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MRCOG PART 2 SBAs and EMQs

MRCOG Part 2, MRCOG 2

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ESSAY 175 - EPILEPSY

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		Posted by Srivas P. Tue Jan 10, 2006 12:27 am
Seizures in pregnancy have an incidence of 0.15-10 % and 1/3rd patients of epilepsy have increased incidence of seizures in pregnancy, may be due to physiological haemodilution of pregnancy along with increased renal clearance, leading to lesser blood levels of the anticonvulsant drug. This woman should be booked into Consultant led maternity units and she would need review by a neurologist as she may require increased dosage of her anti epileptic drugs or an introduction of a newer drug to control her seizures provided she has been compliant with her prescribed drugs. It is also necessary to confirm if she has suffered prolonged diarrhea or vomiting in the past few weeks which might have affected the absorption of the drugs. Her pre pregnancy seizure history would be helpful. Measurement of total and free plasma levels of anti epileptic drugs too may be useful but usually clinical control of seizures alone is enough to adjust the doses. Her LMP history, previous obstetric history, history of NTD in siblings should be taken. Her contraceptive history too should be taken to note if she conceived while on COCP, POPs etc. It is likely she may have conceived due failure of her contraceptives due to liver inducing effect of Anticonvulsant drugs she is taking and she may have needed higher doses than the usual contraceptive doses of COC and POP. These Contraceptives should now be stopped and she should be assured she is not at increased risk of anomalies due to taking these contraceptives and she may continue with pregnancy if she desires. She should have an USG to date her pregnancy and offered AFP level at 16 weeks as usual, to rule out Neural Tube defects as she is at increased risk (6-8%) due to taking anticonvulsant drugs. The risk may be further increased as she is unlikely to have been given prophylactic increased Folic acid doses in first trimester in this unplanned pregnancy. This AFP screening may detect 85% NTD?s but USG at 18-20 weeks is confirmatory in 100% cases. The USG should be done at the tertiary centre. Possible termination of pregnancy should be discussed with her in case of NTD?s being detected. AED may be associated with other major anomalies like congenital heart defect, orofacial defect and renal defects. USG may detect 60-70% of these cardiac defects if done at the tertiary centre. Other minor features of the fetal Hydantoin syndrome include dysmorphic features, stubby distal phalanges and hypoplastic nails. She is at increased risk of premature labor. The steroid dose to improve pulmonary maturity may need to be doubled to 24 mg 12hrly as liver inducing AEDs may metabolize steroids. AED?s may suppress Vit K dependent clotting factors so this premature baby may be at greater risk for HDN. Mother should be started on oral 20 mg Vit K doses. If pregnancy has progressed uneventfully she should be started on Vit K orally at 36 weeks. She should be allowed to labor normally under epidural anesthesia if she desires and achieve vaginal delivery. Her usual doses of AEDs should continue in labor. She has 1-2% risk of throwing fits in labor which may be controlled by I/V boluses of diazepam, up to 10-20 mg totally. I/V Phenytoin too may be given to control fits. If she has uncontrolled fits, she may be taken for LSCS under GA, to avoid possible fetal hypoxia and maternal harm by uncontrolled fits. Postnally. reversal of physiological changes of pregnancy may decrease the dosage of AED?s required. Neonate should be given 1 mg I/M Vit K and should be watched by Neonatologist for possibility of hemolytic Disease of the new born and jaundice. All AED?s cross into breast milk but is at much lower levels than mother and these drugs are not contra indicated. She should be advised to breast feed properly seated to avoid falling during aura before fits. Sometimes the baby may be too sedated in which case bottle feeds may be supplemented with breast milk. She should be given contraceptive advice with higher doses of estrogen in COC?s and she may need double the usual dose of POP?s to avoid unwanted pregnancies. Her next pregnancy should be well planned with proper counseling and pre pregnancy folic acid administration.
