Neurodevelopmental outcomes of children born to mothers with epilepsy

Serum NGF levels may be associated with intrauterine antiepileptic exposure-related developmental problems

OBJECTIVE

It has been shown that maternal epilepsy and antiepileptic drug use during pregnancy have adverse developmental outcomes in children. The aim of this study was to investigate the developmental outcomes of maternal epilepsy and prenatal antiepileptic exposure. We also looked for the associations between serum levels of glial cell-derived neurotrophic factor (GDNF) and nerve growth factor (NGF) and developmental outcomes.

METHODS

This is a retrospective, nonrandomized, case-controlled study. Fifty-three children aged two to six years old with maternal epilepsy were included in the case group. Fifty-three age- and gender-matched children without maternal epilepsy were included in the control group. Developmental assessment was conducted using the Denver II Developmental Screening Test (DDST-II). Serum levels of NGF and GDNF were measured using an enzyme-linked immunosorbent assay (ELISA) kit.

RESULTS

Multiple regression analysis revealed that prenatal antiepileptic exposure was significantly associated with lower global developmental scores (B = -7.5, confidence interval (CI): -13.1; -1.9, p = 0.009) while periconceptional folate use was associated with a reduced risk for adverse developmental outcomes (B = 6.6, CI: 0.91; 12.3, p = 0.024). Children with prenatal antiepileptic exposure are at increased risk for global developmental delay (GDD) particularly for language domain (p = 0.018). We found a statistically significant positive correlation between NGF levels and global developmental scores (r = 0.302, p = 0.009). Serum levels of GDNF in children with maternal epilepsy were significantly lower than the children without maternal epilepsy (p = 0.025).

CONCLUSIONS

Prenatal antiepileptic exposure was related with the increased risk of GDD while periconceptional folate use was related with lower risk. Clinicians should inform all women in reproductive age with epilepsy about the possible benefits and risks of antiepileptic drug use during a possible pregnancy. Periconceptional folate use has protective effect on child development, and all women on antiepileptic drugs should be encouraged for periconceptional folate use. Serum NGF levels may be a promising biomarker for monitoring global development delay in at-risk population.

Bipolar disorder in women

Bipolar affective disorder in women is a challenging disorder to treat. It is unique in its presentation in women and characterized by later age of onset, seasonality, atypical presentation, and a higher degree of mixed episodes. Medical and psychiatric co-morbidity adversely affects recovery from the bipolar disorder (BD) more often in women. Co-morbidity, particularly thyroid disease, migraine, obesity, and anxiety disorders occur more frequently in women while substance use disorders are more common in men. Treatment of women during pregnancy and lactation is challenging. Pregnancy neither protects nor exacerbates BD, and many women require continuation of medication during the pregnancy. The postpartum period is a time of high risk for onset and recurrence of BD in women. Prophylaxis with mood stabilizers might be needed. Individualized risk/benefits assessments of pregnant and postpartum women with BD are required to promote the health of the women and to avoid or limit exposure of the fetus or infant to potential adverse effects of medication.

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.

WITHDRAWN: Preconception counselling for women with epilepsy to reduce adverse pregnancy outcome

This review has been replaced by the protocol 'Preconception counselling for women with epilepsy' (Winterbottom 2014). The full review is expected to be published by 1st July 2014.

The editorial group responsible for this previously published document have withdrawn it from publication.

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.

Neurobehavioral maturation of offspring from epileptic dams: study in the rat lithium-pilocarpine model

In the present study, we explored the consequences of epilepsy on the neurobehavioral development of the offspring in a rat model of spontaneous epilepsy, the lithium-pilocarpine model of temporal lobe epilepsy not dependent on genetic factors and in animals not receiving any antiepileptic treatment. Status epilepticus was induced by lithium-pilocarpine in female rats. After the occurrence of spontaneous seizures the rats were mated and the neurobehavioral development of the offspring was explored. Rat pups were cross-fostered early after birth. We hence obtained pups born from or raised by epileptic or non-epileptic dams. On the dams, we performed a follow-up of maternal care during pregnancy. On the pups, we performed a follow-up of classical parameters of development such as body weight and eyelid opening, and subjected the pups to various tests representative of neurobehavioral maturation extending from postnatal day 4 (PD4) to PD30 (righting reflex, suspension time, negative geotaxis, open field, locomotor coordination and eight arm maze). Altogether our data show that rat pups born from or raised by epileptic dams develop as well as control pups raised by control dams. Intriguingly, pups born from lithium-pilocarpine exposed dams and raised by control mothers tend to have better scores than the two other groups in all tests. This indicates that the exposure to seizures during pregnancy is not harmful for the development of the fetus.

