EPILEPSY AND PREGNANCY
Content
EPILEPSY AND PREGNANCY
to Buccheri La Ferla
Vincenzo Lanza Servizio di Anestesia e Rianimazione Ospedale Buccheri La Ferla FATEBENEFRATELLI Via M. Marine 197, 90123 PALERMO - ITALY E.MAIL. [email protected] Epilepsy is a disease presenting with different kinds of symptoms going from the generalized seizures to an impairment of consciousness of a few seconds. In pregnancy , the most important clinical presentation for the anesthetist is the epilepsy with convulsive symptoms. In the following work we will examine: 1) Classification and clinical presentation of epilepsy 2.1 Gestational epilepsy 2.3 Risks of epilepsy during pregnancy 3.1 Diagnosis and prevention of pregnancy epilepsy 4.1 Anesthesia for epileptic patients delivery Conclusion 2) Epilepsy in pregnancy 2.2Complications of epilepsy during pregnancy 3) Epileptic disorders in peripartum of anesthesiological interest and their prevention 4) Treatment 4.2 Anesthesia for delivery of non epileptic patients presenting seizures References
1)Pathogenesis and clinical features of epileptic disease [1] 1.1 Etiology Epilepsy is a disorder affecting 2% of population when in association with other encefalopathic form and about 0.5% referring with the simple disease.The latter concerns with subjects with normal coefficient intellective without any other mental problem except for the psychological one. In the anamnesis of these patients is often possible to find high temperature the first time convulsive disorders appear while temperature disappearing in the following episodes. Generally "febrile seizures" are considered normal until the age of 6 years because of immaturity of cerebral structures, but they are considered as epileptic disease after the age of 6 years . A differential diagnosis can be made with the EEG : subjects with a pathological EEG without fever surely will have in puberty epilepsy also without clinical crisis.Different features of epilepsy (absence seizures, convulsive seizures etc.) can coexist or replace one another in the same patient. In tab.1 the International Classification of Epileptic Seizures is shown. table1 International Classification of Epileptic Seizures I. PARTIAL (FOCAL, LOCAL SEIZURES) A. Simple partial seizures consciousness not impaired 1. With motor symptoms 2. With somatosensory or special sensory symptoms 3. With autonomic symptoms 4. With psychic symptoms
B. Complex partial seizures with impairment of consciousness 1. Beginning as simple partial seizures and progressing to impairment of consciousness a. With no other features c. With automatisms b. With features in I.A.I-I.A.4 2. With impairment of consciousness at onset a. With no other features c. With automatisms b. With features as in I.A.I-I.A.4 C. Partial seizures evolving to secondarily generalized seizures 1. Simple partial seizures evolving to generalized seizures 2. Complex partial seizures evolving to generalized seizures A. Absence seizures 1. Absence seizures B. Myoclonic seizures D. Tonic seizures F. Atonic seizures jastatic seizures! III. UNCLASSIFIED EPILEPTIC SEIZURES Includes all seizures that cannot be classified This includes some neonatal seizures leg, because of inadequate or incomplete data and rhythmic eye movements, chewing, and some that defy classification in hitherto swimming movements. described categories.
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3. Simple partial seizures evolving to complex partial seizures to generalized seizures
II.GENERALIZED SEIZURES (CONVULSIVE OR NONCONVULSIVE) 2. Atypical absence seizures C . Clonic seizures E. Tonic-clonic seizures
2. Epilepsy in pregnancy
2.1 Gestational epilepsy Pregnancy seems not to be an etiopathological factor of epilepsy. As a matter of fact epilepsy disorders frequently occur approaching the delivery and not during the pregnancy [2]. We can find very few reports (50/100.000 pregnant women) of patients with no previous history of epilepsy that present the appearance of a chronic epileptic disease during pregnancy. Knight et al. reports 16 cases of primigravidas patients with symptoms of epilepsy disappearing one or two months after delivery. No case was reported from 1989 to 1995 in 16000 deliveries at Buccheri La Ferla Hospital. 2.2 Complications of epilepsy during pregnancy Several statistics point out an increase of epileptic crisis frequency. The incidence ranges from 40 to 50%. The causes have to be investigated in the physiological changes of pregnancy:
* Reduction of functional residual capacity with hypocapnia and possible reduction of cerebral flow. * Retention of fluids with consequent cerebral edema. *The typical "nitrogen sparing" of pregnant woman with consequent change of the amino acids pattern. *The increased metabolism and excretion of hidantoyn (100% more) that may reduce plasma concentration to subtherapeutic levels. * The typical hormonal variations of pregnancy 2.3 Risks of epilepsy during pregnancy The epileptic patient shows a greater incidence of neonatal disease. This is likely to be due to toxic effects of anticonvulsant drugs [3] and to epileptic seizures. 2.3.1 Effects of epileptic seizures: 6-10% of epileptic patients in pregnancy shows tonic-clonic seizures. During the seizures, a trauma to mother and fetus, abruptio placental, fetal intra-cranial hemorrhage, miscarriage, fetal neonatal and prenatal death may occur. 2.3.2 Toxic effects of anticonvulsant therapy Treatment of epilepsy often consists of more than one drug administration to prevent the toxic effects of a drug alone. The side-effects of these drugs are often unacceptable in pregnancy, but discontinuation of one or more drugs as well as the physiologic and metabolic changes associated with pregnancy, can trigger a cluster of seizures that can lead to a dangerous status epilepticus.
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The side-effects of anticonvulsant drugs in pregnancy are: * An increased incidence of fetal malformations (from 2-3% in healthy pregnant to 4-6% in epileptic pregnant). * Fetal malformation of the fingers and face occurs in 5-30% up to 40% in untreated patients. These malformations are more frequent in epileptic patients who lack of folates. * Haemorrhagic syndrome produced by a reduction of vit.K-dependent clotting factors. * The treatment with valproic acid may produce an increased incidence (1%) of neural tube defects as spina bifida aperta that raises up to 5% during carbamazepine treatment.
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3. Clinical presentation of epilepsy in peripartum and anesthesia [4, 5, 6] In the late stage of pregnancy, epilepsy is often observed in Eclampsia-related syndromes: - Pre-eclampsia - HELLP syndrome (Hemolysis, Elevated liver function tests, low Platelets)
- Eclampsia Eclampsia is clinically associated with seizures (tab. 2). TABLE 2 - Features of pregnancy diseases susceptible to induce seizures Pre-eclampsia: H.E.L.L.P. Syndrome: Hemolysis (on peripheral smear, or increased haptoglobin) Eclampsia
CLINIC
Hypertension, proteinuria, and Pre-eclampsia with peripheral edema onset Elevated Liver function addition of seizures. after twenty weeks tests T.Bil>1.2, gestational age. LDH>600 SGOT>70 Low Platelets :<100000
Incidence
2.6% of all 4-12% of all prepregnancies; recurs in eclamptics 20% Age between 25-34, Primip/multip 6.8/1, Twin/single 5/1. Blood pression Systolic > 160 Diastolic > 110, proteinuria 2 g/die oliguria < 400 ml/die creatinine 1.2
0.056% of all pregnancies.
Risk factors
pulmonary edema fetal death hemorrhagic shock liver insuff. Seizures
FINDINGS IN SEVERE SINDROME headache visual disturbances, pulmonary edema, intrauterine growth retardation increased liver function tests or thrombocytopenia
In these patients seizures often occur during labor, thus representing a relevant therapeutic problem; differential diagnosis should consider brain tumor . We observed 40 y patient, hospitalized for a bigeminal pregnancy, who developed seizures because of brain tuberculosis. Pre-eclampsia incidence in our hospital and patient outcome are shown in tab.3
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Tab.3 ICU admittance of obstetric patients (January 1993-JUNE 1996 ) Health Pregnancy PRE-ECLAMPSIA NUMBER OF PATIENTS PATIENTS WITH SEIZURES * PATIENTS IN ICU DAYS IN ICU 7863 NONE 8 14 94 4 11 9 HELLP 12 1 5 12 TOT. 7969 5 24 11.6
(MEAN) OUTCOME FAVORABLE FAVORABLE FAVORABLE *PRE-ECLAMPSIA + SEIZURES = ECLAMPSIA 3.1 Diagnosis and prevention of pregnancy epilepsy Patients already known as epileptic do not present problems for diagnosis. Instead, diagnosis can be difficult in patients suffering from absences, often hidden for shame, who develop generalized seizures. Therefore patients who do not have epileptic disease but present risk factors represent the more problematic group. These patients often begin a single seizure and then quickly organize an epilepticus status. In our experience on about 16000 deliveries, just one patient with these characteristics has occurred.