		Posted by Vaani M. Tue Jan 10, 2006 12:58 am
Epilepsy is the most common neurological disorder in pregnancy. It is an important indirect cause of maternal mortality. This woman is 14 weeks pregnant hence it was not a planned pregnancy. A history of anti epileptic drug intake, vomiting, previous convulsions should be noted in detail. Even if she is taking her medication regularly her drug levels may be lower due to vomiting, increased gastric clearance, or haemodilution of pregnancy. She will need a neurological review to assess and increase her drug dose if required. A serum drug level will help assess compliance with anti-epileptic drug therapy. Carbamazepine or lamotrigine would be the preferred drug therapy. Her partner, friend or relative should be involved and aware of care in case of a convulsion to avoid aspiration or injuries to the woman. A detailed ultrasound will be required to assess for neural tube defects( as she would not be taking folic acid) and cardiac anomalies. If a cardiac anomaly is suspected she would need a repeat fetal cardiac scan after 22 weeks. Her child would also be at risk of being an epileptic more if she has an affected previous child or if her partner is an epileptic. As most anti-epileptic agents are hepatic enzyme inducers she would need oral vitamin K during the last 4 weeks of her pregnancy. She will be at increased risk of convulsions in labour and in the immediate postpartum period. She may need parenteral or rectal anti-epileptic treatment in labour. Epidural analgesia will be required to relieve pain and anxiety. Vaginal delivery can be allowed. A caeserean section will be needed only for an obstetric indication or for recurrent convulsions in the mother with a term fetus. Neonatologist needs to see the baby at delivery to look drug withdrawal symptoms and for anomalies including minor abnormalities as facial clefts, hypertelorism and digital hypoplasia. The neonate will need injection vitamin K soon after birth. The mother will need help in care of the baby, adequate rest and sleep. Breast feeding is to be encouraged. Her anti-epileptic drug dose may need to be reduced if it was raised in pregnancy. If the neonate appears sleepy she will have to take her medication prior to breast feeding to maintain low drug levels in breast milk. Information about support groups for help should be given. She will need increased dose of oral hormonal contraceptives due to the enzyme inducing effect of her treatment. Proper counselling of the partners is important for understanding her care and compliance with treatment.
		Posted by Aroosha B. Tue Jan 10, 2006 03:22 am
Pregnancy with epilepsy is associated with an increased risk of congenital anomalies and malformation. The incidence of epilepsy in general population is 1 % and increased to 6 % in children of epileptics. Antenatal care in epileptic should be pre pregnancy and by a multi disciplinary team consisting of an obstetrician and neurologist. However antenatal care now in this patient still needs to be done by multi disciplinary team with clear information to be given to the patient in a sympathetic and non judgmental way. Her history of epilepsy needs to be reviewed in detail to know whether she is currently on any epileptic medication. If she is currently not on any medication or on single drug, her drug therapy needs to be optimized in consultation with neurologist. Her dosage needs to be monitored by free drug levels. The patient should be informed of increasing risk of malformations with increases with increasing no. of drugs. She should be given advice regarding adequate rest and sleep. Although she is 14 weeks pregnant, folic acid still to be advised and continued through out pregnancy. Prenatal diagnosis should be discussed with the patient and a detailed anomaly scan should be carried out at 20 weeks of Gestational age. Vit k should be given daily in a dose of 10 mg for last 4 weeks. Her intrapartum care should be done with continuous fetal heart monitoring . Any seizure should be actively managed. Fits are usually associated with transient fetal heart rate abnormalities. Mode of the delivery should be vaginal with any intervention on obstetric ground. During postnatal period her medication should be gradually reduced. Baby should be given Vit K injection & should be observed for withdrawal symptoms. Breast feeding is safe and will help in gradual withdrawal ion neonate. Importance of sleep and adequate rest should be advised. Patient should be advised to nurse the baby in a safe position like sitting against the wall and to give the bath to the baby in wet foam. Unless some body is around. Postnatal contraception should be discussed if OCPs are given then high dose OCPs are advised. IUCD and Depo-Provera are also very effective methods of contraception.
