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MRCOG PART 2 SBAs and EMQs

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ESSAY 221 - EPILEPSY IN PREGNANCY

Posted by Srivas  P.
a) I would tell her that sodium valproate can increase risk of spina bifida to 1-3% from a background risk of 1-2/1000 cases. The risk of other congenital anamolies too increases to 6-8%, a 2-3 fold increase over the general population. This is due to effect of AED and the effect of disease itself. However I would tell her still there is 90% chance that the baby would be ok. Since she has not been given 5mg/day folic acid in early pregnancy which decreases the risk of a spina bifida, her risks remain. I will also explain risk of epilepsy to the baby which could be 2-3 percent.

I would tell her the risk of uncontrolled epilepsy to her and her baby is more than the risk of congenital anomalies; hence compliance with AED is important.

I would explain about 1% risk of miscarriage with amniocentesis if it is done when AFP is high with no USG abnormality.

Risk of IUGR and risk of neonatal bleeding will be explained. Hence need for fetal surveillance and Vit K to mother from 36 wks for 4 wks and Inj Vit K to baby. Postnatally there is risk of injury to baby if she gets fit while nursing and baby falls. Need to nurse in safe place and in a sitting position.

b)Best outcomes are with multi disciplinary team comprising GP, neurologists and consultant obstetrician and mid wife.

I would find out if she is compliant with AED drugs and non-compliance could have increased her seizure rates. In pregnancy fits may increase because of decreased GI absorption, increased renal clearance and liver metabolism and decreased drug level due to haemodilution. I would find details of fits before this pregnancy, frequency and the period since increase.

Her drug levels need to be monitored initially until seizures are well controlled and later in every trimester and in late pregnancy. In order to ensure sustained level sodium valproate may be given in multiple doses or as sustained release preparation. Her drug doses may need to be increased in consultation with neurologist and may need adding on another AED or changing the drug to affect control. But doses should be minimal necessary to have control. Safety of newer drugs like gabapentine, Topiramate and Lamotrigine in pregnancy is not well documented and should be avoided.

Detailed anomaly scan at 22 weeks, fetal echo at 24 wks as incidence of cardiac anomaly are increased in epileptic woman. Fetal surveillance including monitoring for IUGR- if suspected on clinical examination?BPP, amniotic fluid and NST ?frequency modified by clinical assessment.

Mother must receive 20mg oral Vit K to prevent hemorrhagic complications in mother and baby due to vit K deficiency.

Woman?s partner should be told about measures to be taken in case of fits, emergency telephone numbers to contact.

c)The AED doses should continue as usual. Increased surveillance for fits as they are likely to increase during labor and if it occurs it can be controlled with diazepam or lorazepam. Seizures may be seen in 1-2% patients. Her method of delivery is not affected if her condition is under control. If fits are not in good control or if it is likely she may not co-operate due to altered awareness or she is having uncontrolled fits or status epilepticus, C.S may be indicated, preferably under GA.