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3.1.1 Seizure prevention in epileptic patients To avoid toxic risks shown in the point 2.3.2. ,epilepsy treatment with more than one drug has to be stopped. Phenytoin is the drug more commonly used alone. The drug already used by patient should be preferred. The switch to an alternative drug should be early made to avoid the occurrence of seizures. Sometimes this therapeutic approach is problematic to be applied, as patients a favorable therapeutic balance is achieved after many clinical attempts in the clinical setting. In cases of "drug-resistant" epilepsy a single drug treatment may be ineffective and intravenous Phenytoin i.v. may be tried. 3.1.2 Prevention of seizures in pregnant women at risk not affected by epilepsy. - Patients with pre-eclampsia symptoms require seizure prevention. A weekly EEG monitoring is recommended throughout the two months before delivery. The appearance of EEG changes as delta rhythm (fig.1) suggests to start Magnesium or Phenytoin therapy. (tab.4) - The development of seizures does not seem to be related to patients blood pressure. - Hydration status has to be carefully considered because pre-eclampsia is associated with dehydration : seizures may occur if blood osmolarity raises up 310 mOsm/l. These prophylactic measures should be added to vitamin K administration 3-4 weeks before delivery to reduce the incidence of neonatal hemorrhage
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tab.4 Drugs used in the treatment of the eclampsia related syndrome Drug Magnesium (MgSO4 50%) Loading Dose Maintenance Therapeutic Effects Seizure control Side Effects
12 ml (= 6 g) in 2 g/Hr infusion 100 ml NaCl 0.9% I.V. (15 mins) (25 g MgSO4 / 300 ml NaCl 0.9%) 25ml/Hr
Plasma level 5 mmol/l : loss of Therapeutical 2 - tendon reactions 4 mmol/l 7.5 mmol/l : cardial conduction defect, cessation of breathing > 10 mmol/l :
cardiac arrest treatment CaCL2 10 % 5 - 10 ml iv , O2 with a mask Seizure control Phenytoin 2ff IV (5mins) (aurantin 150mg/f) 5-10mg increments 1 mg/kg 0.25-0.5 ug/kg/Min. 40-120 mg/gtt./nasal 4. Treatment
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200-400mg
Therapeutical 1020mg/l Hypertension Hypertension Hypertension Hypertension crosses placentaneonatal hypotension. no neonatal effects no evidence of fetal cyanide accumulation less fetal distress
Hydralazine Labetelol Nitroprusside Nifedipine
The anesthesiologist is involved in the treatment of epileptic symptoms at delivery and rarely deals with epileptic patients during pregnancy. The seizure presentation is more complex in pre-eclampsia or HELLP-syndrome, as cesarean section and seizures treatment are simultaneously present as problems to face [7]. The anesthesiologist has to give anesthesia to a pregnant woman just reaching the hospital on succeeding tonic-clonic attacks. In these conditions patients present a high anesthetic risk. General anesthesia is not always recommended: the propofol administration to stop the attacks can be followed by spinal anesthesia. 4.1 Anesthesia for epileptic patients delivery When the epileptic patient is well controlled by therapy during pregnancy, it is not usually necessary a special treatment at the delivery. However it is possible that the anesthesiologist is asked to treat epileptic symptoms occurring during labor. If no convulsions are present, a continuous epidural anesthesia throughout labor is preferred. This technique decreases seizure occurrence because 1) it suppresses labor pain, 2) maintains a constant anesthetic plasma concentration producing an anticonvulsant effect. It is important to do not overdosing local anesthetics: bupivacaine 0.25%, 6ml/hour should be indicated. - For patients in advanced labor or near delivery propofol administration (1% 3-4ml in repeatable bolus) should be attempted. If this treatment is effective, the woman may have a normal delivery or a low forcep application with an acceptable level of consciousness. After delivery diazepam 10mg should be given. - For cesarean delivery it is possible to control seizures by propofol and decide about general or spinal anesthesia after evaluating fetal conditions. In our experience good results are achieved by spinal anesthesia (see Tab.5). During surgery a propofol infusion at rate 10-15 ml/h is administered. After delivery diazepam 10 mg is usually given. Other drugs other than their routine therapy are not necessary by using this protocol. In any case thiopental and general anesthesia may also be used with good results, the most known approach, the best
one. An effective support is done by Magnesium administration (see Tab.4).
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4.2 Anesthesia for delivery of non epileptic patients presenting seizures This group is usually represented by patients suffering from eclampsia or the related syndrome, as the HELLP syndrome. The treatment is similar to that for seizure occurrence (more frequently in eclampsia than in HELLP), that is prompt delivery. However, in eclampsia syndrome there is a severe hypertension while in HELLP syndrome there are clotting abnormalities. 4.2.1 Seizure treatment in eclamptic patient Convulsions are only a part of this severe syndrome, due to the severe hemodynamic impairment: blood pressure is often over 200mmHg . In Tab.4 the therapeutic procedures are described . If it is possible, seizure treatment should include prophylactic magnesium or phenytoin because both the drugs are able to stabilize an epileptic patient. However the acute treatment is based on the use of propofol or thiopental as diazepam produces neonatal hypotonia and respiratory depression and cannot be used, except after delivery. The antihypertensive therapy is very important: the drug of choice is hydralazine or, in alternative, labetelol and nitroprusside. Good results are achieved by nifedipine nasal drops [8]. This procedure is of value in an unconscious patient without a venous line. The effect is constant and the dosage ranges 20-80mg . The choice of the anesthesiological technique depends on anesthesiologist experience (see tab.5). During the general anesthesia EEG monitoring is suggested; if the monitoring system does not have any EEG module, an electroencephalograph should be used for the EEG recording that to detect an eventual perioperative status epilepticus. This practice requires specific knowledge. In fact it is difficult to make diagnosis of seizures on curarized patient and the sparing use of hypnotic drugs may be ineffective in switching off a epileptic focus. Skilled professionals should be immediately available to look after the newborn. In his absence the anesthetist has to start neonatal resuscitation and to decide newborn ICU admission. As regards as postoperative treatment, convulsions are prevalent on general anesthesia awakening : diazepam should be given after the delivery and repeated one hour after. The neurologic status has to be carefully assessed. If an hour after the end of the anesthesia the patient is still unconscious, cerebral edema should be suspected and a brain TC scan and patient admission in ICU should be planned (fig.1)
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4.2.2 Seizures treatment in HELLP syndrome The treatment is similar to that of eclampsia (see tab.4) In the HELLP syndrome typical severe clotting abnormality and related bleeding, are the most important findings. Therefore a central venous line, large amounts of blood, plasma and platelets should be available before cesarean section. To gain a central access , a long catheter from an antecubital vein should be advanced to reach the atrium, as significant venous bleeding is frequently observed. Hemothorax by subclavian vein and important neck and thight hematoma by jugular or femoral attempts are the most troublesome complications. In these patients there is a high incidence of myocardial infarction and brain haemorrhage. A brain TC scan is necessary in all patients suffering from HELLP syndrome and seizures. General anesthesia is the technique of choice for cesarean section because clotting abnormalities contraindicate the regional anesthesia. Caution has to be used for intubation to avoid oropharyngeal bleeding. Postoperative management should be careful in the evaluation of hepatic and coagulation function. Patients suffering from severe forms have to be admitted in ICU (fig.2)
figure 2 Tab.5 guidelines for cesarean section in the eclampsia related syndrome Mild Pre-eclampsia Severe Pre-eclampsia HELLP Routine monitors + plus an arterial line, central venous (control the coagulation tests) + EEG monitoring Routine monitors (ECG,non invasive Routine monitors + blood pressure, pulse plus an arterial line, oximeter, central venous or (capnography or pulmonary artery transcutaneus PCO2 in catheter+ EEG regional anesthesia), monitoring stethoscope Whitacre or Sprotte needle, Bupivacaine 1% hyperbaric Spinal anesthesia General anesthesia if General anesthesia if seizure or clotting 10-15mg according to seizure. abnormality. height: < 150 cm 8mg, > 150 cm 10mg, > 160 cm 12mg, > 180 cm 15mg.L1-2 level Specially Indicated after a epidural analgesia labor..10 ml General anesthesia if General anesthesia if of plan Bupivacaine seizure or clotting seizure. 0.5% to have analgesia abnormality. for surgery. Risk of not completed analgesia Clear antacid, metoclopramide IV.Left or right uterine displacement, pre-oxygenate at least 3-4 min. Induction: Rapid sequence: Propofol 100-150 mg or Thiopental 4 mg/kg using cricoid pressure, Succinylcholine 1 mg/kg.