The effectiveness of preconception counseling to reduce adverse pregnancy outcome in women with epilepsy: what's the evidence?

OBJECTIVE

The purpose of this Cochrane review was to determine the effectiveness of delivering preconception counseling interventions to women with epilepsy (WWE) as a means of reducing adverse pregnancy outcomes, increasing knowledge, and increasing intentions to plan pregnancy.

METHODS

Two hundred twenty-five citations were retrieved from a systematic search of the Cochrane Library and electronic databases: Medline (OVID), Scopus, CINAHL, PsychINFO, and ASSIA, and hand searches of relevant epilepsy and obstetric journals.

RESULTS

The search strategy identified 11 studies for consideration for inclusion. However, none met the required criteria for inclusion.

CONCLUSIONS

There is no robust evidence to inform the content, methods of delivery, or likely effectiveness of preconception counseling to improve pregnancy outcomes for WWE and their offspring. The value of counseling WWE prior to conception remains uncertain and requires evaluation in well-designed studies, appropriately powered to detect changes likely associated with both maternal and infant outcomes.

Antiepileptic drugs during pregnancy: what is known and which AEDs seem to be safest?

Most infants born to women with epilepsy are healthy, but there are increased risks related to in utero antiepileptic drug (AED) exposure and seizures. Emerging data from pregnancy registries and other studies allow us to better balance the anatomic teratogenic and neurodevelopmental effects of AEDs against the need to maintain maternal seizure control. Several large prospective pregnancy registries demonstrate a consistent pattern of increased risk for major congenital malformations (MCMs) with valproate (VPA) use as monotherapy, compared to nonexposed populations and to other AEDs used in monotherapy. AED polytherapy likely increases risk for MCMs, but the risk is more pronounced if VPA is included. Reduced cognitive outcomes have been reported with AED polytherapy, and with use of VPA, phenobarbital (PB), and PHT as monotherapy. Dose-dependent risk has been demonstrated with VPA for MCMs and cognitive consequences. CBZ groups show normal neurodevelopment. Increased clearance of most of the AEDs occurs during pregnancy. Use of therapeutic drug monitoring during pregnancy with LTG reduces the risk for seizure worsening. The consistent findings of increased teratogenic risk for VPA should discourage use of this medication as first-line treatment in women of childbearing age.

Preconception counselling for women with epilepsy to reduce adverse pregnancy outcome

BACKGROUND

The provision of preconception counselling to women with epilepsy (WWE) has become established as recommended practice and includes a review of drug treatment and the provision of information and advice on both seizure and treatment-related risks to both mother and child. In this review we assess the evidence regarding the effectiveness of preconception counselling for WWE.

OBJECTIVES

To determine the effectiveness of preconception counselling for WWE, measured by a reduction in adverse pregnancy outcome in both mother and child; increased knowledge of preconception issues in WWE and increasing intention to plan pregnancy.

SEARCH STRATEGY

We searched the Epilepsy Group's Specialized Register (30/01/2008), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 4), and electronic databases: MEDLINE (OVID) (1950-February 2008); SCOPUS (1966-March 2008); CINAHL (1982-March 2008); PsyclNFO (1806-March 2008); ASSIA (1987-March 2008).

SELECTION CRITERIA

Randomised control trials; including cluster and quasi-randomised trials, prospective cohorts, controlled before and after studies, and interrupted time series that compared the outcomes in mothers with epilepsy and infants of mothers with epilepsy who received preconception counselling, to the outcomes of mothers with epilepsy and their infants who received standard care or no intervention.

DATA COLLECTION AND ANALYSIS

The methodological quality of potentially relevant studies were assessed to determine appropriate inclusion. Where necessary, study authors were contacted for additional information. No studies met the review inclusion criteria.

MAIN RESULTS

The search strategy identified 11 studies for consideration of inclusion. However, none met the required criteria for inclusion.

AUTHORS' CONCLUSIONS

There is no evidence to inform the content, methods of delivery or effectiveness of preconception counselling to improve pregnancy outcomes for WWE and their offspring. The value of counselling delivered to WWE prior to conception, with the intention of reducing the risks of adverse outcome in mother and child, requires evaluation in well-designed studies, appropriately powered to detect changes in both maternal and infant outcome.