It she is delivering vaginally it is necessary to reduce anxiety and pain in labor as this may precipitate fits and so Epidural anesthesia should be considered. Avoid opioids as this may precipitate a fit in some woman. Continuous EFM is recommended if fetus is having IUGR. Do not offer water births as it may precipitate a fit and she may drown inside the bath.
Posted by Sarwat F.
Risks to the fetus are related to disease itself and medication she is using. She will be explained that there is a risk of congenital anomalies with the use of antiepileptic medication in the first trimester mainly neural tube defects, cleft lip and palate and cardiac defects. There is also a risk of epilepsy in the offspring if mother has the disease. As antiepileptic drugs interfere with vitamin k metabolism there is a risk of vitamin k deficiency in the newborn and risk of haemorrhagic disease of newborn. There is also risk due to seizure related accidents like trauma, abruption.
Measures to optimize outcome include multidisciplinary care with the involvement of neurologist to modify drug regime necessary to control epilepsy. Necessity for anticonvulsant medication is reviewed. Monotherapy is recommended with the lowest dose of appropriate agent. Free drug levels are monitored at regular intervals preferably monthly. Counseling is done by the epilepsy nurse in detail. She should be explained about the risks of seizures and importance of compliance with medication and antenatal follow up. She should be advised to avoid seizure precipitating factors like sleep deprivation. Advise good diet to optimize better antenatal outcome. She will be offered prenatal diagnosis in the form of triple test, detailed anomaly scan and if the risk is calculated high than amniocentesis and karyotyping. Regular antenatal visits are arranged to monitor fetal and maternal well being. Visits should be 4 weekly till 28 weeks, fortnightly till 36 weeks and weekly thereafter. Vitamin k 10 mg / day will be given in final weeks of pregnancy from 36 weeks to minimize haemorrhagic complications. In well controlled disease spontaneous labour is allowed. Caesarean section is reserved for obstetric indications.
Intrapartum care will include good pain relief to avoid seizure activity and monitoring progress of labour on partogram. In case of any seizures magnesium sulphate is the treatment of choice. In case of seizures delivery may be indicated by caesarean section after stabilization of maternal condition. Management will be multidisciplinary with the involvement of anaesthetist, senior obstetrician and neurologist. Dose of antiepileptic medicines need to be adjusted after delivery to prepregnancy dose. Patient is educated regarding seizure related accidents and avoidance of precipitating factors. After delivery neonate is examined to identify any structural defects, vitamin k is given, monitoring is done for neonatal withdrawal. Breast feeding is safe, however sedative effects are monitored. Followup is maintained with the GP and neurology team. Appropriate contraception is provided as some antiepileptic medicines interfere with metabolism of oral contraceptive pills.
Posted by Farzana N.
a)Pts on anti epileptic drugs have 2-3 fold increased risk of having children with major malformations compared to general population,and this risk is even higher in pts on valproate therapy. This pt has been exposed to valproate during the period of organogenesis ,.she should be couselled well that there is 1-2% risk of NTD ,such as spina bifida.other skeletal defects ,radial aplasia and urinary defects ,such as hypospadias.Increasd frequency of seizures put the fetus at risk of hypoxia,intracranial hemorrhage and increased fetal loss.During the first 2yrs the child may at risk of delayed cognitive and neurodevelopmental delay.
b)Antenatal management should be undertaken jointly by obstetrician with special interest in epilepsy,with neurologist and midwife, to provide optimum care.She should be provided information and advised to register with Uk register of Antiepileptic Drugs in Pregnancy
Since the pt is experiencing increased frequency in seizures,dose of volproate need to be increased to provide optimum seizure control,which are harmful both to the mother and fetus.She should be advised to get adequate sleep, as sleep deprivation may increase seizure frequency.She should be advised to take shower not bath,as there is a risk of drowning in the bath tub.
She should be offered high resolution USS at 18-20 wks .Prenatal serum screening with AFP at 15-20wks together with USS can detect 95% of open NTD .Amniocentesis may be done for AFP and Ach.Fetal echocardiography may be required to detect cardiac anomalies.If the fetus is found to be affected,mother should be told about the diagnosis,implications of spina bifida .She can be offered TOP,if she opts for. Maternal wt gain or fundal height growth are monitored and serial growth scans may be required to detect any IUGR at the earliest.Seizures occurring in pregnancy may be aborted by diazepam.She should be given weekly injections of vit k from 36wks to prevent hemorrhagic tendency in the new born.
c)During labour ,she should be managed in a consultant led unit fully equipped with maternal and neonatal resuscitation facilities,bearing in mind that the pt is at highest risk of seizure in the peripartum period.Antiepileptic drugs should be continued and given by parenteral or rectal route.She can be allowed normal delivery .CS will be for obstetric indications or if she has recurrent seizures.Prolonged and recurrent seizures can be aborted by giving iv diazepines.neonate should be given vit k im as the greates risk of hemorrhage is on the first day of life.neonate should be examined for anomalies.Since valproate is highly protein bound,low levels are found in milk and beast feeding is appropriate.
Posted by Sreekala S.
a) I will tell her that there is an increased risk of teratogenicity for the fetus due to exposure to sodium valproate during the important phase of organogenesis. There is an increased risk of fetal anticonvulsant syndrome with congenital malformations like neural tube defects, cardiac defects, cleft lip/palate, dysmorphic facies, microcephaly, hypertelorism, epicanthic folds, low set ears, flat nasal bridge, distal digital and nail hypoplasia and long philtrum. I will also inform her about the increased risk of spontaneous miscarrige, IUGR and stillbirth with this pregnancy. There is also a risk of radial aplasia and urogenital defects like hypospadias in the newborn. I would inform her the increased risk of fetal hypoxic damage and even fetal death due to uncontrolled recurrent fits. The newborn carries an increased risk of haemorrhagic disease due to Vit.K deficiency that may occur due to the enzyme inducing effects of the anticonvulsants. There is an increased risk of withdrawal effects manifesting as jitteriness, poor feeding and even convulsions after birth. I would also inform her about the possibility of developmental delay, behavioural problems and learning difficulties in the baby. There is an increased risk of the newborn inheriting epilepsy from her. I would also inform her the increased risk of developing childhood malignancies like neuroblastoma. I will be sensitive in disclosing this information, providing her with support and information leaflets.
b) To optimise the outcome of the pregnancy she should have a multidisciplinary team care comprising of an obstetrician, neurophysician, midwife, paediatrician and GP. Her anticonvulsant medication should be reviewed and modififed by the neurophysician. Admission of the patient may be required to rule out the other causes of epilepsy, titrate the dosage of anticonvulsants in the event of repeated convulsions. Monotherapy is preferable to polytherapy and the lowest effective dose should be given to minimize the side effects. Drugs levels may have to be checked if there is a doubt about drug compliancy or concerns about side effects. She should be made to understand that risks of uncontrolled fits outweighs the risks associated with the use of anticonvulsants and therefore should be advised to take the medication regularly.
She should be offered serum screening for fetal anomalies at 15weeks. A detailed anomaly scan should be performed at 20-22 weeks to detect any congenital anomalies. A fetal cardiac scan should be done to rule out cardiac defects. She should be given the option of TOP in the event of a major anomaly.
Regular assessment should be done with ultrasound monitoring of fetal growth and Doppler assessment. Oral Vitamin K 20mg/day should be given from 36 weeks onwards until delivery to combat the deficiency caused by the anticonsultants. Dosage of steroids has to be increased to 48mg (Two doses of 24mg given 24hrs apart) if steroids are required to enhance fetal lung maturity. The woman should be given general advice about avoiding driving. She should be advised to eat regularly and sleep adequately as sleep deprivation and starvation can trigger fits. She should be advised to use showers and avoid baths. She should be given information leaflets and contacts of support groups.
c) Her intrapartum care should involve the consultant obstetrician, anaesthetist, neurophysician and an experienced midwife. Vaginal delivery should be the aim. Caesarean section should be reserved for obstetric indications. A continuous CTG in labour is required. Adequate labour analgesia should be provided. Anticonvulsants should be continued in labour. There is an increased risk of convulsions in labour due to sleep deprivation, pain, hyperventilation and due to non-compliancy with the medication. If she develops convulsions in labour, should be turned to the left lateral position and given IV benzodiazepines. Rectal diazepam can be used in the absence of an IV access. Delivery by caesarean section may be required in the presence of status epilepticus.
Posted by kiria O.
Woman should be exsplained that her baby at increased risk of congenital defects because of disease it self even without use of antiepleptic drugs, whish is 3 folds more than general population.
The risk of congenital malformation is increased with antiepleptic treatment and its great with poly thearapy.
As she is taking sod.valproate during pregnanacy, her fetus has increased risk of neural tube defects mainly spina bifida 1 in 100 compared to 1in 1000 in general population.
Also her baby at risk of fetal growth restriction especially if her epilepsy is not well controlled.
Woman should be exsplained that she and her baby at risk of vit k deficiency and this means that increased risk of heamorrahge, so, vit k supplement from 36 weeks would reduce this risk.
Also, her baby has increased risk of having epilepsy(3%) and this risk increased if both parent are epileptic (10-15%).