Monitoring
Epidural anesthesia
General anesthesia
Maintenance: Short acting curare 1) 50% N2O until delivery, then add fentanyl, isoflurane. Or 2) Propofol infusion +N2O 50% until delivery then add fentanyl Accurate decurarization (Hypertension ) Conclusions
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Epileptic pregnant women have to be carefully evaluated and a polytherapy should be changed in a monotherapy to avoid toxic fetal effects. The occurrence of seizures in non epileptic patients should suggest an eclamptic syndrome. In this case the delivery is the treatment more effective for seizures. Drugs of choice in seizures therapy are magnesium, propofol, thiopental and phenytoin. References
1. Dichter M.A.: The epilepsies and convulsive disorders. In Harrisonn's Principles of 2. 3. 4. 5. 6. 7. 8.
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Internal Medicine.10th ed., RG Petersdorf, RD Adams, E. Braunwald, KJ isselbacher, JB Martin, JD Wilson, eds. McGraw-Hill, New York, 1983, pp 2018-2028 Bjerkedal T., Bahna SL: The course and outcome of pregnancy in women with epilepsy. Acta Obstet Gynecol Scand 52:245-248, 1973 Lander CM, Edwards VE, Eadie MJ et al: Plasma anticonvulsivant concentrations during pregnancy. Neurology 27:128-131, 1977 Ramanathan-J. "Pathophysiology & anesthetic implications in pre-eclampsia". Clinical Obstetrics & Gynecology. 35: 414-25. June, 1992 Arbogast-BK, et.al. "Which plasma factors bring about disturbance of endothelial function in pre-eclampsia?". Lancet. 343:340-1. Feb 5, 1994 Barton-JR, et.al. "Care of the pregnancy complicated by HELLP syndrome". Gastroenterology Clinics of North America 21:937- 50, 1992 Belfort-MA, et.al. "Effect of magnesium sulfate on maternal brain blood flow". American Journal of Obstetrics & Gynecology. 167:661-6. 1992 Fenakel-K, et.al. "Nifedapine in the treatment of severe pre-eclampsia". Obstetrics & Gynecology. 77:331-7. Mar, 1991
visitors n. http://anestit.unipa.it/OBSTE/EPILING.HTM
A guide to starting a family
If you have epilepsy it doesn’t automatically mean that having a family will be any more difficult for you than for anyone else. But it might mean that as a parent-to-be you have more things to consider before, during and after the pregnancy. These pages look at the
issues around pregnancy and parenting that sometimes affect people with epilepsy. It aims to help you look at how these issues might relate to your epilepsy.
I have epilepsy - can I have children?
Having epilepsy doesn’t usually make it harder to have a family – but it might mean that you have more things to consider when starting to try for a family. Some people with epilepsy feel that their sexual response or sex drive is low which may make it difficult for a couple to “get pregnant”. This can happen for a number of different reasons; anxiety, depression, and the side effects of some anti-epileptic drugs (AEDs) may all contribute. If you are concerned about your sex drive or sexual response you can ask your doctor for advice. Certain AEDs may reduce the production of sperm for some men, which could reduce a man’s fertility. Some women with epilepsy have irregular periods or a condition called Polycystic Ovary Syndrome. These can be side effects of some AEDs. Both these side effects are treatable but can make becoming pregnant more difficult. More information on polycystic ovary syndrome is on the women and epilepsy page Back to top
Could my child inherit my epilepsy?
Although you may be concerned that AEDs might affect your chances of becoming pregnant it is important never to stop taking AEDs suddenly and without the medical guidance of your neurologist or GP. Sometimes epilepsy happens as part of an inherited medical condition, passed from parent to child. This is rare, but includes the conditions neurofibromatosis and tuberous sclerosis. Genetics play a part in the development of epilepsy in everyone, but how important this is varies. As every situation is different, it can be helpful to talk about this with a doctor who specialises in genetics (geneticist). Information on different types of seizures Back to top
Can being pregnant affect my AEDs?
During pregnancy your body uses up more of your AEDs than usual. This means the amount of AEDs you normally take may not be enough to stop your seizures from happening. Your neurologist might ask you to have a blood test to make sure that the amount of AEDs you take is at the right level for you and your baby. Testing the levels of the AED in your blood helps your neurologist decide if the dose needs to be changed. Testing blood levels works for some AEDs but not all. With all AEDs, the frequency of seizures will be watched to see if the dose of the drug needs to be increased. If it does need to be increased, the dose will usually be slowly reduced to its original level after the birth. Back to top
Can morning sickness affect my AEDs?
Despite the name, morning sickness can happen at any time of the day and affects some women when they’re pregnant. If you’re sick after taking your AEDs, the medication may not have a chance to work properly. You might consider changing the time you take your AEDs, for example taking them when you’ve stopped feeling sick. Your doctor should be able to advise you on how best to cope with morning sickness and how to manage your AEDs. Back to top
Can AEDs affect an unborn baby?
If the baby’s father has epilepsy, his epilepsy and any AEDs he takes will not affect the baby’s development, because the baby will not come into contact with his AEDs. For a woman with epilepsy who takes AEDs during her pregnancy, her baby will be exposed to the AEDs in the womb. Although while she is pregnant a mother’s bloodstream is kept separate from her unborn baby’s, some substances can pass from her blood into her baby’s blood via the placenta. These substances include nutrients, oxygen, antibiotics, alcohol and medication, including AEDs. Some AEDs can affect how the baby grows and develops in the womb, particularly so in the first 15 weeks of pregnancy when the baby’s main organs and skeleton are developing. Back to top
Pregnancy and birth defects
For any pregnant woman there is a small risk (a ‘background’ risk) that her baby may be born with a birth defect. Birth defects, or developmental abnormalities as they are sometimes called, are physical problems that happen when the development of a baby is affected while it is in the womb. There are different types of birth defects, which can affect different organs in the body, and happen for different reasons. Sometimes birth defects are classed as minor and major. Minor malformations are those that do not require surgery, and major malformations are those that do need surgery to correct them. Major birth defects include cleft lip, cleft palate and problems with the development of the spine and nervous system (called neural tube defects). Other defects include problems with how the internal organs (such as the heart and lungs) develop. Sometimes the child’s arms, legs, or the way their face looks, may also be affected. If you are pregnant, avoiding alcohol, smoking and other drugs will help minimise the risk of birth defects. Back to top
AEDs and birth defects
If For a woman with epilepsy taking AEDs during her pregnancy, the risk of a birth defect to her baby is slightly increased above the background risk. How much the risk increases depends on which AEDs are being taken and at what dose. • • Women who don’t take AEDs during pregnancy have a 3% (3 in 100) risk that their baby will have a major birth defect. Taking one AED increases this risk to around 3 - 7% (3 in 100 to 7 in 100).
•
If two or more AEDs are taken, the risk increases to around 10% (1 in 10).
For example, looking at neural tube defects (a group of major defects, which include spina bifida): • In the general population the risk of a baby being born with a neural tube defect is around 0.2 - 0.5% (1 in 500 to 1 in 200). If a woman is taking sodium valproate (Epilim) during her pregnancy this risk is around 1 - 2% (1 in 100 to 1 in 50). If a woman is taking carbamazepine (Tegretol) it is 0.5% (1 in 200).
• •
Different AEDs vary in the risk they pose; and the risk is often greater the higher the dose of the drug. At the moment sodium valproate (Epilim) appears to have greater risks than other AEDs. An ongoing study into the effects and risks of AEDs on an unborn baby’s development aims to help understand those risks and to find out whether any specific drugs should be avoided during pregnancy. However it is worth remembering that about 95% (95 in 100) of pregnant women with epilepsy have a perfectly normal pregnancy and a healthy baby with no malformations. Back to top Foetal anti-convulsant syndrome Some AEDs are thought to affect a child’s development after they are born, this is called foetal anti-convulsant syndrome (FACS). The risk of this happening appears to be higher with sodium valproate. FACS can affect a child as they grow by causing developmental or learning difficulties, and problems with behaviour. Often these effects are not seen until the child starts to get older.
