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Epilepsy in Pregnancy

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Maria Muscat

on 10 December 2015

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Transcript of Epilepsy in Pregnancy

Epilepsy in Pregnancy
Presentation by Rachael Torrance and Maria Muscat

What is Epilepsy
Pregnancy, Labour and Delivery
2,500 women with epilepsy give birth in the UK every year
21% had not received pre-conceptual counselling and only 38% received a regular folic acid prescription
Highlights the importance of pre conception counselling
Common neurological disease which manifests when the neurons within the brain signal abnormally and excessively and sometimes due to imbalances of natural chemicals.

(Wylie & Bryce, 2008)
Some causes of epilepsy include:
Pregnancy
Morning sickness could reduce the level AED in the system and increase dehydration which are triggers for an increase in seizures
Considerations for Labour and Delivery
Delivery in consultant led obstetric unit would be advised
One to one continuous care in labour
Use of a birth pool is contraindicated on safety grounds
Consider appropriate pain relief - TENs, Entonox, Epidural
Adhere to unit policy
If a woman is on enzyme inducing AEDs then a 20mg dose of Vit K may be recommended from 36 weeks gestation or 4 weeks before delivery
2% of women have a seizure during labour/delivery
Hyperventilation, exhaustion, dehydration, emotional stress and pain can induce seizure
Pethidine can increase the risk of seizures and is best avoided
Prolonged or repeated seizures can lead to fetal hypoxia

Risk of seizures is increased for the first few months after delivery due to hormone fluctuation, sleep disturbances and tiredness

(McAuliffe, Burns-Kent, Frost & Howarth, 2013; Wylie & Bryce, 2008)

QOF indicator required contraception, conception and pregnancy advice to be given to women under 55 - Epilepsy was removed in April
Dr Ian Minshall, a GPSI in epilepsy based in Cheshire is urging Commissioners to fund further community based GPSIs and ENSs
Sally is a woman with a medical condition for which she requires ongoing treatment. She lives in an urban city and has lived with partner Jed for 3 years. She is now 12 weeks pregnant and has attended the booking clinic for care throughout the childbirth continuum.
A recent study links Sodium Valproate with development problems in the womb and highlights the lack of data on other medications
5mg dose of Folic Acid should be offered to all women of childbearing age or started at least 3 months before conception - can react negatively with some Anti Epilepsy medications
Maternal deaths related to epilepsy are rare but are still 10x higher in this cohort
Oxygen deprivation during childbirth
Brain infections
Traumatic brain/head injuries
Stroke
Alzheimers disease
Genetic disorders
Hormonal Changes
Lifestyle choices
(McAuliffe, Burns-Kent, Frost & Howarth, 2013)

UK Epilepsy and Pregnancy Register - Epilepsyandpregnancy.co.uk
Epilepsy and Pregnancy
Pre Conception Care and Early Pregnancy
Enzyme Inducing:
Phenobarbital
Phenytoin
Primidone
Carbamazepine
Topiramate
Oxcarbazepine
Rufinamide
Non-Enzyme Inducing:
Clonazepam
Clobazam
Ethosuximide
Gabapentin
Lamotrigine
Levetiracetam
Sodium valproate
Tiagabine
Vigabatrin
Zonisamide
The Midwife's Role
Epilepsy is outside the midwife's scope of practice
Must gain a detailed booking history with an emphasis on current AEDs
Referral to consultant led unit - Care given by the midwife, obstetrician and neurologist
Advocate the importance of AED compliance and refer if seizures increase
Ascertain expectations, discuss realistic birth plans and the options which are available
Encourage breastfeeding and discuss post delivery safety and care
(NICE, 2010; NMC, 2008)
Regular blood tests recommended to assess compliance and levels of medication in the bloodstream
References
Minshall I, Neligan A (2014). Have the new GP contract and NICE guidelines improved the clinical care of people with epilepsy?
Seizure
, 23 (2014) 874-877
McAuliffe F, Burns-Kent E, Frost D, Howarth E S (2013)
Neurological Disorders
in S E Robson, J Waugh. Medical disorders in pregnancy: A manual for midwives (2nd Ed.) West Sussex. John Wiley and Sons.
Shallcross R, Winterbottom J, Bromley R (2011). Prenatal exposure to anti-epileptic drugs: the need for preconception counselling.
The Practising Midwife
, 11 (2011) 20-21
CMACE (2011). Saving mothers' lives: reviewing maternal deaths to make motherhood safer: 2006 - 2008. The eighth report on confidential enquiries into maternal deaths in the United Kingdom.
BJOG
, 118(1): 1-203
https://www.epilepsy.org.uk [accessed November 2014]
www.epilepsyandpregnancy.co.uk [accessed November 2014]
Absence
Staring, blinking, daydreaming, mainly affects children, can lose awareness for 5-20 seconds
Myoclonic
Brief muscle jerking of one or both arms and legs. Can last a fraction of a second but usually remain conscious.
Tonic
All muscles of the body contract causing a fall but without a convulsion. Usually lasts <20 seconds.
Tonic Clonic
Most common form of seizure. Two stages: whole body contracts and then arms and legs convulse/twitch. Can last 1-2 minutes. Possible incontinence. Usually post ictol afterwards (confused, aggressive, pulling at own clothes, or sleepy).
Atonic
All muscle tone can be lost briefly causing a fall to the ground. Head injury can sometimes occur. No confusion and can get up from the floor straight away.

(McAuliffe, Burns-Kent, Frost & Howarth, 2013)

Types of Seizures and Symptoms
(McAuliffe, Burns-Kent, Frost & Howarth, 2013)
(McAuliffe, Burns-Kent, Frost & Howarth, 2013)

(McAuliffe, Burns-Kent, Frost & Howarth, 2013; Wylie & Bryce, 2008)
Full transcript