To optimise outcome during antenatal period, multidiciplinary care is of a great value, involving senior obstetrician, neurologist and midwife. liasion between obstetrician and neurologist to optimise drug doses to achieve control of epilepsy and prevent fits.
Woman need to be advised to take her medication regulary and have adequate sleep and healthy diet with folic acid throughout the pregnancy to prevent megaloblastic anaemia.
Early dating scan is very important to determine gestational age which is essential for serum screening and timing of induction of labour.
Offering woman maternal serum AFP test at 15 weeks gestation could be usefull in early detection of open neural tube defects and early termination.
Anomaly scan at 20 weeks gestation can detect 92% of spina bifida, however acetylcholin estrase level can be tested in presence of high MSAFP with negative USScan.
Fetal growth scans forthnightly from 24 to36 weeks to detect fetal growth restriction and ensure adequate fetal monitoring in such cases.
Vitamin K should be given to the woman orally from 36weeks gestation to minimise the risks of postpartum heamorrhge and heamorrhagic disease of a newborn.
The aim is for spontanous labour and vaginal delivery, Cs is only recommended for obstetrical reasons.
Most women with epilepsy would have favourable outcome but regular follow up and good antenatal care will maximise this results.
Her intrapartum care should aim for adequate analgesia as pain and stress may induce fits and this can be ensured by epidural analgsia.
woman\'s medication must be given regularly and adequate hydration with small meals to prevent hypoglycemia.
Continous fetal monitoring to detect any fetal heart abnormality especially if fetal growth is restricted.
If assisted delivery is needed, forceps may be more appropriate than ventouse extractor because, of risk of ceplaheamatoma and retinal heamorrhage as the baby at increased risk of heamorrhage due to vit k deficency.
Neonatolgist should be informed and attend the delivery and neonate should be given intramuscular vit k.
Active managment of 3rd stage to reduce risk of ppH and appropriate use of uterotonics is recommended.
Posted by Mary M.
The women with increased frequency of seizures & use of sodium valproate in first tri mester will be told about the risk to fetus are more than general populatiom and they are only partly contributed by medicines.Risk of congenital anomalies is2-3 folds and it is dose related.The risk is more with first trimester exposure.Volproate is associated with neural tube defect especially spina bifde.This risk is greatest if serum level of valproate is more than 1000mg/day.
b) Multidisciplanry approach , consultant led care& liasation with neurologist for control of seizures , she will be offered routire screening for anueuploidy &detailed anomaly scan to measure the drug level @ 15-16, 28 & 34-36 wks.Valproate level falls througout during pregnancy. Materal vit K supprementalen from 34 wks to reduce the risk of fetal & maternal haemorrhages, in oral or I/M form, she will be adviced to have adequate sleep & reduce stress & fatigue because these factors can increase the seizures frequency .Her partner will be told about the recovery position when she will have seizures and bring her quickly to hospital for assessment.Fetal monitoring in form of non-stress tese & growth scan is done .
c) The chances of seizurnes are highest peripartum. So delivery should take place in unit where specialized care for epilepic women & neonatal intensive care unit is available.Epilepsy is not an indication for C-Section. Continue antiepileptic drugs during labour, parental/rectal treatment may be required.Neonates are increased risk of haemorrhage and this is greatest on the first day of life.Neonatal vit K is given & examine neonate for anomalies.
Posted by sailaja devi K.
I will reassure the women that majority of the pregnancies proceed without difficulties .I will discuss the risk of major malformations and potential long term effects.
Women with epilepsy have a 2 fold increased risk of fetal loss and perinatal death.There is 2 fold risk of IUGR.Sodium valproate is a teratogenic drug so the risk of congenital malformation is increased by 2-3 fold. The risk of malformation is dose related.Valproate is associated with neural tube defects open spinabifida , skeletal defect like radial aplasiaand urogenital like hypospadiasis.Discuss prenatal diagnostic procedures and women?s view on management of anamolies.Antiepileptics have increased risk of developmental delay in child in first 2 years of life.Children of epileptics have 4-5 % risk of epilepsy compared to 1 % in general population.