Preconception counselling
Because of the possible effects of AEDs on an unborn baby, having your AEDs reviewed before you get pregnant can help you and your neurologist to make sure that you are taking the most appropriate AED and at the most suitable dose during your pregnancy. Preconception counselling is an opportunity for you and your doctor to consider any changes to your epilepsy treatment that might be helpful before you become pregnant. It helps you to be fully informed about the effects pregnancy may have on your epilepsy, as well as the effect your epilepsy and AEDs may have on your pregnancy and unborn baby. If you have seizures you are likely to be advised to keep taking your AEDs throughout your pregnancy. However your doctor may suggest taking the lowest possible dose that will still control your seizures. Or they might suggest a change to the AEDs that you take. Back to top Some women prefer not to take AEDs during their pregnancy and may want to discuss this option with their neurologist. If you have seizures during pregnancy there is a risk of injury to yourself and your baby. This risk could be higher (depending on the type and frequency of seizures you have) than the risk of the AED affecting your baby.
If you have been seizure-free for two or three years, your doctor might suggest slowly stopping your AEDs before starting your family. However there is a risk if your AEDs are stopped that your seizures could start again. Having seizures again could affect your lifestyle - for example your home or work life and if you are currently driving you would need to hand your driving licence in until you were seizure-free for one year. Making decisions about your medication is not always easy and preconception counselling should give you the chance to ask any specific questions or talk about any concerns you may have. Back to top What if I'm already pregnant? If you become pregnant without having the chance to speak to your neurologist first it is recommended that you keep taking your AEDs and start taking folic acid. It is also recommended that you make an appointment to see your neurologist as soon as possible.
Why is taking folic acid recommended?
Folic acid is a vitamin that helps a developing baby’s spine to form. The Department of Health recommends that all women take folic acid throughout their pregnancy and ideally before becoming pregnant. Women who increase their intake of folic acid at the time their baby’s spine is forming (in the first three months of pregnancy) reduce the risk of having a baby with neural tube defects. It is strongly recommended that women with epilepsy take 5mg of folic acid daily before they become pregnant. Folic acid is available free of charge on prescription. Back to top
What is pre-natal screening?
Pre-natal screening is the name for a number of different checks that are done during pregnancy to see how the baby is developing in the womb. This includes ultrasound scans which are done at certain intervals throughout the pregnancy. As part of the pre-natal screening checks, some women have their alpha-fetoprotein (AFP) levels checked in a blood test at around 15-16 weeks into their pregnancy. AFP is a type of protein which is passed from an unborn baby to its mother. The levels of AFP in a mother’s blood can indicate the risk of their baby being born with certain health disorders including spina bifida. Screening does not say for certain if a baby will be born with or without any birth defects or developmental abnormalities. It just uses the information collected to determine the risk of an unborn baby being born with birth defects or developmental abnormalities.
Why is vitamin K prescribed?
Vitamin K plays an important part in making our blood thicken (clot). A very small number of newborn babies (about 0.01% or 1 in 10,000) are born without enough vitamin K. This can cause nose bleeds, mouth bleeds and in some cases internal bleeding. The risk of having low vitamin K is slightly higher for babies whose mothers have taken certain AEDs during their pregnancy. The Department of Health recommends that all newborn babies are given extra vitamin K at birth or within the first month of being born. Depending which AEDs you take you may also be prescribed a daily 10mg dose of vitamin K during the last month of your pregnancy, as well as your baby being given vitamin K at birth (usually by injection).
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Will having epilepsy affect my labour?
Most women with epilepsy have normal deliveries and healthy children. It is useful for the midwife and medical team who will be at the birth to know about your epilepsy, including what type of seizures you have, which AEDs you take (if any) and when you normally take them. Ideally, AEDs are taken as normal during labour. If you want to have a home birth you will need to carefully consider the possible effects of having a seizure during labour, which could lead to complications. Women who would like to have a water birth may also need to consider the effect of seizures if they become confused or lose awareness during their seizures. Generally, caesarean sections are only necessary if this is in the best interests of the mother and her baby. About 1 - 2% (1 in 100 to 1 in 50) of women with epilepsy have a tonic clonic seizure during labour - even if they don’t normally have tonic clonic seizures. If a seizure happens during labour, drugs can usually be given to control it. A further 1 - 2% (1 in 100 to 1 in 50) will have a tonic clonic seizure up to 24 hours after the birth. Back to top
What pain relief can I have?
Women with epilepsy can have most types of pain relief during labour. These include: • • • • an epidural (an anaesthetic into the spine); breathing techniques; gas and air; and a TENS machine (which uses electrical impulses to stop pain signals getting to the brain).
Pethidine, a strong painkiller, has been thought to trigger seizures in some women and therefore caution is advised. It is helpful to tell the midwife and medical team if your seizures have any particular triggers. For example if pain, tiredness or over-breathing have triggered seizures in the past. Back to top
The UK Epilepsy and Pregnancy Register (UKEPR)
If you have epilepsy and are thinking of becoming pregnant, or you are already pregnant, you might like to contact the UKEPR. The UKEPR is a long-term study looking at the effect of AEDs on unborn babies and the effect of having seizures while pregnant. The study lets you speak to an epilepsy nurse and ask questions about your pregnancy and epilepsy. If you would like to join the UKEPR you will be asked about your epilepsy and your AEDs (if you take them). Being a part of the study is free of charge. The UKEPR may want to contact you after your baby is born. It is hoped that the findings from the study will provide some answers and guidance for other women in the future.
More details about the UKEPR (opens in new window) Alternatively call: 0800 389 1248 from UK or: 1 800 320 820 from ROI Back to top
Childcare
If you or your partner’s seizures are controlled then epilepsy may not affect how you look after your child. However, parents who still have seizures may find taking extra safety measures helpful. This depends on the type of seizures the person has and the activity involved. Can I breast-feed my baby? The Department of Health recommends that every woman should be encouraged to breastfeed her baby. Breast milk provides all the nutrients a baby needs, for the first six months of their life. Breastfeeding is recommended even if you take AEDs. Your baby will have become used to the drugs while in your womb, and only a small amount of AEDs is in breast milk. Some drugs (for example phenobarbital) can make a baby over sleepy, so it may be a good idea to alternate between formula and breastfeeds. Patient information leaflets, which come with each new prescription of an AED, often include information about breastfeeding for that particular drug. If you have any doubts, talking this through with your neurologist, midwife, or health visitor may help. If you’re more likely to have seizures when you’re over tired, you may want to consider if breastfeeding your baby during the night is a good option for you. If possible, sharing night time feeds with a partner might be one way to increase the chance of a good night’s sleep. Back to top Ideas for keeping you and your baby safe If your seizures happen suddenly and without warning the following ideas may be helpful to keep your baby safe. These might not always be necessary, especially if there’s someone else around to help you, but they could be helpful if you’re home on your own. • • • • • • Dressing and changing your baby on the floor means they only have a short fall if you have a seizure. Sponging your baby down on a changing mat on the floor is safer than bathing the baby in water. When carrying your baby it may be safer to use a carrycot or sling than to carry them in your arms. A padded carrycot will help protect your baby if you have a seizure. Putting a deadlock on your baby’s pram means the pram will stay in place if you let go of it during a seizure. When feeding your baby, a lower highchair is less likely to tip over than a taller one. Feeding your baby while you sit on the floor, surrounded by cushions and leaning against the wall may help to make your baby safer if you suddenly have a seizure. Back to top Talking about epilepsy to your child Children can often be taught at quite a young age what to do if someone has a seizure. Some children learn what to do from watching other people. During a seizure your child could: • stay with you so they don't get lost
• •
get help from someone else, for example a neighbour or friend help you themselves if they know what to do.
Information on first aid for seizures. Some people wear medical jewellery or carry an ID card saying that they have epilepsy and what to do if a seizure happens. Even if children are too young to manage seizures, they may be able to let other people know about the card or jewellery. Information about the medical and ID bracelets. Free identity cards are available from the NSE online shop Back to top
What about immunisation?
