epilepsy in pregnancy multidisplinary.pptx

epilepsy multidisciplinary approach

1. EPILEPSY IN PREGNANCY PRESENTER: DR. CHIKONDE MODERATOR: DR. NAMUYAMBA

2. Epilepsy Epilepsy is a chronic disorder or group of disorders characterized by recurrent, unpredictable seizures. A seizure is a temporary physiological dysfunction of the brain, in which neurons will produce excessive electrical discharge. It is mainly presents in childhood, although there is a second peak of incidence in older years and women of childbearing age account for 23% of the population affected by epilepsy, with a prevalence in pregnancy of 0.35%.

3. The complications associated with the epilepsy are: Trauma occurring during the seizure and include tongue biting and head or limb injury Status epilepticus: a seizure lasting for > 30 minutes, or a series of seizures without regaining consciousness in between. Sudden unexpected death in epilepsy (SUDEP) of which there is no cause for sudden death.

4. Maternal death: the risk of sudden maternal death in pregnancy remains higher in women with epilepsy than those with other long- term conditions.

5. TYPES OF EPILEPSY A. Partial Simple: Characteristics Remains conscious Experiences as aura (premonition) Pins and needles sensation in arms or legs Pallor, or alternatively a flushed face with sweating Muscle twisting in limbs with some stiffness

6. Cont….. Complex: Characteristics: Awareness of changes, loses of the memory of the event. Rubbing of the hands Chewing and smacking of lips Makes random noises Exhibits usual posture

7. Cont….. B. Generalized: Absence: Characteristics: Staring and blinking, daydreaming , loss of awareness for 5-20 seconds (mainly affects children)

8. Cont….. Myoclonic: Characteristics: Brief muscle jerking in an arm or leg. Lasts for a fraction of a second and individual remains conscious. Tonic: Characteristics: All body muscles contract for < 20 seconds, but there are no convulsions. The individual falls.

9. Cont….. Tonic-clonic: Characteristics: The whole body contracts, arms and legs convulse. Incontinence is possible. Last 1-2 minutes and the individual appears tired, wanting to sleep. The most common type of seizure (60% of cases). Atonic: Characteristics All muscle tone is lost momentarily. The individual falls limply and head injury is probable, but gets up immediately with no confusion.

10. PATHOGENESIS Most cases: idiopathic and no underlying cause is found. 30%: a family history of epilepsy. secondary epilepsy: may be encountered in pregnancy in patients who have the following: - Previous surgery to the cerebral hemispheres.

11. cont’ Intracranial mass lesions (meningioma's and arteriovenous malformations enlarge during pregnancy. This should always be considered if the first seizure occurs in pregnancy) Antiphospholipid syndrome

12. Other causes of seizures in pregnancy Eclampsia Cerebral vein thrombosis (CVT) Thrombotic thrombocytopenic purpura (TTP) Stroke Subarachnoid hemorrhage.

13. Cont…. Drug and alcohol withdrawal Hypoglycemia Infections: tuberculoma, toxoplasmosis Gestational epilepsy: seizure are confined to pregnancy

14. DIAGNOSIS Most women have already been diagnosed, but when a first seizure occurs in pregnancy, the following investigations are appropriate: Blood pressure, urinalysis, platelet count, clotting screen, blood film Blood glucose, serum calcium, serum sodium, liver function tests. CT or MRI of the brain. Although this is not necessarily recommended for the first seizure in the non-pregnant women, there is no doubt of its value in pregnancy. EEG

15. EFFECTS OF PREGNANCY ON EPILEPSY The effects of pregnancy on epilepsy is uncertain. All anticonvulsants interfere with folic acid metabolism. folic acid deficiency has been associated with neural tube defects and other congenital malformations.

16. EFFECTS OF EPILEPSY ON PREGNANCY Relatively resistant to short episodes of hypoxia and there is no evidence of adverse effects of single seizures on the fetus. No increased risk of miscarriage or obstetric complications in women with epilepsy unless a seizure results in abdominal trauma. Incidence of fetal malformations, IUGR, oligohydramnios, pre- eclampsia and stillbirths is increased.

17. Cont’ Birth defects are increased by two fold. This could be related to the severity of the disease with its genetic predilection and also due to the anticonvulsants. The malformations include- cleft lip and/ or palate, mental retardation, cardiac abnormalities. Limb defects and hypoplasia of the terminal phalanges.

18. MANAGEMENT Pre- pregnancy counselling: Co ntrol of epilepsy should be maximized prior to pregnancy wit h the lowest dose of the most effective treatment that gives best seizure control. Review of antiepileptic drugs (AED) should taken into account the risk of teratogenesis and other adverse neurodevelopmental effects.

19. Cont’ If a decision is taken to stop treatment, AEDs should be withdrawn slowly in order to reduce the risk of withdrawal- associated seizures. This is particularly important for benzodiazepines and phenobarbitone.

20. Cont’ The current recommendations are to stop driving from the commencement of the period of drug withdrawal and for a period of six months after cessation of treatment, even if there is no recurrence of seizures. All women receiving AEDs should be advised to take pre-conception folic acid (5mg/day)

21. ANTENATAL MANAGEMENT The dose of the chosen drug should be kept as low as possible and to be monitored regularly from the serum level. The commonly used drugs are: Phenobarbitone 60-100mg daily in two to three divided doses. Phenytoin 150-300mg daily in two divided doses.

22. Cont’ - Carbamazepine 0.8-1.2g daily in divided doses. Folic acid daily prior to conception, continues throughout pregnancy, as there is also a small risk of folate-deficiency anemia.

23. Cont’ Relatives, friends and/or partners should be advised on how to place the women in the recovery position to prevent aspiration in the event of a seizure. Vitamin K 10 mg daily must be given orally in the last 2 weeks.

24. INTRAPARTUM MANAGEMENT The risk of seizures increases around the time of delivery. Women with major convulsive seizures should deliver in hospital. Anticonvulsant medication continue throughout the labor regular review by the obstetric team is indicated. If seizures recur, short-acting benzodiazepines are administered.

25. Cont’ The women should not be left alone in labor, and dehydration, hyperventilation and exhaustion should be avoided as they can trigger a seizure. The birth can be spontaneous facilitated by the midwife. Following obtaining informed consent from the women , vitamin K should be administered to the baby promptly after birth to protect against AED- induced hemorrhage disease. Caesarean section is only required if there are recurrent generalized seizure in late pregnancy or labor.

26. POSTNATAL MANAGEMENT In the first 24 hours of birth the women has an increased risk of a seizure and so should remain in hospital. Breastfeeding is encouraged. The baby should be carefully observed and any concern reported to the pediatrician immediately. Advice should be given about safety when caring for the baby in case of maternal seizure.

27. REFERENCE DC Dutta’s. Textbook of obstetrics including perinatology and contraceptive. 7 th . New Delhi: Jaypee brothers; Nov2013. p. 291 Myles. Textbook for midwives. 16 th edition. New York: Elsevier; 2014. p . 277-279 . https://www.slideshare.net/elnashar/epilepsy-and-pregnancy-49895122 https://www.rcog.org.uk/globalassets/documents/guidelines/green-top- guidelines/gtg68_epilepsy.pdf http://www.bioline.org.br/pdf?jp06020 https://www.mayoclinic.org/healthy-lifestyle/pregnancy-week-by-week/in- depth/pregnancy/art-20048417