Antenatal care is by consultant led care in close liaison with neurologist.Continue folic acid supplementation of 5 mg / day.Offer the women routine screening for aneuploidy.Screen for structural anamolies between 18 ? 20 wks.Prenatal screening using serum afphafetoprotein at 15 -22 wks combined with structural ultrasound scan can identify 95 % of fetuses with open neural tube defects.Detailed scan with fetal echocardiogram and imaging of fetal face is required.Monitor for fetal growth clinically ,if inappropriate followup with ultrasound scan. Valproate should be changed to 3-4 times daily dose to lower peak concentration .Alteration in dose should be made on clinical grounds , routine measurement of drug level is not recommended.Dose measurement may be used to ascertain symptoms of toxicity or drug adherence. Measure drug levels at 6-10 wks,15-16wks,28 wks,34-36 wks. If steroids are needed for lung maturity ,higher doses are needed.
Seizure during pregnancy should be managed as any person with epilepsy, should be in close collaboration with epilepsy team. Women should be supplemented with vitamin K oral or intramuscular route from 36 wks till delivery.This is to reduce risk of maternal and neonatal bleeding associated with vit k deficiency.
Encourage the women to have adequate sleep as sleep deprivation will increase seizure frequency.Women should be adviced to bathe in shallow waters or shower.