There has been some concern that the MMR (measles, mumps and rubella) vaccine may be linked to causing seizures. However, current research suggests that there is no connection between the vaccine and epilepsy. If you are concerned about any vaccination your child may need, you can talk about this with your child’s doctor or paediatrician. It is your choice whether your child is vaccinated, and having more information might help you make that choice.The following guidelines are taken from the Department of Health publication ‘Immunisation against Infectious Disease’. They state that: “No child should be denied immunisation without serious thought as to the consequences, both for the individual child and for the community. Where there is doubt, advice should be sought from a Consultant Paediatrician, District (Health Board) Immunisation Co-ordinator, or Consultant in Communicable Disease Control”. Immunisation Against Infectious Disease 2006 - "The Green Book" (opens new window)
UK Epilepsy Helpline: 01494 601400 Monday - Friday 10am - 4pm
© The National Society for Epilepsy April 2007
http://www.epilepsynse.org.uk/pages/info/leaflets/preg.cfm
to Buccheri La Ferla
Vincenzo Lanza Servizio di Anestesia e Rianimazione Ospedale Buccheri La Ferla FATEBENEFRATELLI Via M. Marine 197, 90123 PALERMO - ITALY E.MAIL. [email protected] Epilepsy is a disease presenting with different kinds of symptoms going from the generalized seizures to an impairment of consciousness of a few seconds. In pregnancy , the most important clinical presentation for the anesthetist is the epilepsy with convulsive symptoms. In the following work we will examine: 1) Classification and clinical presentation of epilepsy 2.1 Gestational epilepsy 2.3 Risks of epilepsy during pregnancy 3.1 Diagnosis and prevention of pregnancy epilepsy 4.1 Anesthesia for epileptic patients delivery Conclusion 2) Epilepsy in pregnancy 2.2Complications of epilepsy during pregnancy 3) Epileptic disorders in peripartum of anesthesiological interest and their prevention 4) Treatment 4.2 Anesthesia for delivery of non epileptic patients presenting seizures References
1)Pathogenesis and clinical features of epileptic disease [1] 1.1 Etiology Epilepsy is a disorder affecting 2% of population when in association with other encefalopathic form and about 0.5% referring with the simple disease.The latter concerns with subjects with normal coefficient intellective without any other mental problem except for the psychological one. In the anamnesis of these patients is often possible to find high temperature the first time convulsive disorders appear while temperature disappearing in the following episodes. Generally "febrile seizures" are considered normal until the age of 6 years because of immaturity of cerebral structures, but they are considered as epileptic disease after the age of 6 years . A differential diagnosis can be made with the EEG : subjects with a pathological EEG without fever surely will have in puberty epilepsy also without clinical crisis.Different features of epilepsy (absence seizures, convulsive seizures etc.) can coexist or replace one another in the same patient. In tab.1 the International Classification of Epileptic Seizures is shown. table1 International Classification of Epileptic Seizures I. PARTIAL (FOCAL, LOCAL SEIZURES) A. Simple partial seizures consciousness not impaired 1. With motor symptoms 2. With somatosensory or special sensory symptoms 3. With autonomic symptoms 4. With psychic symptoms
B. Complex partial seizures with impairment of consciousness 1. Beginning as simple partial seizures and progressing to impairment of consciousness a. With no other features c. With automatisms b. With features in I.A.I-I.A.4 2. With impairment of consciousness at onset a. With no other features c. With automatisms b. With features as in I.A.I-I.A.4 C. Partial seizures evolving to secondarily generalized seizures 1. Simple partial seizures evolving to generalized seizures 2. Complex partial seizures evolving to generalized seizures A. Absence seizures 1. Absence seizures B. Myoclonic seizures D. Tonic seizures F. Atonic seizures jastatic seizures! III. UNCLASSIFIED EPILEPTIC SEIZURES Includes all seizures that cannot be classified This includes some neonatal seizures leg, because of inadequate or incomplete data and rhythmic eye movements, chewing, and some that defy classification in hitherto swimming movements. described categories.
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3. Simple partial seizures evolving to complex partial seizures to generalized seizures
II.GENERALIZED SEIZURES (CONVULSIVE OR NONCONVULSIVE) 2. Atypical absence seizures C . Clonic seizures E. Tonic-clonic seizures
2. Epilepsy in pregnancy
2.1 Gestational epilepsy Pregnancy seems not to be an etiopathological factor of epilepsy. As a matter of fact epilepsy disorders frequently occur approaching the delivery and not during the pregnancy [2]. We can find very few reports (50/100.000 pregnant women) of patients with no previous history of epilepsy that present the appearance of a chronic epileptic disease during pregnancy. Knight et al. reports 16 cases of primigravidas patients with symptoms of epilepsy disappearing one or two months after delivery. No case was reported from 1989 to 1995 in 16000 deliveries at Buccheri La Ferla Hospital. 2.2 Complications of epilepsy during pregnancy Several statistics point out an increase of epileptic crisis frequency. The incidence ranges from 40 to 50%. The causes have to be investigated in the physiological changes of pregnancy:
* Reduction of functional residual capacity with hypocapnia and possible reduction of cerebral flow. * Retention of fluids with consequent cerebral edema. *The typical "nitrogen sparing" of pregnant woman with consequent change of the amino acids pattern. *The increased metabolism and excretion of hidantoyn (100% more) that may reduce plasma concentration to subtherapeutic levels. * The typical hormonal variations of pregnancy 2.3 Risks of epilepsy during pregnancy The epileptic patient shows a greater incidence of neonatal disease. This is likely to be due to toxic effects of anticonvulsant drugs [3] and to epileptic seizures. 2.3.1 Effects of epileptic seizures: 6-10% of epileptic patients in pregnancy shows tonic-clonic seizures. During the seizures, a trauma to mother and fetus, abruptio placental, fetal intra-cranial hemorrhage, miscarriage, fetal neonatal and prenatal death may occur. 2.3.2 Toxic effects of anticonvulsant therapy Treatment of epilepsy often consists of more than one drug administration to prevent the toxic effects of a drug alone. The side-effects of these drugs are often unacceptable in pregnancy, but discontinuation of one or more drugs as well as the physiologic and metabolic changes associated with pregnancy, can trigger a cluster of seizures that can lead to a dangerous status epilepticus.
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The side-effects of anticonvulsant drugs in pregnancy are: * An increased incidence of fetal malformations (from 2-3% in healthy pregnant to 4-6% in epileptic pregnant). * Fetal malformation of the fingers and face occurs in 5-30% up to 40% in untreated patients. These malformations are more frequent in epileptic patients who lack of folates. * Haemorrhagic syndrome produced by a reduction of vit.K-dependent clotting factors. * The treatment with valproic acid may produce an increased incidence (1%) of neural tube defects as spina bifida aperta that raises up to 5% during carbamazepine treatment.
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3. Clinical presentation of epilepsy in peripartum and anesthesia [4, 5, 6] In the late stage of pregnancy, epilepsy is often observed in Eclampsia-related syndromes: - Pre-eclampsia - HELLP syndrome (Hemolysis, Elevated liver function tests, low Platelets)
- Eclampsia Eclampsia is clinically associated with seizures (tab. 2). TABLE 2 - Features of pregnancy diseases susceptible to induce seizures Pre-eclampsia: H.E.L.L.P. Syndrome: Hemolysis (on peripheral smear, or increased haptoglobin) Eclampsia
CLINIC
Hypertension, proteinuria, and Pre-eclampsia with peripheral edema onset Elevated Liver function addition of seizures. after twenty weeks tests T.Bil>1.2, gestational age. LDH>600 SGOT>70 Low Platelets :<100000
Incidence
2.6% of all 4-12% of all prepregnancies; recurs in eclamptics 20% Age between 25-34, Primip/multip 6.8/1, Twin/single 5/1. Blood pression Systolic > 160 Diastolic > 110, proteinuria 2 g/die oliguria < 400 ml/die creatinine 1.2
0.056% of all pregnancies.
Risk factors
pulmonary edema fetal death hemorrhagic shock liver insuff. Seizures
FINDINGS IN SEVERE SINDROME headache visual disturbances, pulmonary edema, intrauterine growth retardation increased liver function tests or thrombocytopenia
In these patients seizures often occur during labor, thus representing a relevant therapeutic problem; differential diagnosis should consider brain tumor . We observed 40 y patient, hospitalized for a bigeminal pregnancy, who developed seizures because of brain tuberculosis. Pre-eclampsia incidence in our hospital and patient outcome are shown in tab.3
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Tab.3 ICU admittance of obstetric patients (January 1993-JUNE 1996 ) Health Pregnancy PRE-ECLAMPSIA NUMBER OF PATIENTS PATIENTS WITH SEIZURES * PATIENTS IN ICU DAYS IN ICU 7863 NONE 8 14 94 4 11 9 HELLP 12 1 5 12 TOT. 7969 5 24 11.6
(MEAN) OUTCOME FAVORABLE FAVORABLE FAVORABLE *PRE-ECLAMPSIA + SEIZURES = ECLAMPSIA 3.1 Diagnosis and prevention of pregnancy epilepsy Patients already known as epileptic do not present problems for diagnosis. Instead, diagnosis can be difficult in patients suffering from absences, often hidden for shame, who develop generalized seizures. Therefore patients who do not have epileptic disease but present risk factors represent the more problematic group. These patients often begin a single seizure and then quickly organize an epilepticus status. In our experience on about 16000 deliveries, just one patient with these characteristics has occurred.