		Posted by adnan S. Tue Jan 10, 2006 05:43 am
Seizure during pregnancy is associated with increase maternal morbidity and perinatal mortality. Maternal risk during pregnancy are due to aspiration during seizures and increase in the frequency of seizure .Fetal risks are due to congenital anomalies associated with antiepileptic drugs. major risks are neural tube defects ,orofascial defects ,and congenital heart defects and minor risks are dysmorphic features like hyprtelorism distal digital hypoplasia,nail hypoplasia etc. Antenatal care should be consultant-led care jointly with neurologist. Pregnancy occurring on anticonvulsant drug should be notified to the UK Register of antiepileptic drugs in pregnancyDetailed history is taken about the frequency of seizures ,AEDs she is using ,compliance of her treatment ,Family history of epilepsy Routine screening for down syndrome should be done ,detail anomaly scan should be done particular attention paid to neural tube defects, cardiac defects & orofacial defects. A fetal cardiac scan should be done at 22 weeks Gestation. If seizures are not controlled drug therapy should be modified in liasion with neurologist . valproate should be change to a 3 ? 4 times daily regime to lower peak concentration. Drug level monitoring should be done till the seizures are controlled & may not need to be carried out as routine once seizures are controlled. Folic acid 5 mg should be given thro out pregnancy . Oral vitamin K supplementation should be given from 34 ? 36 weeks onwards( 10 mg/day) to prevent hemorrhagic disease of the new born. I will advice her to have adequate sleep as sleep deprivation may increase seizure frequency & to take showers rather than baths. I will educate the partner on use of recovery positioning in the event of seizures.If corticosteroids are needed for fetal lung maturity, higher doses are needed if she is taking phenytoin , carbamazepins.Induction of labour & caesarean section are indicated for the usual obstetric indications. Labour carries a higher risk of seizure due to sleep disruption,reduced intake & absorption of AEDs & hyperventilation, which may alter free levels of AEDs.Delivery should take place in unit with facilities for providing specialized care to epileptic patients & neonatal intensive care unit.Continue antiepileptic drugs . Parental/rectal treatment may be required.In case of seizures during labour are controlled with IV diazepam or clonazepam. Continuous fetal heart rate should be monitored.In case of recurrent seizures or status epilepticus caesaren section should be done for fetal reasons. Neonatologist should be present at the time of delivery.injection vitamin K is given & neonat examine for anomalies. The serum levels of AEDs may rise in the postpartum period & monitoring may be necessary to prevent maternal toxic side effects, hence a reduction in doses may be necessary. Adequate sleep should be advice. Breast feeding is encouraged , maternal wishes should be taken into consideration. Neonatal side effects are rare, but sedation and withdrawal effects must be watched in particular phenobarbitone & benzodizepines have been used. Contraceptive advice should be given before discharge home.The enzyme inducers will reduce the contraceptive efficacy of cocp, minipill & depo-provera injection. A cocp containing 50microgram of oestrogen should be used,tricycling will reduce chances of ovulation. Depo-provera should be given every 10 weeks instead of every 12. The Mirena IUS is ideal,as the locally administered progestogen will not be affected by induced lever enzymes. Special advice to be given,to ask for extra help if she is not getting enough sleep, ensure someone else is present when she is giving bath to the baby, cushions & pillows should surrounds herself when she is holding the baby etc.