Women should be delivered in consultant led obstetric unit equipped with facilities for maternal and neonatal resuscitation.1-2 % of women with epilepsy can have seizure in labour. The risk of seizure is highest in peripartum period.Women should continue her regular antiepileptic drugs in labour .Parentral or rectal route may be required because of delayed gastric emptying during labour.If there is concern regarding risk of intrapartum seizures corbamazepine can be administered rectally ,phenytoin can be administered iv. If recurrent seizures occur in labour IV lorazepam is appropriate.
Early epidural is considered to limit the risk of precipitating seizure due to pain and anxiety.Most women with epilepsy will have normal yaginal delivery ,caesarean section is required if there are recurrent generalized seizures.
Examine the neonate for anamolies . Neonate is at increased risk of haemorrhage so administer vit k 1 mg im route.
Posted by Randa E.
She should know that the offspring?s of epileptic mothers are at heightened risk for a variety of pregnancy outcomes, either from maternal epilepsy itself or from in-utero exposure to AEDs for they carry teratogenic risks. She will have a greater risk of fetal anomalies like neural tube and cardiovascular defects. Spina-bifida occurs with significantly greater frequency in mothers taking Na Valpoarate. Her fetus also has an increased risk of developing antiepileptic drug syndrome which includes typical craniofacial abnormalities, distal digital hypoplasia and developmental delay esp. in the 1st two years. She should know that the epilepsy itself carries a risk of congenital anomalies compared to the normal population even if not on treatment. She has an increased risk of miscarriage, IUGR and stillbirth. Children of epileptics have a higher chance of developing epilepsy in the future. She should be made aware that neonates might manifest signs of drug withdrawal such as jitterness, hypotonia, hypoglycaemia, apnoic episodes or seizures after delivary. She should also be reassured that most women deliver normal babies.
To optimize outcome the measures taken should be that this lady should be under consultant led care. Early liason with neurologist is important .Her antiepileptic drug therapy will probably need adjustment esp. that she has an increase in the frequency of the seizures. Serum drug levels and seizures frequency are used to guide to drug dosage. Na volpoarate therapy is usually changed to 3-4 times daily to lower peak concentration. Since she has been counselled about the fetal anomalies then an anomaly scan should be offered including a cardiac scan. She should however be warned that some of the minor abnormalities might not be detected. Screening for neural tube defects using MS-AFP and U/S should also be offered. Since she is not seizure free then drug levels need to be monitered at 15-16, 28 and 34-38 weeks since Na volproate levels fall continuously during pregnancy. Also to ensure that increased dug dosage will not result in toxicity. Regular growth scans should be done if epilepsy remains poorly controlled. Folic acid supplements should be given throughout the pregnancy to prevent development of folate defeciancy. Vit k oral or IM supplementation is given from 34-36 wks to reduce the risk of maternal and fetal bleeding. The partner should be educated on use of recovery positions during seizures and the woman advised to bath in shallow waters or shower. Advise on avoiding stress, sleep deprivation and other factors that trigger fits should be provided. Emergency numbers should also be provided.
Ideally delivery should take place in a unit with facilities for providing specialized care to epileptic patients and a neonate intensive care unit. The aim should be a vaginal delivery with c/s reserved for obstetrical cases. Water births should be avoided. Antiepileptic drugs should be continued and parentral/rectal treatment may be required because of decreased gastric emptying. Adequate pain relief should be ensured and opiates such as pethidine which may trigger seizures in some women should be avoided. Continuous fetal monitoring should be undertaken esp. if there are frequent seizures. If seizures have become well controlled then a normal labour and birth can be anticipated.



Posted by Parveen  Q.
This patient has to be told of the following risks;
1.Risk of epilepsy in the foetus; if one parent is epileptic, the risk of epilepsy in the foetus is 5%, if one sibling is epileptic, the risk is increased to 10%, if both parents are epileptic, the risk is further increased to 15-20%.There is 2-3 times risk of congenital malformation than the general polpulation.
2. Risk of antiepileptic drug- all AED are teratogenic, with sodium valporate there is increase risk of CNS(neural tubal defects) and CVS deformalties. As the seizure frequency has increased in this patient , on higher dosage of sodium valporate, the risk of congenital malformation is increased by 6folds.
3.No increase in obstetric complications provided there is no abdominal trauma as a result of seizures.
4. Haemorrahagic disease of the new born is increased due to vit k dependent clotting factors deficiency.

Antenatally she should be followed in consultant unit, by multidisciplinary team involving neurologist, specialsit midwife and health visitor. There is no need to change the AED ,but to avoid peak plasma concentration, the daily dosage has to be given in 2-3 divided dosas. Free drug change to a lesser degree, so it should be used to monitor patient. Basic serum level or salivary drug level can be used for monitoring. Drug level monitoted once every trimester and in the last month. Eventhough folic acid was not given earlier in her case to avoid NTD , it can still be given throughout her pregnancy to reduce the risk of folate deficiency anaemia. Screening for NTD by nuchal translucency scan, and MSAFP should be done. Aminicentesis, done after counselling her about the risk of fotal loss at 15 weeks and AFP, acteylcholinestrase level determined to screen for NTD . Detailed ultrasound , anamaly scan done at 18-20weeks, if heart defedts are suspected, repeat scan done at 22 weeks by foetal cardiologist. Vitamin K 10-20mg given in the last 4weeks of pregnancy as the vit k dependent clotting factors are reduced by AED. General advise given to her, regarding avoiding trauma, and to take shallow water bath or shower. Relaitves and partner should be given instruction to place her in lateral positon in the event of seizures to avoid aspiration .