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3.1.1 Seizure prevention in epileptic patients To avoid toxic risks shown in the point 2.3.2. ,epilepsy treatment with more than one drug has to be stopped. Phenytoin is the drug more commonly used alone. The drug already used by patient should be preferred. The switch to an alternative drug should be early made to avoid the occurrence of seizures. Sometimes this therapeutic approach is problematic to be applied, as patients a favorable therapeutic balance is achieved after many clinical attempts in the clinical setting. In cases of "drug-resistant" epilepsy a single drug treatment may be ineffective and intravenous Phenytoin i.v. may be tried. 3.1.2 Prevention of seizures in pregnant women at risk not affected by epilepsy. - Patients with pre-eclampsia symptoms require seizure prevention. A weekly EEG monitoring is recommended throughout the two months before delivery. The appearance of EEG changes as delta rhythm (fig.1) suggests to start Magnesium or Phenytoin therapy. (tab.4) - The development of seizures does not seem to be related to patients blood pressure. - Hydration status has to be carefully considered because pre-eclampsia is associated with dehydration : seizures may occur if blood osmolarity raises up 310 mOsm/l. These prophylactic measures should be added to vitamin K administration 3-4 weeks before delivery to reduce the incidence of neonatal hemorrhage
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tab.4 Drugs used in the treatment of the eclampsia related syndrome Drug Magnesium (MgSO4 50%) Loading Dose Maintenance Therapeutic Effects Seizure control Side Effects
12 ml (= 6 g) in 2 g/Hr infusion 100 ml NaCl 0.9% I.V. (15 mins) (25 g MgSO4 / 300 ml NaCl 0.9%) 25ml/Hr
Plasma level 5 mmol/l : loss of Therapeutical 2 - tendon reactions 4 mmol/l 7.5 mmol/l : cardial conduction defect, cessation of breathing > 10 mmol/l :
cardiac arrest treatment CaCL2 10 % 5 - 10 ml iv , O2 with a mask Seizure control Phenytoin 2ff IV (5mins) (aurantin 150mg/f) 5-10mg increments 1 mg/kg 0.25-0.5 ug/kg/Min. 40-120 mg/gtt./nasal 4. Treatment
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200-400mg
Therapeutical 1020mg/l Hypertension Hypertension Hypertension Hypertension crosses placentaneonatal hypotension. no neonatal effects no evidence of fetal cyanide accumulation less fetal distress
Hydralazine Labetelol Nitroprusside Nifedipine
The anesthesiologist is involved in the treatment of epileptic symptoms at delivery and rarely deals with epileptic patients during pregnancy. The seizure presentation is more complex in pre-eclampsia or HELLP-syndrome, as cesarean section and seizures treatment are simultaneously present as problems to face [7]. The anesthesiologist has to give anesthesia to a pregnant woman just reaching the hospital on succeeding tonic-clonic attacks. In these conditions patients present a high anesthetic risk. General anesthesia is not always recommended: the propofol administration to stop the attacks can be followed by spinal anesthesia. 4.1 Anesthesia for epileptic patients delivery When the epileptic patient is well controlled by therapy during pregnancy, it is not usually necessary a special treatment at the delivery. However it is possible that the anesthesiologist is asked to treat epileptic symptoms occurring during labor. If no convulsions are present, a continuous epidural anesthesia throughout labor is preferred. This technique decreases seizure occurrence because 1) it suppresses labor pain, 2) maintains a constant anesthetic plasma concentration producing an anticonvulsant effect. It is important to do not overdosing local anesthetics: bupivacaine 0.25%, 6ml/hour should be indicated. - For patients in advanced labor or near delivery propofol administration (1% 3-4ml in repeatable bolus) should be attempted. If this treatment is effective, the woman may have a normal delivery or a low forcep application with an acceptable level of consciousness. After delivery diazepam 10mg should be given. - For cesarean delivery it is possible to control seizures by propofol and decide about general or spinal anesthesia after evaluating fetal conditions. In our experience good results are achieved by spinal anesthesia (see Tab.5). During surgery a propofol infusion at rate 10-15 ml/h is administered. After delivery diazepam 10 mg is usually given. Other drugs other than their routine therapy are not necessary by using this protocol. In any case thiopental and general anesthesia may also be used with good results, the most known approach, the best
one. An effective support is done by Magnesium administration (see Tab.4).
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4.2 Anesthesia for delivery of non epileptic patients presenting seizures This group is usually represented by patients suffering from eclampsia or the related syndrome, as the HELLP syndrome. The treatment is similar to that for seizure occurrence (more frequently in eclampsia than in HELLP), that is prompt delivery. However, in eclampsia syndrome there is a severe hypertension while in HELLP syndrome there are clotting abnormalities. 4.2.1 Seizure treatment in eclamptic patient Convulsions are only a part of this severe syndrome, due to the severe hemodynamic impairment: blood pressure is often over 200mmHg . In Tab.4 the therapeutic procedures are described . If it is possible, seizure treatment should include prophylactic magnesium or phenytoin because both the drugs are able to stabilize an epileptic patient. However the acute treatment is based on the use of propofol or thiopental as diazepam produces neonatal hypotonia and respiratory depression and cannot be used, except after delivery. The antihypertensive therapy is very important: the drug of choice is hydralazine or, in alternative, labetelol and nitroprusside. Good results are achieved by nifedipine nasal drops [8]. This procedure is of value in an unconscious patient without a venous line. The effect is constant and the dosage ranges 20-80mg . The choice of the anesthesiological technique depends on anesthesiologist experience (see tab.5). During the general anesthesia EEG monitoring is suggested; if the monitoring system does not have any EEG module, an electroencephalograph should be used for the EEG recording that to detect an eventual perioperative status epilepticus. This practice requires specific knowledge. In fact it is difficult to make diagnosis of seizures on curarized patient and the sparing use of hypnotic drugs may be ineffective in switching off a epileptic focus. Skilled professionals should be immediately available to look after the newborn. In his absence the anesthetist has to start neonatal resuscitation and to decide newborn ICU admission. As regards as postoperative treatment, convulsions are prevalent on general anesthesia awakening : diazepam should be given after the delivery and repeated one hour after. The neurologic status has to be carefully assessed. If an hour after the end of the anesthesia the patient is still unconscious, cerebral edema should be suspected and a brain TC scan and patient admission in ICU should be planned (fig.1)
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4.2.2 Seizures treatment in HELLP syndrome The treatment is similar to that of eclampsia (see tab.4) In the HELLP syndrome typical severe clotting abnormality and related bleeding, are the most important findings. Therefore a central venous line, large amounts of blood, plasma and platelets should be available before cesarean section. To gain a central access , a long catheter from an antecubital vein should be advanced to reach the atrium, as significant venous bleeding is frequently observed. Hemothorax by subclavian vein and important neck and thight hematoma by jugular or femoral attempts are the most troublesome complications. In these patients there is a high incidence of myocardial infarction and brain haemorrhage. A brain TC scan is necessary in all patients suffering from HELLP syndrome and seizures. General anesthesia is the technique of choice for cesarean section because clotting abnormalities contraindicate the regional anesthesia. Caution has to be used for intubation to avoid oropharyngeal bleeding. Postoperative management should be careful in the evaluation of hepatic and coagulation function. Patients suffering from severe forms have to be admitted in ICU (fig.2)
figure 2 Tab.5 guidelines for cesarean section in the eclampsia related syndrome Mild Pre-eclampsia Severe Pre-eclampsia HELLP Routine monitors + plus an arterial line, central venous (control the coagulation tests) + EEG monitoring Routine monitors (ECG,non invasive Routine monitors + blood pressure, pulse plus an arterial line, oximeter, central venous or (capnography or pulmonary artery transcutaneus PCO2 in catheter+ EEG regional anesthesia), monitoring stethoscope Whitacre or Sprotte needle, Bupivacaine 1% hyperbaric Spinal anesthesia General anesthesia if General anesthesia if seizure or clotting 10-15mg according to seizure. abnormality. height: < 150 cm 8mg, > 150 cm 10mg, > 160 cm 12mg, > 180 cm 15mg.L1-2 level Specially Indicated after a epidural analgesia labor..10 ml General anesthesia if General anesthesia if of plan Bupivacaine seizure or clotting seizure. 0.5% to have analgesia abnormality. for surgery. Risk of not completed analgesia Clear antacid, metoclopramide IV.Left or right uterine displacement, pre-oxygenate at least 3-4 min. Induction: Rapid sequence: Propofol 100-150 mg or Thiopental 4 mg/kg using cricoid pressure, Succinylcholine 1 mg/kg.
