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New guidelines on epilepsy in pregnancy

Risk of maternal death increases tenfold for women with epilepsy

Mark Gould

Monday, 20 June 2016

Pregnant women with epilepsy need specialist help to control the condition, and so prevent unnecessary deaths, according to the first ever guidance on epilepsy in pregnancy launched today by the Royal College of Obstetricians and Gynaecologists. The college says the guidelines will provide clarity for healthcare professionals and women with the condition.

An estimated 2,500 babies are born to women with epilepsy each year, and while most women have healthy pregnancies and healthy babies, the guidance says that having frequent seizures during pregnancy can be harmful to both mother and baby and the risk of maternal death is increased tenfold.

From 2009 to 2013, 21 women died during pregnancy as a result of epilepsy and the 2014 Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE-UK) report highlighted the urgent need to develop national guidance to improve care. In the majority of cases, the deaths occurred because seizures were poorly controlled. Women were often not given any preconception counselling and were not cared for by an epilepsy nurse or specialist during their pregnancies.

Research has shown that children born to mothers who take anti-epileptic drugs (AEDs) during pregnancy, in particular sodium valproate, are at an increased risk of physical and developmental problems including spina bifida, heart defects and autism. However, the guideline emphasises that stopping AEDs completely or altering the dose can worsen seizures and pose a serious risk to both mother and baby. Women are advised to seek advice from their GP and/or specialist team before conception or as soon as they are aware that they are pregnant. The lowest effective dose of the most appropriate AED should be prescribed.

The guideline also advises women to take a higher dose of folic acid (5mg) to reduce the risk of their baby developing spinal defects. Adequate pain relief and appropriate care and AEDs to minimise the risk of seizures during pregnancy, such as insomnia, stress and dehydration, are also vital. Women at risk of seizures during labour should give birth in consultant-led units with facilities for one-to-one midwifery care and a special care baby unit should extra care be needed.

Mothers should also be well supported in the postnatal period to ensure that seizure triggers such as sleep deprivation, stress and pain are minimised. If the AED dose was increased in pregnancy, it should be reviewed within 10 days of delivery to avoid side effects to the mother from exposure to a high dose. The guidelines also recommend women be screened for signs of depression and anxiety in the postnatal period.

Shakila Thangaratinam, Professor of Maternal and Perinatal Health and consultant obstetrician at Barts and The London School of Medicine and Dentistry and lead author of the guideline, said:

“As emphasised in the 2014 MBBRACE-UK report, women with epilepsy require multidisciplinary care throughout their pregnancy, and healthcare professionals need to be aware of the small but significant increase in risks.

“While most women who have epilepsy remain free of seizures throughout their pregnancy, some may have more seizures if they are pregnant. This is usually because they have stopped taking AEDs or are not taking them regularly. Pregnancy itself or tiredness can also increase the number of seizures.

“It is important that these women receive preconception counselling, meet with an epilepsy specialist, and are monitored closely for seizure risk factors. Their adherence to anti-epileptic drugs, seizure type and frequency during the antenatal period should also be closely assessed.”

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