Intrapartum care involves continuous CTG monitoring for the foetus. The AED should be contiued throughout labour. There is 1-2% increased risk of seizure in labour and another 1-2%in the first 24hours postpartum. Neurologist should be involved in the care, anasthetist and paediatrician informed . If due to fear or anxiety provokig a seizure, early epidural analgesia given. Status epiletics can be controlled by lorazepam. Vaginal delivery is anticipated. Caesarean section should be reserved for status attacks and for those cases intractable to medical treatment in the last few weeks of pregancy and in labour. Vitamin k 1mg im given to the neonate. Breast feeding not contraindicated. Sodium valporate is not an enzyme inducer, so any types of contraception can be used taking her preference into consideration. contraception should be used untill the seizures are controlled by the lowest dose possible. preconceptual foilc acid of 5mg daily should be advised.
Posted by Freha Z.
I would inform her that sodium valporate crosses the placenta and is teratogenic. The major malformations caused are neural tube defects (1-4%), orofascial defects and congenital heart defects. Minor malformations are dysmorphic features(V shapped eye brows, low set ears, broad nasal bridge and irregular teeth and hypoplasia of midface). There is also a risk of impaired psychomotor developement and educational needs. She would be offered detailed fetal anomaly scan to detect any abnormality although it may not exclude 100% anomalies. She should know that fetus is resistant to short episodes of hypoxia during seizure. The risk of miscarriage is not increased unless seizures result in abdominal trauma.
She should also be informed that the risk of the child developing epilepsy is 4-5% above background. Risk is higher if other parent is also effected and if she herself developed epilepsy before age of 10. All the information should be shared sympathetically and clearly and supprted by leaflets. The discussion should be clearly documented in the notes.
(b) Pregnancy should be managed by multidiscipliary team including obstetrician, neurologist, midwife and neonatologist. If the epilepsy is well controlled there is no need to change the drug. She should be reassured that the risk of congenital abnormality due to drugs has passed after first trimester. Relatives, friends or parteners should be advised how to put the women in recovery position to prevent aspiration in the event of seizure. Women should be advised to bathe in shallow water or in shower.

Prenatal screening for congenital abnormalities with detailed scan at 18--20 weeks should be offered. A repeat scan (preferably by fetal cardiologist) at 22 weeks is advisable if cardiac defects suspected. The frequency of seizures may increase during pregnancy. Dosage of drugs need to be optimized by neurologist due to fall in free drug concentration because of increased plasma volume and enhanced renal and hepatic clearance. A baseline serum or salivary drug level is required to establish compliance and to inform future changes in drug dosages. If a woman is seizure free than there is no need to measure drug level serially.

Vitamin K (10--20mg) should be prescribed in last four weeks of pregnancy for epileptic women taking hepatic enzyme-inducing drugs because the babies of women receiving these drugs, vit. K dependent clotting factors may be reduced and there is risk of hemorrhagic disease of newborn.

(c)The risk of seizures increase during delivery therefore women need to be delivered in hospital and should not be left unattended in labour or first 24 hours postpartum period due to increased seizure frequency. Women should continue their antiepileptic drugs during labour. Early epidural should be considered to reduce pain and anxiety which may predispose to seizure. If seizures are not self limiting in labour, oxygen and intravenous lorazepam or diazepam should be given. Vaginal delivery should be the aim, caesarean section only required in obstetric indications or recurrent generalized seizures in late pregnancy or labour. Neonatologist should attend the baby to examine for congenital anomalies and effect of drugs.
Posted by M M A.
I will tell her that the possible fetal risk is mainly attributable to the medication,and the the risk to the fetus from the fit is small but significant.
The associated risk with with Valproate rxposure in utero is both major malformations and developmental delay .
I will tell her that the major malformations caused by Valproate is fetal spina bifida ( 1-2 %) and congenital heart defects. Valproate has been associated with skeletal defects such as radial aplasia and urogenital defects like hypospadias.
I will tell her also, about the possibility of association between tonic-clonic seizures and fetal hypoxia , fetal intracranial haemorrhage and fetal loss.
The risk of an epileptic mother having an epileptic baby is 1 in 40.

