnancies are unintended, it is likely that women with epilepsy taking these medications could unknowingly put a growing fetus at risk. For women using contraception while taking these medications, many choose combined hormonal contraceptives (CHCs). Drug-drug interactions exist between AEDs and CHCs that may decrease contraceptive efficacy. The aim of this study was to evaluate prescribing patterns for potentially teratogenic AEDs and contraceptive use in WWE of childbearing ability, including those with potential drug-drug interactions. This study also determined the number of WWE of childbearing ability prescribed potentially teratogenic AEDs and documentation of a pregnancy or contraception plan.

METHODS

This was a retrospective, observational study of WWE age 15-44 years, of childbearing ability, prescribed an AED from July 1, 2011 to June 30, 2012, and who had an appointment at the University of Colorado Hospital Outpatient Neurology Clinic (Anschutz Medical Campus).

RESULTS

One hundred fifteen women with an average age of 30.7 years and various types of seizures were evaluated. The majority of patients were prescribed topiramate (34/115, 30%) or carbamazepine (27/115, 23%). Of the women, 30/115 (26%) had a documented contraception method when taking a potentially teratogenic AED. Of these women prescribed contraception, most (18/30, 60%) used an oral combined hormonal contraceptive or progestin-only pill, a majority of which had a potential for a drug-drug interaction with their AEDs (16/18, 89%). Less than 7% of women received counseling on a contraception plan, and 18% of subjects received counseling on a pregnancy plan.

CONCLUSIONS

Most WWE of childbearing ability taking potentially teratogenic AEDs were not using contraception. Those using contraception frequently had a method that has a significant drug-drug interaction which reduces the effectiveness of contraception. Women with epilepsy of childbearing ability prescribed an AED should be using effective contraception or participating in active discussions about pregnancy planning to avoid unplanned pregnancies and possible teratogenic effects of these AEDs. Documentation about pregnancy planning or contraceptive use in WWE of childbearing ability is minimal and should be discussed at least annually. It is critical for providers to discuss with WWE of childbearing ability the benefits and risks of various AED treatments; the need to select appropriate, effective contraception when pregnancy is not desired; and the importance of counseling regarding contraceptive or pregnancy planning.

Pregnancy outcome of 149 pregnancies in women with epilepsy: Experience from a tertiary care hospital

INTRODUCTION

Epilepsy has a prevalence of 1.65% in adults, and every 1 in 200 pregnancies encounters its complications. We aimed to present the existing condition of and our experience with epileptic pregnant women for whom the prepregnancy counseling is inadequate in Turkey.

METHODS

We evaluated 149 epileptic pregnant women between March 2009 and January 2015. Demographic features of the patients, along with type and duration of epileptic seizure, time of diagnosis, date of last seizure prior to pregnancy, number and duration of seizures during pregnancy, type of AEDs, result and week of termination of pregnancy, and birth weight were registered, and also, we evaluated perinatal complications and fetal malformations.

RESULTS

Mean age of the patients was 27.12 ± 5.4 years, and mean duration from the diagnosis of epilepsy to pregnancy was 9.68 ± 5.91 years. Twenty-seven (18.12%) and 101 (67.78%) patients had polytherapy and monotherapy, respectively. We observed epileptic seizures in 103 (69.12%) patients during pregnancy, and seizures mostly occurred in the first and third trimesters. Forty-one (39.80%) patients had seizures in all three trimesters. Forty-two (28.18%) patients among all patients who had seizures during pregnancy had 5 or more seizures. Major malformations, namely, cleft lip and palate, ventriculoseptal defect, and spina bifida were observed in the patients. Mean birth week was 38.43 ± 1.68 weeks, and mean birth weight was 2965.31 ± 453.94 grams. Twenty-two patients had normal spontaneous vaginal delivery whereas 118 patients had cesarean section.

CONCLUSIONS

Pregnant women with epilepsy have their own risks. These women should be followed by experienced obstetricians and neurologists during their pregnancies. Appropriate management and follow-up lead to good results almost the same as general population.