Effect of anti-epileptic drugs in pregnancy and teratogenesis

Epilepsy raises special concern in women during pregnancy. Antiepileptic drugs are known to induce major and minor malformations in the foetus. Aim of the study was to find an association between maternal serum alpha fetoprotein levels, foetal abnormalities and antiepileptic drugs mediated teratogenicity. Maternal serum alpha feto protein levels, kidney and liver function tests in age matched normal pregnant women and seizure free epileptic pregnant women during 12-14 weeks of gestation were estimated. Cases were subjected to ultrasonography at 11(th)-14(th) week of pregnancy and again at 20(th) week of pregnancy. maternal serum alfa feto protein was assayed by a specific Electro Chemiluminescence Immuno Assay test. There was no significant difference in kidney and liver function tests in cases as compared to controls. There were elevated levels of alpha feto protein in cases as compared to controls but this was not statistically significant. No anomalies were detected in ultrasound reports. Most women had normal full term delivery with healthy children but of low birth weight. No correlation was seen between maternal serum alfa feto protein levels and antiepileptic drug leading to teratogenesis.

Therapeutic monitoring of antiepileptic drugs during pregnancy and in the postpartum period: is it useful?

As in all patient populations, epilepsy is common in pregnant women. Consequently, approximately 1 in 200 pregnancies is exposed to antiepileptic drugs (AEDs). Although exposure to AEDs in utero has been associated with an increased risk of major fetal malformations, most women with epilepsy require medication throughout pregnancy, since seizures themselves may be potentially harmful not only for the mother but also for the developing fetus. Physiological changes during pregnancy result in a reduction in the serum concentrations of most AEDs, particularly in late pregnancy. Changes in protein binding lead to a greater reduction in total than free (active) drug concentrations. Pharmacokinetic changes in pregnancy show interindividual variability and are not well understood for most newer AEDs. However, recent studies have shown that changes in lamotrigine clearance are particularly marked, with increases in each trimester and a significant fall in plasma concentrations, leading to consequent breakthrough seizures in some women. Concentrations may then rise precipitously after delivery, leading to symptoms of lamotrigine toxicity. Therapeutic drug monitoring could theoretically guide adjustment of AED dosage to achieve good seizure control while minimising fetal exposure, although there are several limitations to such monitoring. Firstly, there are wide interindividual variations in serum drug concentrations, with seizure control often correlating poorly with a given therapeutic range. Secondly, therapeutic ranges have not been well defined for newer AEDs and their measurement is often not always available. Thirdly, for highly protein-bound drugs, although measurement of free drug concentrations may more accurately reflect drug availability during pregnancy than total drug concentrations, assays for this are not always available and may be unreliable. Thus, it may be useful, prior to pregnancy, to establish the total and free drug concentrations required to achieve optimal seizure control in a given individual. Regular monitoring of AEDs has been advocated in each trimester and shortly after delivery, with adjustment of dosage to avoid seizure precipitation during pregnancy or symptoms of toxicity after birth. More frequent monitoring has been recommended for lamotrigine. However, aggressive drug monitoring of any AED has yet to be proven to be effective in improving seizure control or care. Furthermore, higher doses may be associated with a greater potential for teratogenicity and it is not yet known whether longer term adverse effects may be related to in utero exposure in the latter half of pregnancy. There is limited evidence about the relationship of maternal serum drug concentrations and teratogenicity. While there is a theoretical role for therapeutic drug monitoring in improving the risk-to-benefit ratio of AED therapy during pregnancy, there are many practical limitations. Future work is needed to clarify its role in improving seizure control during pregnancy and identifying serum drug concentrations that may be considered safe for fetal exposure.

[Neuropsychological outcome following intrauterine exposure to valproate]

A number of recent studies suggest a link between in utero exposure to valproate (VPA) and low IQ and behavioural disorders in children of mothers with epilepsy. In this review, a commission of the German Section of the International League Against Epilepsy discusses the evidence in the literature and practical recommendations for the use of VPA in women of childbearing potential. It is concluded that despite methodological shortcomings--largely due to the complexity of the problem and small case numbers in prospective studies--the existing data are sufficiently alarming to require great caution in the use of VPA in women who could become pregnant. The underlying mechanisms of how antiepileptic drugs may lead to neurodevelopmental problems are unclear. Further prospective studies are urgently needed to clarify this clinically important issue, and a collaborative study is suggested based on the international network established by the European Registry of Antiepileptic Drugs and Pregnancy.

Seizures and Antiepileptic Drugs: Does Exposure Alter Normal Brain Development?

Seizures and antiepileptic drugs (AEDs) affect brain development and have long-term neurological consequences. The specific molecular and cellular changes, the precise timing of their influence during brain development, and the full extent of the long-term consequences of seizures and AEDs exposure have not been established. This review critically assesses both the basic and clinical science literature on the effects of seizures and AEDs on the developing brain and finds that evidence exists to support the hypothesis that both seizures and antiepileptic drugs influence a variety of biological process, at specific times during development, which alter long-term cognition and epilepsy susceptibility. More research, both clinical and experimental, is needed before changes in current clinical practice, based on the scientific data, can be recommended.