		Posted by Sreekala S. Tue Jan 10, 2006 06:34 am
Epilepsy in pregnancy significantly affects the maternal and fetal outcome. A detailed history should be obtained from the woman regarding the frequency of fits, medications if taken and their dosages and compliancy of medications. Her obstetric history and desire to continue the pregnancy should be asked for as it is an unexpected one. She should be given multidisciplinary team care involving a neuro physician, high risk obstetrician and paediatrician. The medication and dosage of the anticonvulsant medication may have to be altered during pregnancy to optimise the seizure control and to avoid fetal/maternal toxicity. She may need to be admitted to the hospital to adjust the dose, especially when she has recurrent episodes of fits. The serum levels of the anticonvulsants should be regularly measured to avoid toxicity preferably every 3 months. Monotherapy with the lowest effective dose should be the aim but, if the fits are not controlled, then she may be given multiple therapy in consultation with the neurophysician. If she has been taking anticonvulsants, the baby will be at a higher risk of teratogenic effects. She should therefore be advised serum screening at 15-16 weeks and a detailed anomaly scan at 18-20 weeks as there is a higher incidence of neural tube defects, cardiovascular anomalies, cleft lip/palate, IUGR and neuro developmental problems.Termination of pregnancy may be offered in the event of major fetal anomalies. Growth scans should be carried out 28 weeks and 32 weeks as there is a risk of IUGR. Vitamin K 10mg orally should be advised in the final month of pregnancy as the anticonvulsants induce the cytochrome P450 and deplete maternal circulating Vit K levels with a poor placental transfer to the fetus and may lead to neonatal haemorrhagic problems. She should be given advice regarding nutrition,adequate sleep and compliancy with the medication, as poor nutrition, sleep deprivation and poor compliancy with medication is associated with an increase in seizure activity. General advice regarding avoiding driving and precipitating factors should be discussed. Her partner and the close family members should be taught about first aid measures like placing her in recovery position in the event of a fit and provide with contact numbers in emergency. Information leaflets should be provided along with information about support groups. Normal vaginal delivery at term should be anticipated in the absence of any growth retardation and with good fit control.But, caesarean section may have to be considered if there is poor control of fits or if there are concerns with the fetal growth and progress of labour. A continuous electronic fetal monitoring is required during labour. Epidural anesthesia can be considered in consultation with the consultant anesthetist. A paediatrician should be available at delivery to evaluate the baby for any congenital malformations. Parenteral Vit K should be given to the baby to avoid neonatal bleeding problems. The neonate should be observed for any signs of anti convulsant toxicity like lethargy, poor feeding and hypotonia. The baby may develop withdrawal symptoms if bottle feeding is given. Breast feeding can be given. But, as most of the anticonvulsants are secreted in breast milk, signs of toxicity should be looked for if breast feeding is given. She should be advised to feed the baby in a secured place and not to bathe the neonate alone as there is a risk of neonatal injury if she develops a fit while caring the baby. Following delivery, the anticonvulsant medication may have to be altered back to the preconceptional dose to avoid toxicity. If the dose is being reduced, then it should be gradually tapered over a period of 6-8 weeks. Contraceptive advice should be given at the 6week post natal visit. COCP and minipills are not effective if she has been taking carbamazepin/phenytoin/phenobarbitone as these drugs induce the cytochrom P450 and reduce the efficacy of the hormonal preparations. Therefore, barrier method of contraception or IUCD should be advised for contraception. Sodium valproate, gabapentine and lamotrigine do not alter the efficacy of the COCP. Advise should be given regarding future pregnancies. She should ideally plan a pregnancy following atleast 2year fit free period and take 5mg of folic acid during the peri conceptual period to reduce the incidence of neural tube defects.