Management of epilepsy during pregnancy: evidence-based strategies

Child-bearing years are often the most precarious management period in the life of a woman with epilepsy. This article reviews the results of many different studies with findings that enable the healthcare team to make confident decisions and recommendations during these critical periods. Preconceptional planning, effective contraception and folic acid supplementation are important fundamentals in preparation for pregnancy. There is growing evidence to avoid valproic acid use during the child-bearing years. Emerging data on congenital malformations and neurocognitive outcomes are available for some of the second-generation antiepileptic drugs and appear reassuring for lamotrigine and levetiracetam. Also reviewed are the benefits of postpartum drug tapers and favorable breastfeeding facts. Counseling the mother and her family on medication choices enables the healthcare team to implement informed decisions that are beneficial for the mother and child.

Electroconvulsive therapy during pregnancy: a systematic review of case studies

This study aims to explore practice, use, and risk of electroconvulsive therapy (ECT) in pregnancy. A systematic search was undertaken in the databases Medline, Embase, PsycINFO, SveMed and CINAHL (EBSCO). Only primary data-based studies reporting ECT undertaken during pregnancy were included. Two reviewers independently checked study titles and abstracts according to inclusion criteria and extracted detailed use, practice, and adverse effects data from full text retrieved articles. Studies and extracted data were sorted according to before and after year 1970, due to changes in ECT administration over time. A total of 67 case reports were included and studies from all continents represented. Altogether, 169 pregnant women were identified, treated during pregnancy with a mean number of 9.4 ECTs, at mean age of 29 years. Most women received ECT during the 2nd trimester and many were Para I. Main diagnostic indication in years 1970 to 2013 was Depression/Bipolar disorder (including psychotic depression). Missing data on fetus/child was 12 %. ECT parameter report was often sparse. Both bilateral and unilateral electrode placement was used and thiopental was the main anesthetic agent. Adverse events such as fetal heart rate reduction, uterine contractions, and premature labor (born between 29 and 37 gestation weeks) were reported for nearly one third (29 %). The overall child mortality rate was 7.1 %. Lethal outcomes for the fetus and/or baby had diverse associations. ECT during pregnancy is advised considered only as last resort treatment under very stringent diagnostic and clinical indications. Updated international guidelines are urgently needed.

Perinatal Influences of Valproate on Brain and Behaviour: An Animal Model for Autism

Valproic acid or valproate (VPA) is an anti-convulsant and mood stabiliser effective in treating epilepsy and bipolar disorders. Although in adults VPA is well tolerated and safe, there is convincing evidence that it has teratogenic properties, ranging from mild neurodevelopmental changes to severe congenital malformations. In particular, studies involving humans and other animals have shown that prenatal exposure to VPA can induce developmental abnormalities reminiscent of autism spectrum disorder (ASD). In this chapter, we discuss the connection between VPA and ASD, evaluate the VPA animal model of ASD, and describe the possible molecular mechanisms underlying VPA's teratogenic properties.

Treatment of bipolar disorders during pregnancy: maternal and fetal safety and challenges

Treating pregnant women with bipolar disorder is among the most challenging clinical endeavors. Patients and clinicians are faced with difficult choices at every turn, and no approach is without risk. Stopping effective pharmacotherapy during pregnancy exposes the patient and her baby to potential harms related to bipolar relapses and residual mood symptom-related dysfunction. Continuing effective pharmacotherapy during pregnancy may prevent these occurrences for many; however, some of the most effective pharmacotherapies (such as valproate) have been associated with the occurrence of congenital malformations or other adverse neonatal effects in offspring. Very little is known about the reproductive safety profile and clinical effectiveness of atypical antipsychotic drugs when used to treat bipolar disorder during pregnancy. In this paper, we provide a clinically focused review of the available information on potential maternal and fetal risks of untreated or undertreated maternal bipolar disorder during pregnancy, the effectiveness of interventions for bipolar disorder management during pregnancy, and potential obstetric, fetal, and neonatal risks associated with core foundational pharmacotherapies for bipolar disorder.

Neurologic disease with pregnancy and considerations for the obstetric anesthesiologist

Women with neurologic conditions present a challenge during pregnancy and in the peripartum period. Given the low prevalence of these diseases during pregnancy, most management decisions are guided by retrospective reviews and case reports. This article reviews current literature for some of the more common or complex neurologic conditions affecting pregnancy with special consideration for anesthetic management. In particular, epilepsy; multiple sclerosis; primary intracranial hypertension; secondary intracranial hypertension-Arnold-Chiari malformations and intracranial neoplasms; spinal cord injury; neuromuscular junction disorders-myasthenia gravis; and hereditary neuromuscular disorders-myotonic dystrophy and spinal muscular atrophy will be discussed. By increasing understanding of anesthetic issues for parturients with neurologic disease, providers may more effectively anticipate anesthetic considerations, thereby optimizing care plans.