2005 AES Annual Course: Evidence Used to Treat Women with Epilepsy

Although most female-specific considerations for treatment of epilepsy cannot be answered by Class I evidence, significant progress in our knowledge base has occurred in the past few years. Open-label studies of progesterone supplementation showed promising results; an ongoing randomized trial may provide definitive evidence for therapeutic use of progesterone in women. A randomized trial of hormone replacement therapy demonstrated a dose-related increase in seizure frequency in postmenopausal women with epilepsy. The use of different AED regimens during pregnancy cannot be explored with randomized, controlled trials; we must rely on the best available evidence from ongoing observational studies. The consistent findings of large prospective pregnancy registries reveal a consistent pattern of amplified risk for major congenital malformations in pregnancies exposed to valproate. These registries have also highlighted the concern for the effect of shifting hormones on AED concentrations. An increased frequency of seizures during pregnancy has been noted with lamotrigine (LTG) and oxcarabazepine, both of which undergo glucuronidation. Other studies have demonstrated an increased clearance of LTG during pregnancy and with exogenous estrogen use. It may be prudent to closely monitor serum concentrations of these AEDs with hormonal changes. An increased risk for neurodevelopmental consequences has been demonstrated for the fetus exposed to AED polytherapy, valproic acid, or frequent maternal convulsive seizures. Preliminary information about breastfeeding with LTG and levetiracetam is available. These newly released findings provide the tools to begin to practice evidence-based medicine when treating our female patients during their reproductive and postmenopausal years.

Antiepileptic drugs and neurodevelopment

Clinical studies have documented the teratogenic potential of antiepileptic drugs (AEDs). More recent cohort studies have been trying to sort out which AEDs impose the highest risk of teratogenicity. Currently, there is evidence demonstrating an increased risk of major congenital malformations (MCMs) for valproate, phenobarbital, and polytherapy during pregnancy. Based on the current data from multiple studies, the risk for valproate is the highest. Additional studies are needed to fully delineate if differences exist for other AEDs, especially the newer AEDs. However, although MCMs are easy to recognize and have been shown to be more common after in utero exposure to AEDs, there are insufficient data regarding their long-term effects on cognition and behavior in exposed children. Although most children born to women with epilepsy are healthy, in recent years there has been increasing awareness of the long-term effects of in utero exposure to AEDs. Recent discovery of neuronal apoptosis following in utero AED exposure in animals during a period that corresponds to the third trimester and early infancy in humans raises further concerns. Prospective clinical studies seem necessary in order to better understand the long-term neurodevelopmental effects of in utero exposure to AEDs.

Community-based, prospective, controlled study of obstetric and neonatal outcome of 179 pregnancies in women with epilepsy

PURPOSE

This study evaluated obstetric and neonatal outcome in a community-based cohort of women with active epilepsy (WWAE) compared with the general pregnant population receiving modern obstetric care.

METHODS

We reviewed the total population who gave birth between January 1989 and October 2000 at Kuopio University Hospital. Obstetric, demographic, and epilepsy data were collected prospectively from 179 singleton pregnancies of women with epilepsy and from 24,778 singleton pregnancies of unaffected controls. The obstetric data from the pregnancy register was supplemented with detailed neurologic data retrieved from the medical records. The data retrieved were comprehensive because of a follow-up strategy according to a predecided protocol.

RESULTS

During pregnancy, the seizure frequency was unchanged, or the change was for the better in the majority (83%) of the patients. We found no significant differences between WWAE and controls in the incidence of preeclampsia, preterm labor, or in the rates of caesarean sections, perinatal mortality, or low birth weight. However, the rate of small-for-gestational-age infants was significantly higher, and the head circumference was significantly smaller in WWAE. Apgar score at 1 min was lower in children of WWAE, and the need for care in the neonatal ward and neonatal intensive care were increased as compared with controls. The frequency of major malformations was 4.8% (-0.6-10.2%; 95% confidence interval) in the 127 children of WWAE.

CONCLUSIONS

Pregnancy course is uncomplicated and neonatal outcome is good in the majority of cases when a predecided protocol is used for the follow-up of WWAE in antenatal and neurologic care. Long-term follow-up of the neurologic and cognitive development of the children of WWAE is still needed.