Close liaison between epilepsy team , obstetrician and midwives will allow careful planning and care during the pregnancy. Treatment should be optimized and where necessary the continuation of the Antiepileptic drugs reviewed .Antiepileptic drug therapy needs to be adjusted with advise from neurolofist.
Serum drug levels and seizure frequency are used to guide drug dosage.
Prenatal screening using maternal serum alphaprotein at 15 ? 22 weeks combined with structural ultrasound scan can identify 95 % of fetuses with open neural tube defects. More detailed scanning with fetal echocardiography is performed. This is a valuable to detect congenital heart defects.Regular growth scan is needed ,if epilepsy remains poorly controlled . Increased surveillance for intrauterine growth restriction in later pregnancy is preferred if the mother weight and fundal growth are not appropriate. The antiepileptic drug levels should be monitored at 15 - 16 , 28 and 34 ? 36 weeks , as valproate levels fall continuously during pregnancy. Increased dosage of valproate as pregnancy advances . This is because of the increased blood volume and binding proteins , which reduce the concentration of free valproate. Folic acid supplementation 5mg daily should be continued throughout pregnancy to reduce risk of folate deficiency. Vitamin K 10 mg daily should be given orally from 36 weeks gestation , which mainly to reduce the the risk of haemorrhagic disease of the newborn and also to reduce the maternal bleeding. Dietary advice and general health measures should be offered , with special regard to what to do when fits occur. The husband must be educated on use of recovery positioning in the event of seizure and the patient should be advised to bathe in shallow water or shower . Also, advice regarding avoidance of stress and ensuring adequate sleep is useful.
Her delivery should be conducted in a unit equipped with facilities for maternal and neonatal resuscitation . Adequate pain relief should be provided , but opiates such as pethidine should be avoided as may trigger seizures . Antiepileptic drugs should be continued during labour . Parenteral or rectal treatment may be required because of decreased gastric emptying during labour. Recurrent or single prolonged tonic-clonic seizures can be terminated with subbuccal midazolam , intravenous lorazepam or rectal diazepam. Delivery should be closely monitored , with continuous fetal monitoring is important. There is an association between tonic-clonic seizures and fetal hypoxia anf fetal loss . Caesarean section only should be done for obstetric indications. Intramuscular 1 mg Vitamin K should be given to the neonate at birth to reduce risk of haemorrhage. Neonate should be examined by neonatologist
Posted by neera  B.
a) I would ascertain the dose and duration of Sodium Valproate therapy. I shall reassure her that most fetuses would be normal. However, the risk of neural tube defects NTD ( anencephaly and spina bifida) is increased to 3-5 % compared to 1 in 1000 for normal pregnancy. These can be picked up in 95 -100 % cases on ultrasound and termination considered accordingly. There is 4% risk of epilepsy in baby of an epileptic mother, irespective of medication. Hemorrhagic disease of newborn due to Vit K defeciency, neonatal drug withdrawal symptoms and developmental delay is more common. Leaflts will be given.
b) She should be booked under a consultant and followed in joint clinic with neurologist. MDT should be involved . Folic acid 4 mg/ day should be started and continued throughout pregnancy. She should be advised to shower and not to take bath , to prevent drowning. An ultrasound should be offered for dating, it may pick up anencephaly at 14 wks. Maternal serum Alfafetoprotein should be offered at 16 wks, a raised value is suggestive of NTD . Ultrasound picks up anencephaly with 100 % sensitivity and spinabifida with about 96% sensitivity. So repeat scan is offered at 18 wks by a specialist, if previous was normal. If fetus has NTD, termination is offered. Drug levels monitoring is not recommended, an alteration in drug dose may be required. Oral Vit K should be started from 36 wks , as this decreases the chance of postpartum hemorrhage, is cheap , effective and oral.
A carefully documented management plan for delivery should be made by MDT including Neurologist, senior anaesthetist , Neonatologist and consultant Obstetrician. Compliance with medication is emphasised. In absence of complications, she should proceed till term and have vaginal delivery. Caesarian section is only for obstetric indications. Labour carries high risk for convulsions. So antiepileptic medication must not be omitted during labour. If convulsions occur, intravenous Diazepam should be given. But I/v route is not established, rectal diazepam is given. Epidural can be given but GA is avoided due to risk of hypoxia with GA . Railed bed should be provided so that she does not fall down in case of a fit. She should not be left unattended in labour. Monitoring by pulse oximetry. BP and CTG should be done. Partogram should be maintained and prolonged valsalva manoeuvre is avoided due to risk of hypoxia precipitating a fit . Caesarian is only for obstetric indications. Active management of 3rd stage is done due to risk of PPH. If status epilepticus or recurrent fits occur, Caesarian section should be considered due to reduce risk to fetus. Neonatologist should be present at delivery due risk of drug withdrawal symptoms. Baby should be examined for NTD and I/M Vit K injection must be given to prevent Hemorrhagic disease of the newborn.
Posted by Abi T.
a)I will tell her that the majority of pregnancies progress normally. There is an increased risk of 1-2% above general population of the fetus having a congenital anomaly which is not related to antiepileptic drugs alone. There is an increased risk of open neural tube defects ie, spina bifida but not anencephaly ,especially in women taking sodium valproate. There is also an increased risk of cardiac defects, IUGR and still birth. Written information should be provided detailing these risks.