Monitoring
Epidural anesthesia
General anesthesia
Maintenance: Short acting curare 1) 50% N2O until delivery, then add fentanyl, isoflurane. Or 2) Propofol infusion +N2O 50% until delivery then add fentanyl Accurate decurarization (Hypertension ) Conclusions
[Contents]
Epileptic pregnant women have to be carefully evaluated and a polytherapy should be changed in a monotherapy to avoid toxic fetal effects. The occurrence of seizures in non epileptic patients should suggest an eclamptic syndrome. In this case the delivery is the treatment more effective for seizures. Drugs of choice in seizures therapy are magnesium, propofol, thiopental and phenytoin. References
1. Dichter M.A.: The epilepsies and convulsive disorders. In Harrisonn's Principles of 2. 3. 4. 5. 6. 7. 8.
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Internal Medicine.10th ed., RG Petersdorf, RD Adams, E. Braunwald, KJ isselbacher, JB Martin, JD Wilson, eds. McGraw-Hill, New York, 1983, pp 2018-2028 Bjerkedal T., Bahna SL: The course and outcome of pregnancy in women with epilepsy. Acta Obstet Gynecol Scand 52:245-248, 1973 Lander CM, Edwards VE, Eadie MJ et al: Plasma anticonvulsivant concentrations during pregnancy. Neurology 27:128-131, 1977 Ramanathan-J. "Pathophysiology & anesthetic implications in pre-eclampsia". Clinical Obstetrics & Gynecology. 35: 414-25. June, 1992 Arbogast-BK, et.al. "Which plasma factors bring about disturbance of endothelial function in pre-eclampsia?". Lancet. 343:340-1. Feb 5, 1994 Barton-JR, et.al. "Care of the pregnancy complicated by HELLP syndrome". Gastroenterology Clinics of North America 21:937- 50, 1992 Belfort-MA, et.al. "Effect of magnesium sulfate on maternal brain blood flow". American Journal of Obstetrics & Gynecology. 167:661-6. 1992 Fenakel-K, et.al. "Nifedapine in the treatment of severe pre-eclampsia". Obstetrics & Gynecology. 77:331-7. Mar, 1991
visitors n. http://anestit.unipa.it/OBSTE/EPILING.HTM
A guide to starting a family
If you have epilepsy it doesn’t automatically mean that having a family will be any more difficult for you than for anyone else. But it might mean that as a parent-to-be you have more things to consider before, during and after the pregnancy. These pages look at the
issues around pregnancy and parenting that sometimes affect people with epilepsy. It aims to help you look at how these issues might relate to your epilepsy.
I have epilepsy - can I have children?
Having epilepsy doesn’t usually make it harder to have a family – but it might mean that you have more things to consider when starting to try for a family. Some people with epilepsy feel that their sexual response or sex drive is low which may make it difficult for a couple to “get pregnant”. This can happen for a number of different reasons; anxiety, depression, and the side effects of some anti-epileptic drugs (AEDs) may all contribute. If you are concerned about your sex drive or sexual response you can ask your doctor for advice. Certain AEDs may reduce the production of sperm for some men, which could reduce a man’s fertility. Some women with epilepsy have irregular periods or a condition called Polycystic Ovary Syndrome. These can be side effects of some AEDs. Both these side effects are treatable but can make becoming pregnant more difficult. More information on polycystic ovary syndrome is on the women and epilepsy page Back to top
Could my child inherit my epilepsy?
Although you may be concerned that AEDs might affect your chances of becoming pregnant it is important never to stop taking AEDs suddenly and without the medical guidance of your neurologist or GP. Sometimes epilepsy happens as part of an inherited medical condition, passed from parent to child. This is rare, but includes the conditions neurofibromatosis and tuberous sclerosis. Genetics play a part in the development of epilepsy in everyone, but how important this is varies. As every situation is different, it can be helpful to talk about this with a doctor who specialises in genetics (geneticist). Information on different types of seizures Back to top
Can being pregnant affect my AEDs?
During pregnancy your body uses up more of your AEDs than usual. This means the amount of AEDs you normally take may not be enough to stop your seizures from happening. Your neurologist might ask you to have a blood test to make sure that the amount of AEDs you take is at the right level for you and your baby. Testing the levels of the AED in your blood helps your neurologist decide if the dose needs to be changed. Testing blood levels works for some AEDs but not all. With all AEDs, the frequency of seizures will be watched to see if the dose of the drug needs to be increased. If it does need to be increased, the dose will usually be slowly reduced to its original level after the birth. Back to top
Can morning sickness affect my AEDs?
Despite the name, morning sickness can happen at any time of the day and affects some women when they’re pregnant. If you’re sick after taking your AEDs, the medication may not have a chance to work properly. You might consider changing the time you take your AEDs, for example taking them when you’ve stopped feeling sick. Your doctor should be able to advise you on how best to cope with morning sickness and how to manage your AEDs. Back to top
Can AEDs affect an unborn baby?
If the baby’s father has epilepsy, his epilepsy and any AEDs he takes will not affect the baby’s development, because the baby will not come into contact with his AEDs. For a woman with epilepsy who takes AEDs during her pregnancy, her baby will be exposed to the AEDs in the womb. Although while she is pregnant a mother’s bloodstream is kept separate from her unborn baby’s, some substances can pass from her blood into her baby’s blood via the placenta. These substances include nutrients, oxygen, antibiotics, alcohol and medication, including AEDs. Some AEDs can affect how the baby grows and develops in the womb, particularly so in the first 15 weeks of pregnancy when the baby’s main organs and skeleton are developing. Back to top
Pregnancy and birth defects
For any pregnant woman there is a small risk (a ‘background’ risk) that her baby may be born with a birth defect. Birth defects, or developmental abnormalities as they are sometimes called, are physical problems that happen when the development of a baby is affected while it is in the womb. There are different types of birth defects, which can affect different organs in the body, and happen for different reasons. Sometimes birth defects are classed as minor and major. Minor malformations are those that do not require surgery, and major malformations are those that do need surgery to correct them. Major birth defects include cleft lip, cleft palate and problems with the development of the spine and nervous system (called neural tube defects). Other defects include problems with how the internal organs (such as the heart and lungs) develop. Sometimes the child’s arms, legs, or the way their face looks, may also be affected. If you are pregnant, avoiding alcohol, smoking and other drugs will help minimise the risk of birth defects. Back to top
AEDs and birth defects
If For a woman with epilepsy taking AEDs during her pregnancy, the risk of a birth defect to her baby is slightly increased above the background risk. How much the risk increases depends on which AEDs are being taken and at what dose. • • Women who don’t take AEDs during pregnancy have a 3% (3 in 100) risk that their baby will have a major birth defect. Taking one AED increases this risk to around 3 - 7% (3 in 100 to 7 in 100).
•
If two or more AEDs are taken, the risk increases to around 10% (1 in 10).
For example, looking at neural tube defects (a group of major defects, which include spina bifida): • In the general population the risk of a baby being born with a neural tube defect is around 0.2 - 0.5% (1 in 500 to 1 in 200). If a woman is taking sodium valproate (Epilim) during her pregnancy this risk is around 1 - 2% (1 in 100 to 1 in 50). If a woman is taking carbamazepine (Tegretol) it is 0.5% (1 in 200).
• •
Different AEDs vary in the risk they pose; and the risk is often greater the higher the dose of the drug. At the moment sodium valproate (Epilim) appears to have greater risks than other AEDs. An ongoing study into the effects and risks of AEDs on an unborn baby’s development aims to help understand those risks and to find out whether any specific drugs should be avoided during pregnancy. However it is worth remembering that about 95% (95 in 100) of pregnant women with epilepsy have a perfectly normal pregnancy and a healthy baby with no malformations. Back to top Foetal anti-convulsant syndrome Some AEDs are thought to affect a child’s development after they are born, this is called foetal anti-convulsant syndrome (FACS). The risk of this happening appears to be higher with sodium valproate. FACS can affect a child as they grow by causing developmental or learning difficulties, and problems with behaviour. Often these effects are not seen until the child starts to get older.