Children exposed to valproate in utero—Population based evaluation of risks and confounding factors for long-term neurocognitive development

PURPOSE

To evaluate neurological and cognitive functioning of school-aged (> or =6 years) children exposed to valproate monotherapy in utero in a population based, evaluator-blinded, controlled study.

METHODS

Studied children (N=39, aged 6.6-13.4 years) and their mothers were identified through a population based pregnancy registry. Mothers with carbamazepine monotherapy and mothers with epilepsy but without antiepileptic drug (AED) treatment during pregnancy and their age and gender matched children served as controls. Hospital records were reviewed and neurological examination (Touwens test), intelligent quotients (IQ) of mothers (WAIS), and children (WISC-III) and neuropsychological assessment of children (NEPSY) were performed evaluator-blinded.

RESULTS

The prevalence of low intelligence (FIQ<80) was 19% (4/21) and the prevalence of exceptionally low intelligence (FIQ<70) 10% (2/21) in valproate (VPA) monotherapy exposed children. Children exposed to carbamazepine (CBZ) and children of women with epilepsy but without AED exposure during pregnancy had all at least low average intelligence. The mothers using valproate scored significantly lower (p<0.05) in FIQ, VIQ and PIQ tests and had also significantly lower (p=0.035) educational level. Altogether 21% (8/39) of the children had minor neurological dysfunctions.

CONCLUSIONS

In a population based setting inheritance and cumulating environmental factors may partly explain the increased prevalence of neurocognitive symptoms in children exposed to valproate in utero although concern about the possible long-term effects of intrauterine valproate exposure does exist.

Using current evidence in selecting antiepileptic drugs for use during pregnancy

Children born to mothers taking antiepileptic drugs (AEDs) are at increased risk for findings of fetal anticonvulsant syndrome. Accepted treatment paradigms to minimize fetal risks include use of AED monotherapy and folic acid supplementation. However, as data are acquired from several ongoing pregnancy registries, differential risks among the various AED monotherapy regimens are being defined, further improving fetal outcomes.

Pregnancy in women who have epilepsy

Ideal, comprehensive care of women who have epilepsy during the reproductive years must include effective preconceptional counseling and preparation. The importance of planned pregnancies with effective birth control should be emphasized, with consideration of the effects of the enzyme-inducing AEDs on lowering efficacy of hormonal contraceptive medications and the need for back-up barrier methods. Before pregnancy occurs, the patient's diagnosis and treatment regimen should be reassessed. Once the diagnosis of epilepsy is confirmed, it is important to verify if the individual patient continues to need medications and if she is taking the most appropriate AED to balance control of her seizures with teratogenic risks. For most women who have epilepsy, withdrawal of all AEDs before pregnancy is not a realistic option. A decision to undergo a trial while not taking AEDs before a planned pregnancy should be based on the same principles used for AED withdrawal in any person who has epilepsy. The taper should be completed at least 6 months before planned conception to provide some reassurance that seizures are not going to recur. If a woman who has epilepsy is in the more prevalent category of needing AEDs for seizure control, then monotherapy at the lowest effective dosage should be used. If large daily doses are needed, then frequent smaller doses or extended-release formulations may be helpful to avoid high peak levels. Some of the newest information about differential risks between AEDs also should be considered. The woman's AED regimen should be optimized and folate supplementation should begin before pregnancy. Given that 50% of pregnancies are unplanned in the United States, folate supplementation should be encouraged in all women of childbearing age who are taking any AED for any indication. Dosing recommendations vary from 0.4 mg/d to 5 mg/d. It is not uncommon for a physician to consider changing AED regimens when the patient first reports that she is pregnant. In many cases, she already is in or past the critical period of organogenesis (Table 3). If a woman who has epilepsy presents after conception and is taking a single AED that is effective, her medication usually should not be changed. Exposing the fetus to a second agent during a crossover period of AEDs only increases the teratogenic risk, and seizures are more likely to occur with any abrupt medication changes. If a woman is on polytherapy, it may be possible to switch to monotherapy safely. Seizure control remains an important goal during pregnancy. In particular, convulsive seizures place the mother and fetus at risk. Nonconvulsive seizures also may be harmful, especially if they involve falling or other forms of trauma. Monitoring serum AED levels during pregnancy can be helpful in optimizing seizure control. Prenatal screening can detect major malformations in the first and second trimesters. Vitamin K1 is given 10 mg/d orally during the last month of pregnancy followed by 1 mg intramuscularly or intravenously to the new-born. Although women who have epilepsy and women who are taking AEDs for other indications do have increased risks for maternal and fetal complications, these risks can be reduced considerably with effective preconceptional planning and careful management during pregnancy and the postpartum period.