Alteration of bioelectrically-controlled processes in the embryo: a teratogenic mechanism for anticonvulsants

Maternal use of anticonvulsants during the first trimester of pregnancy has been associated with an elevated risk of major congenital malformations in the offspring. Whether the increased risk is caused by the specific pharmacological mechanisms of certain anticonvulsants, the underlying epilepsy, or common genetic or environmental risk factors shared by epilepsy and malformations has been controversial. We hypothesize that anticonvulsant therapies during pregnancy that attain more successful inhibition of neurotransmission might lead to both better seizure control in the mother and stronger alteration of bioelectrically-controlled processes in the embryo that result in structural malformations. We propose that development of pharmaceuticals that do not alter cell resting transmembrane voltage levels could result in safer drugs.

Birth defects and epilepsy medication

Epilepsy is one of the most common neurological problems in pregnancy. Approximately one in 200 pregnancies is to a woman with epilepsy taking antiepileptic drugs. For the majority of women, pregnancy proceeds without any apparent difficulties but there is growing evidence of an increased risk of major malformations and later cognitive problems in children exposed to antiepileptic drugs in utero. This review summarizes the available evidence for these risks and examines the implications of these in the counseling and treatment of women with epilepsy.

Preschool behavioral problems in children prenatally exposed to antiepileptic drugs - a follow-up study

We studied the association between maternal epilepsy, antiepileptic drug (AED) treatment, and behavioral problems in preschool children. In the Danish National Birth Cohort, we identified 4- to 5-year-old children whose mothers had epilepsy and received AED treatment (n=133) or not (n=304) during pregnancy and compared them with randomly selected children whose mothers did not have epilepsy (n=1193). The children's behavioral problems were assessed by the use of the Strengths and Difficulties Questionnaire (SDQ). Children prenatally exposed to AEDs more often had an abnormal total SDQ score as compared with children of women without epilepsy (odds ratio (OR)=4.8 (95% CI: 1.9-12.1)) and as compared with children of women with epilepsy who were not treated with AEDs during their pregnancy (OR=4.0 (95% CI: 1.3-12.8)). In conclusion, prenatal AED exposure may increase the risk of behavioral problems in preschool children even after adjustments for potential confounders and maternal epilepsy.

Teratogenic risk and contraceptive counselling in psychiatric practice: analysis of anticonvulsant therapy

BACKGROUND

Anticonvulsants have been used to manage psychiatric conditions for over 50 years. It is recognised that some, particularly valproate, carbamazepine and lamotrigine, are human teratogens, while others including topiramate require further investigation. We aimed to appraise the documentation of this risk by psychiatrists and review discussion around contraceptive issues.

METHODS

A retrospective review of prescribing patterns of four anticonvulsants (valproate, carbamazepine, lamotrigine and topiramate) in women of child bearing age was undertaken. Documented evidence of discussion surrounding teratogenicity and contraceptive issues was sought.

RESULTS

Valproate was most commonly prescribed (n=67). Evidence of teratogenic risk counselling at medication initiation was sub-optimal--40% of individuals prescribed carbamazepine and 22% of valproate. Documentation surrounding contraceptive issues was also low- 17% of individuals prescribed carbamazepine and 13% of valproate.

CONCLUSION

We found both low rates of teratogenic risk counselling and low rates of contraception advice in our cohort. Given the high rates of unplanned pregnancies combined with the relatively high risk of major congenital malformations, it is essential that a detailed appraisal of the risks and benefits associated with anticonvulsant medication occurs and is documented within patients' psychiatric notes.