		Posted by Zaibunnisa khan K. Thu Jan 12, 2006 12:36 am
Pregnancy with epilepsy is a high risk condition because of its association with fetal malformation and maternal mortality.It is a second most commonest indirect cause of maternal mortality. Therefore she should be cared by a multidisciplinary team of general practionar ,neurologist ,obstetrician and neonatologist. Detailed history of patient should be obtained regarding the frequency of the seizures,type of anticonvulsant medication,dosages and her compliancy .History of associated pregnancy complications such as nausea and vomiting which may altered drug level. Past obstetric history regarding her previous pregnancies ,their outcome and any affected sibling should be obtained.Her last menstrual period should be confirmed.Her detailed family history of epilepsy and congiental malformations should be obtained . Her routine antenatal examination should be performed .Along with routine antenatal investigations she also need free anticonvulsant levels to assess her compliance and to adjust the drug dosages. She is at high risk of developing neral tube defect, cleft lip and plate and congenital cardiac malformations therefore her serum alphafetoprotein should be measured at 14 -16weeks and detailed ultrasound scan at 16 -20 weeks. In most cases the frequency of seizures is not altered by pregnancy but patient with poorly controlled epilepsy are more likely to deteriorate in pregnancy.The primary goal of treatment is to control seizures.She should be explained about the risk of seizures and about the importance of compliance with medication.She may need neurological assessment and admission to the hospital to adjust the dosages and control her seizures. Carbamazepine and slow release preparation would be the preferred options.The dosage should be adjusted according to her clinical wellbeing and drug level may need to be monitored at interval. General advise regarding diet ,sleep and avoidance of precipitating factors should be given.Family member or supportive partner need to be involved in her care and to be aware of care in case of a convulsion to avoid aspiration and maternal trauma. She should be advised to bathe in shallow water or to take shower. The risk of fetal congenital malformatioms and the risk of epilepsy need to be discussed. She need frequent antenatal visit as she is at high risk of preterm labour,premature rupture of membranes and atepartum haemorrhage. Fetal growth need to be monitored by serial ultrasound scan as there is risk of intrauterine growth retardation. Termination of pregnancy may be an option as the pregnancy is unplanned or in case of severe fetal malformation if the she is unwilling to continue pregnancy .Vitamin k 10 milligram per day should be started at 36 weeks as all anticonvulsants are hepatic enzyme inducers. Labour should be managed in a normal way.Vaginal delivery should be aimed and caesarean section will be reserved for obstetric indications or in case of recurrent maternal seizures. The anticonvulsant should be continued during labour as risk of convulsions is increased during labour and immediate postpartum.She may need intervenouse or rectal anticonvulsant to control seizures.Epidural analgesia should be instituted early in labour to limit the risk of seizure due to pain and stress of labour. The neonate should be examined by the neonatologist for fetal anomaloies and neonatal withdrawal affects.The neonate should also receive 1milligram of vitamin k soon after birth.Breast feeding is safe and should be encouraged.She should be helped in taking care of the baby, for adequate rest and proper diet and sleep. She should not take bath un attended Anticonvulsant dosage can be reduced gradually during the first 6-8 weeks postpartum with monitoring of drug levels and according to the clinical wellbeing. Anticonvulsant reduce the efficacy of combined oral contraceptive and the progestogen only pills ,therefore high dose combined oral contraceptive pill is recommended.
		Posted by M H. Sat Jan 14, 2006 01:05 am
During the initial consultation, it would be important to establish an accurate history of her epilepsy, what antiepileptics she was taking, how frequent her fits were and when her last fit was. This pregnancy should be managed jointly by a neurology and obstetrics team; if needs be, the dosage of her antiepileptic should be increased by the neurologists to adequately control her seizures. The lady and her partner should then be counselled regarding the pregnancy. Antiepileptics carry a tetratogenic risk, especially neural tube, cardiovascular and orofacial defects. She should also be made aware that epilepsy itself carries an increased risk of congenital anomalies compared to normal population (information for future pregnancy). She should be adviced to continue her antiepileptics as inadequate control of her epilepsy may lead to intractable seizures and neurological damage to her. An ultrasound should be offered to this lady with special attention to look for NTD, cardiovascular and orofacial defects. The lady and her partner should be adviced to deliver in a hospital setting with neonatal and operative facilities. Intrapartum, she should be offered adequate analgesia to prevent exhausted and undue stress. A neonatologist / paediatrician should be on hand to examined the baby after the delivery. Electronic foetal monitoring should be offered. Post partum, she should be encouraged to breastfeed. If antiepileptic dosage has been increased, drug levels should be monitored and dosages adjusted accordingly. She should be given contraception advice. Antiepileptics (except Valproate) are enzyme inducers and thus reduce the efficacy of hormonal contraception such as OCP, POP and injectable progesogens. She should also be adviced to take preconception folic acid supplementation prior to embarking on her next pregnancy to reduce incidence of NTD. All information and advice should be reinforced with written materials. Information on relevant support groups should also be supplied to her and her partner.