b) Outcome is optimized if care is provided in a multidisciplinary setting involving obstetrician with special interest in epilepsy, neurologist and midwife. As she has increased frequency of fits, her drug levels need to be monitored monthly to ensure adequate plasma levels. Any change in dosage should be done in consultation with a neurologist. The choice of drug need not be changed as she has passed the period of organogenesis.
Advice should be given for her to have showers rather than baths, to get adequate rest and sleep and that the risk of fits is highest at the end of third trimester and peripartum.Her partner should be taught how to place her in the recovery position should she have a fit and emergency contact numbers given. This should be supported with written information and details of support groups given.
An appointment should be made to see the anesthetist to discuss her analgesic and anaesthetic options.
Vitamin K 10mg should be prescribed from about 36 weeks gestation as she is at risk of PPH and to prevent hemorrhagic disease of the newborn. she should be advised to consent for the baby to have vitamin K as well.
Serum screening should be offered at 15-16 weeks gestation to detect NTDs. A detailed anomaly scan should be offered at 20 weeks gestation with special reference to the spine and cerebellar structures, however the accuracy of detecting spina bifida is about 92%. A fetal cardiac echo should also be done around 24 weeks gestation.Serial growth scans should also be performed to detect IUGR.
c) The risk of fits is highest peripartum due to lack of sleep, anxiety and tiredness in the mother. The aim should be for vaginal delivery and C/Section only for obstetric reasons. Water births are a contraindication.
Her usual dose of antiepileptic drug should be continued in labour, however due to poor GI absorption an alternate route of administration, ie;parenteral or rectal ,may be necessary. Resuscitaiton equipment should be available nearby and IV access should be obtained.
Continuous CTG monitoring is indicated in epileptics.
Maternal pain and anxiety should be reduced to prevent fits by providing adequate and effective analgesia.
Posted by Shyamaly S.
A) I would explain that most pregnancies have a good outcome so this is not an indication for termination. Epilepsy increases the risk of congenital malformations to 4% compared to the background risk of 3%. Valproate is associated with a higher risk (2%) of Neural Tube Defects (NTDs), cardiac defects, facial clefting and other minor abnormalities like dysmorphic features. However not complying with, or inadequate dosing increases her risk of status epilepticus which is dangerous for the fetus and recurrent fits are associated with growth retardation of the fetus. There is no increased miscarriage rate and single fits are not associated with poorer outcomes. I would support this information with written information and liaison with GP, CMW and support groups
B) A multidisciplinary approach is crucial. This would include an obstetrician to ensure maternal and fetal wellbeing, a neurologist to optimise drug treatment and minimise seizure frequency at the lowest possible dose of a single drug in this case valproate. Slow Release formulations help reduce fit frequencies. Community MW, Specialist nurses and GPs are important in further support and ensuring compliance with treatment and follow up. She should be given daily high dose (4mg) folate- at this stage it will not reduce her risk of NTDs but will minimise the risk of folate deficiency anaemia. She should be offered serum screening to assess for trisomy 21, but a raised AFP component will raise the suspicion of open NTDs. A 20 week anomaly scan will assess for congenital malformations and together with AFP will detect around 90% of open NTDs. At 22 weeks a fetal cardiac scan will assess for cardiac malformations. 4 weekly growth scans will assess for IUGR. As her seizure frequency has increased, serum valproate levels should be monitored every month to improve drug dosing. From 36 weeks onwards she should be given 10mg daily Vitamin K orally to reduce the risk of haemorrhagic disease of the newborn and reduce her risk of Post partum haemorrhage, as valproate affects hepatic clotting factor synthesis. She should be advised to have showers not baths to avoid the risk of drowning incase of seizures. As she is currently experiencing fits she should be reminded not to drive. Her family should be taught about the recovery position and what to do if she does fit, and they should encourage her to rest and sleep regularly to minimise fits.
C) This is a high risk pregnancy. The aim should be vaginal delivery with Caesarean reserved for the usual indications and also in the case of generalised recurrent seizure activity. Continuous CTG monitoring in labour is necessary and 1 to 1 midwifery care and the presence of a doula will support, reduce anxiety thus minimising fits. She should not labour in the pool or be offered a bath for pain relief as she may drown if she fits. Antiepileptic drugs should be continued in labour but it maybe necessary to give them IV or rectally as GI absorption falls. IV lorazepam and the resus trolley should be readily available in case of fits. An early epidural offers good pain relief thereby minimising fits. Breath holding should be avoided and she should be encouraged to rest when possible to minimise fits.
Posted by M M A.
Dear Sir,
I\'d like to ascertain about the role of Vitamin K in this case specifically, please.
Does Vitamin K is given to all pregnant ladies on any epileptic drug [ including Na valproate, Gapapentine, Lamotrigine, etc]? Or it should be limited to certain drugs like Carbimazepine, phenytoin and phenobarbitone that are known to cause Vitamin K deficiency and neonatal bleeding?
For your opinion please.
Thanks.