Seizures in pregnancy: epilepsy, eclampsia, and stroke

Seizures during pregnancy complicate <1% of all gestations; however, they are associated with increased adverse maternal and perinatal outcomes (acute and long term). The differential diagnosis of seizures in pregnancy is extensive. Determining the underlying etiology is crucial in the management of these patients. Medical providers caring for pregnant women should be educated about possible etiologies of seizures during pregnancy and the importance of prompt management of these women in a timely fashion. Evaluation and management should be performed in a stepwise fashion and may require a multidisciplinary approach with other specialties such as neurology. The objective of this review is to increase awareness and to provide a stepwise approach toward the diagnosis and management of pregnancies complicated by seizures.

Seizures and intracranial hemorrhage

Seizures and intracranial hemorrhage are possible medical diseases that any obstetrician may encounter. This article reviews the cause, treatment, and medical management in pregnancy for seizures and intracranial hemorrhage, and how the two can overlap into preeclampsia or eclampsia. This article also highlights some challenging management issues from the obstetrician's perspective.

Oxidative stress is increased in women with epilepsy: Is it a potential mechanism of anti-epileptic drug-induced teratogenesis?

Context:

Oxidative stress can be a final common pathway for AED-induced teratogenesis.

Aims:

To compare the oxidative stress of women with epilepsy (WWE) and unfavorable pregnancy outcome (fetal malformation or spontaneous abortion - group EM) with that of WWE with normal pregnancy outcome (group ENM) and healthy women with normal pregnancy outcome (group C).

Materials and Methods:

We identified WWE under group EM (n = 43) and group ENM (n = 22) from the Kerala Registry of Epilepsy and Pregnancy (KREP). Group C was constituted of healthy volunteers (N = 20). Oxidative stress was assessed by estimating serum levels of malondialdehyde (MDA) and isoprostane (ISP). The antioxidant profile was evaluated as activity of superoxide dismutase (SOD), glutathione reductase (GR), catalase (CAT), total antioxidant status (TAO), and glutathione (GSH) content.

Results:

The MDA and ISP levels for group EM (3.46 + 0.82 and 17.77 + 3.0) were higher than that of group ENM (3.07 + 1.02 and 14.0 + 5.3), and both were significantly higher than that of group C (2.42 + 0.51 and 10.77 + 4.1). Their levels of SOD (146.82 + 42.64 vs. 175.81 + 42.61) and GSH (0.98 + 0.98 vs. 1.55 + 1.3) were significantly lower than those of controls. No significant changes were seen in TAO and GR. WWE on polytherapy showed significant increase in MDA when compared to monotherapy group.

Conclusion:

WWE (group EM and ENM) had higher oxidative stress and reduced antioxidant activity. The subgroup of WWE with unfavorable pregnancy outcome (group EM) had higher oxidative stress. Excess oxidative stress can be a final common pathway, by which AEDs exert teratogenic effects.

Prenatal-onset neurodevelopmental disorders secondary to toxins, nutritional deficiencies, and maternal illness

Neurodevelopmental disorders result from an inordinate number of genetic and environmental causes during the embryological and fetal periods of life. In the clinical setting, deciphering precise etiological diagnoses is often difficult. Newer screening technologies allow a gradual shift from traditional nature-versus-nurture debates toward the focused analysis of gene-by-environment interactions (G X E). Further understanding of developmental adaptation and plasticity requires consideration of epigenetic processes such as maternal nutritional status, environmental toxins, maternal illnesses, as well as genetic determinants, alone or in combination. Appreciation of specific G X E mechanisms of neurodevelopmental pathogenesis should lead to better risk-modifying or preventive strategies. We provide a brief overview of clinical and experimental observations that link prenatal-onset toxic exposures, metabolic disturbances, and maternal illnesses to certain neurodevelopmental disorders.

Use of topiramate in pregnancy and risk of oral clefts

OBJECTIVE

The objective of this study was to evaluate the association between the use of monotherapy topiramate in pregnancy and cleft lip with or without cleft palate (CL/P) in the offspring.

STUDY DESIGN

Data from the Slone Epidemiology Center Birth Defects Study (BDS) from 1997 to 2009 and the National Birth Defects Prevention Study (NBDPS) from 1997 to 2007 were analyzed. Conditional logistic regression was used to compare the first-trimester use of topiramate monotherapy to no antiepileptic drug use during the periconceptional period between the mothers of infants with CL/P and the mothers of controls for each study separately and in pooled data.

RESULTS

The BDS contained 785 CL/P cases and 6986 controls; the NBDPS contained 2283 CL/P cases and 8494 controls. The odds ratios (exact 95% confidence intervals) for the association between topiramate use and CL/P were 10.1 (1.1-129.2) in the BDS, 3.6 (0.7-20.0) in the NBDPS, and 5.4 (1.5-20.1) in the pooled data.

CONCLUSION

First-trimester use of topiramate may be associated with CL/P.

Managing epilepsy during pregnancy: assessing risk and optimizing care

OPINION STATEMENT

Epilepsy is the most common neurologic condition found in pregnancy. As such, all neurologists, internists, and obstetricians should know how to counsel women with epilepsy as they are considering pregnancy. While all of the usual recommendations for women of childbearing potential apply, including preconceptual and ongoing use of folic acid, calcium, and vitamin D, additional consideration must be given to the need for adjustment or change of anticonvulsant therapy. Monotherapy with the lowest dose of medication needed to control seizures should be prescribed prior to conception. Most anticonvulsants have a favorable profile when used in pregnancy; older anticonvulsants such as valproate and carbamazepine should be avoided, as they are associated with higher rates of fetal malformation, and in the case of valproate, with proven cognitive deficits in children exposed to this medication in utero. With use of any anticonvulsant medication, dosing throughout pregnancy will need to be adjusted to maintain an appropriate serum concentration. Dosing of anticonvulsants needs to be decreased after delivery to avoid medication-related toxicity, although sleep deprivation and hormonal fluctuation can increase the risk of seizures in postpartum women. With proper management, the majority of women with epilepsy can have uneventful pregnancies and healthy babies.

Utilization of topiramate during pregnancy and risk of birth defects

OBJECTIVE

To evaluate the risk of oral cleft and major congenital malformation occurrence in infants born to women exposed to topiramate in their first trimester of pregnancy compared with women who used other anti-epileptic drugs or those with disease states in which topiramate may have been used.

METHODS

Sourced from patients' pharmacy and medical claims from 2002 through 2010, this study identified infants born from mothers exposed to topiramate (n = 870) and other anti-epileptic drugs (n = 3615) in the first trimester of pregnancy. First trimester exposure was based on prescription dispensing dates and days supplied relative to infant birth date, accounting for premature delivery. Infants born to women with migraine without epilepsy (n = 26,865), women with epilepsy (n = 2607), and women with diabetes mellitus (n = 13,062), as well as randomly sampled women (n = 99,761), were used for comparison. Topiramate use was excluded from all groups with the exception of the topiramate and random sample cohorts. Non-anti-epileptic drug teratogens were excluded from each cohort (except random sample). Unadjusted relative risks and 95% confidence intervals for topiramate vs each comparator were calculated. Risks >1 indicate a higher risk with topiramate vs comparator, whereas risks <1 indicate a lower risk with topiramate vs comparator.

RESULTS

The frequency of oral clefts was 0.23% for topiramate use, 0.17% for other anti-epileptic drug use (topiramate vs comparator relative risk = 1.39 [95% confidence interval: 0.28-6.85]), 0.16% for migraineurs (1.47 [0.36-6.06]), 0.31% for epileptics (0.75 [0.16-3.52]), 0.26% for diabetics (0.88 [0.21-3.67]), and 0.16% for the random sample (1.44 [0.36-5.81]). The frequency of major congenital malformations was 4.33% for topiramate use, 3.21% for other anti-epileptic drugs (1.33 [0.92-1.90]), 3.79% for migraineurs (1.12 [0.81-1.55]), 4.33% for epileptics (0.98 [0.68-1.41]), 6.58% for diabetics (0.65 [0.47-0.89]), and 3.77% for the random sample (1.13 [0.82-1.55]).

CONCLUSIONS

This retrospective study quantified the association between topiramate exposure during pregnancy and the risk of oral cleft or major congenital malformations, and suggested little or no increase in risk in comparison with exposure to other anti-epileptic drugs or to disease states, such as migraine, epilepsy, or diabetes. However, small numbers of events limit the strength of inferences.

Multiple fetal anomalies in association with topiramate and oxcarbezepine treatment

We present a case of a woman who used topiramate (100 mg) and oxcarbazepine (300 mg) continuously during pregnancy. Multiple fetal anomalies including limp defects of the lower extremities, pericardiac fluid collection, cardiomegaly, cleft lip and palate, absent right kidney, and dysplastic left kidney were found by ultrasonography. Labor was induced and anomalies were confirmed by autopsy. The malformation rate after exposure to oxcarbazepine in utero as a monotherapy was calculated to be 2.4%, which is compatible with the malformation rate seen in the general population. Topiramate is teratogenic in mice, rats, and rabbits, but there are very few reports about its teratogenicity in humans.

An update in the treatment of neurologic disorders during pregnancy--focus on migraines and seizures

When drug therapy is necessary and cannot be avoided during a pregnancy, the decision of what drug therapy is best may be difficult for the health care provider because the vast majority of drugs are classified as Pregnancy Category C. This classification indicates that information regarding the risk to the fetus is unknown. For ethical reasons, pregnant women are not included in drug studies, so most decisions regarding the safety of a particular drug are based on animal studies, available cases reports, or are theoretical and are based on pharmacokinetic properties. Fortunately, with the development of Pregnancy Registries, more information has been collected, analyzed, and is available regarding the safety of drugs during pregnancy. These registries have expanded in recent years allowing better determination of fetal safety for triptans and antiepileptic drugs (AEDs). The information assists health care providers in selecting optimal therapy for women seeking pregnancy or those already pregnant. This review presents the most recent information for the treatment and prophylaxis of migraines and seizures during pregnancy.

The course and outcome of pregnancy and neonatal situation in epileptic women

Background:

Epilepsy is a rare neurologic disorder during pregnancy. Despite its rarity, it could cause different clinical problems in this natural phenomenon of a woman's life. The aim of this study was to evaluate and compare the course of pregnancy and labor and their outcome in epileptic and healthy women.

Materials and Methods:

This study was performed during years 2009--2011 in Alzahra and Beheshti hospitals affiliated to Isfahan University of Medical Sciences. A total of 51 pregnant women, who were known cases of epilepsy and were on antiepileptic drugs treatment for at least 3 months, were compared with 47 matched healthy pregnant women without epilepsy. They were followed before and during their pregnancy in several visits and all of their neurologic and obstetric information were collected. For statistical analysis of continuous variables, the t-test was used. The chi-square test was used for dichotomous variables.

Results:

The rate of monotherapy was more than polytheraphy especially during the pregnancy. The epileptic attacks stopped in majority of patients during the pregnancy. Vaginal bleeding (P=0.020) and abortion (P=0.015) were significantly more frequent among epileptic mothers. The gestational age was lower meaningfully (P= 0.010) in epileptic patients’ neonates and the first minute Apgar score was lower in these babies too (P=0.028).

Conclusions:

Antiepileptic drugs could have some unsuitable effects on pregnancy course especially by increasing the rate of abortion, preterm labor, and vaginal bleeding. Their adverse effects on neonates’ health could not be neglected.

Use of antiepileptic medications in pregnancy in relation to risks of birth defects

PURPOSE

To evaluate use of specific antiepileptic drugs (AEDs) in pregnancy in relation to specific birth defects.

METHODS

Using data from the National Birth Defects Prevention Study, we assessed use of AEDs and the risk of neural tube defects (NTDs), oral clefts (OCs), heart defects (HDs), hypospadias, and other major birth defects, taking specific agent, timing, and indication into consideration.

RESULTS

Drug-specific increased risks were observed for valproic acid in relation to NTDs [adjusted odds ratio (aOR), 9.7;, 95% confidence interval (CI), 3.4-27.5], OCs (aOR, 4.4; 95% CI, 1.6-12.2), HDs (aOR, 2.0; 95% CI, 0.78-5.3), and hypospadias (aOR. 2.4; 95% CI, 0.62-9.0), and for carbamazapine in relation to NTDs (aOR, 5.0; 95% CI, 1.9-12.7). Epilepsy history without AED use did not seem to increase risk.

CONCLUSIONS

Valproic acid, which current guidelines suggest should be avoided in pregnancy, was most notable in terms of strength and breadth of its associations. Carbamazapine was associated with NTDs, even after controlling for folic acid use. Sample sizes were still too small to adequately assess risks of less commonly used AEDs, but our findings support further study to identify lower risk options for pregnant women.