Preconception counselling
Because of the possible effects of AEDs on an unborn baby, having your AEDs reviewed before you get pregnant can help you and your neurologist to make sure that you are taking the most appropriate AED and at the most suitable dose during your pregnancy. Preconception counselling is an opportunity for you and your doctor to consider any changes to your epilepsy treatment that might be helpful before you become pregnant. It helps you to be fully informed about the effects pregnancy may have on your epilepsy, as well as the effect your epilepsy and AEDs may have on your pregnancy and unborn baby. If you have seizures you are likely to be advised to keep taking your AEDs throughout your pregnancy. However your doctor may suggest taking the lowest possible dose that will still control your seizures. Or they might suggest a change to the AEDs that you take. Back to top Some women prefer not to take AEDs during their pregnancy and may want to discuss this option with their neurologist. If you have seizures during pregnancy there is a risk of injury to yourself and your baby. This risk could be higher (depending on the type and frequency of seizures you have) than the risk of the AED affecting your baby.
If you have been seizure-free for two or three years, your doctor might suggest slowly stopping your AEDs before starting your family. However there is a risk if your AEDs are stopped that your seizures could start again. Having seizures again could affect your lifestyle - for example your home or work life and if you are currently driving you would need to hand your driving licence in until you were seizure-free for one year. Making decisions about your medication is not always easy and preconception counselling should give you the chance to ask any specific questions or talk about any concerns you may have. Back to top What if I'm already pregnant? If you become pregnant without having the chance to speak to your neurologist first it is recommended that you keep taking your AEDs and start taking folic acid. It is also recommended that you make an appointment to see your neurologist as soon as possible.
Why is taking folic acid recommended?
Folic acid is a vitamin that helps a developing baby’s spine to form. The Department of Health recommends that all women take folic acid throughout their pregnancy and ideally before becoming pregnant. Women who increase their intake of folic acid at the time their baby’s spine is forming (in the first three months of pregnancy) reduce the risk of having a baby with neural tube defects. It is strongly recommended that women with epilepsy take 5mg of folic acid daily before they become pregnant. Folic acid is available free of charge on prescription. Back to top
What is pre-natal screening?
Pre-natal screening is the name for a number of different checks that are done during pregnancy to see how the baby is developing in the womb. This includes ultrasound scans which are done at certain intervals throughout the pregnancy. As part of the pre-natal screening checks, some women have their alpha-fetoprotein (AFP) levels checked in a blood test at around 15-16 weeks into their pregnancy. AFP is a type of protein which is passed from an unborn baby to its mother. The levels of AFP in a mother’s blood can indicate the risk of their baby being born with certain health disorders including spina bifida. Screening does not say for certain if a baby will be born with or without any birth defects or developmental abnormalities. It just uses the information collected to determine the risk of an unborn baby being born with birth defects or developmental abnormalities.
Why is vitamin K prescribed?
Vitamin K plays an important part in making our blood thicken (clot). A very small number of newborn babies (about 0.01% or 1 in 10,000) are born without enough vitamin K. This can cause nose bleeds, mouth bleeds and in some cases internal bleeding. The risk of having low vitamin K is slightly higher for babies whose mothers have taken certain AEDs during their pregnancy. The Department of Health recommends that all newborn babies are given extra vitamin K at birth or within the first month of being born. Depending which AEDs you take you may also be prescribed a daily 10mg dose of vitamin K during the last month of your pregnancy, as well as your baby being given vitamin K at birth (usually by injection).
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Will having epilepsy affect my labour?
Most women with epilepsy have normal deliveries and healthy children. It is useful for the midwife and medical team who will be at the birth to know about your epilepsy, including what type of seizures you have, which AEDs you take (if any) and when you normally take them. Ideally, AEDs are taken as normal during labour. If you want to have a home birth you will need to carefully consider the possible effects of having a seizure during labour, which could lead to complications. Women who would like to have a water birth may also need to consider the effect of seizures if they become confused or lose awareness during their seizures. Generally, caesarean sections are only necessary if this is in the best interests of the mother and her baby. About 1 - 2% (1 in 100 to 1 in 50) of women with epilepsy have a tonic clonic seizure during labour - even if they don’t normally have tonic clonic seizures. If a seizure happens during labour, drugs can usually be given to control it. A further 1 - 2% (1 in 100 to 1 in 50) will have a tonic clonic seizure up to 24 hours after the birth. Back to top
What pain relief can I have?
Women with epilepsy can have most types of pain relief during labour. These include: • • • • an epidural (an anaesthetic into the spine); breathing techniques; gas and air; and a TENS machine (which uses electrical impulses to stop pain signals getting to the brain).
Pethidine, a strong painkiller, has been thought to trigger seizures in some women and therefore caution is advised. It is helpful to tell the midwife and medical team if your seizures have any particular triggers. For example if pain, tiredness or over-breathing have triggered seizures in the past. Back to top
The UK Epilepsy and Pregnancy Register (UKEPR)
If you have epilepsy and are thinking of becoming pregnant, or you are already pregnant, you might like to contact the UKEPR. The UKEPR is a long-term study looking at the effect of AEDs on unborn babies and the effect of having seizures while pregnant. The study lets you speak to an epilepsy nurse and ask questions about your pregnancy and epilepsy. If you would like to join the UKEPR you will be asked about your epilepsy and your AEDs (if you take them). Being a part of the study is free of charge. The UKEPR may want to contact you after your baby is born. It is hoped that the findings from the study will provide some answers and guidance for other women in the future.
More details about the UKEPR (opens in new window) Alternatively call: 0800 389 1248 from UK or: 1 800 320 820 from ROI Back to top
Childcare
If you or your partner’s seizures are controlled then epilepsy may not affect how you look after your child. However, parents who still have seizures may find taking extra safety measures helpful. This depends on the type of seizures the person has and the activity involved. Can I breast-feed my baby? The Department of Health recommends that every woman should be encouraged to breastfeed her baby. Breast milk provides all the nutrients a baby needs, for the first six months of their life. Breastfeeding is recommended even if you take AEDs. Your baby will have become used to the drugs while in your womb, and only a small amount of AEDs is in breast milk. Some drugs (for example phenobarbital) can make a baby over sleepy, so it may be a good idea to alternate between formula and breastfeeds. Patient information leaflets, which come with each new prescription of an AED, often include information about breastfeeding for that particular drug. If you have any doubts, talking this through with your neurologist, midwife, or health visitor may help. If you’re more likely to have seizures when you’re over tired, you may want to consider if breastfeeding your baby during the night is a good option for you. If possible, sharing night time feeds with a partner might be one way to increase the chance of a good night’s sleep. Back to top Ideas for keeping you and your baby safe If your seizures happen suddenly and without warning the following ideas may be helpful to keep your baby safe. These might not always be necessary, especially if there’s someone else around to help you, but they could be helpful if you’re home on your own. • • • • • • Dressing and changing your baby on the floor means they only have a short fall if you have a seizure. Sponging your baby down on a changing mat on the floor is safer than bathing the baby in water. When carrying your baby it may be safer to use a carrycot or sling than to carry them in your arms. A padded carrycot will help protect your baby if you have a seizure. Putting a deadlock on your baby’s pram means the pram will stay in place if you let go of it during a seizure. When feeding your baby, a lower highchair is less likely to tip over than a taller one. Feeding your baby while you sit on the floor, surrounded by cushions and leaning against the wall may help to make your baby safer if you suddenly have a seizure. Back to top Talking about epilepsy to your child Children can often be taught at quite a young age what to do if someone has a seizure. Some children learn what to do from watching other people. During a seizure your child could: • stay with you so they don't get lost
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get help from someone else, for example a neighbour or friend help you themselves if they know what to do.
Information on first aid for seizures. Some people wear medical jewellery or carry an ID card saying that they have epilepsy and what to do if a seizure happens. Even if children are too young to manage seizures, they may be able to let other people know about the card or jewellery. Information about the medical and ID bracelets. Free identity cards are available from the NSE online shop Back to top
What about immunisation?
There has been some concern that the MMR (measles, mumps and rubella) vaccine may be linked to causing seizures. However, current research suggests that there is no connection between the vaccine and epilepsy. If you are concerned about any vaccination your child may need, you can talk about this with your child’s doctor or paediatrician. It is your choice whether your child is vaccinated, and having more information might help you make that choice.The following guidelines are taken from the Department of Health publication ‘Immunisation against Infectious Disease’. They state that: “No child should be denied immunisation without serious thought as to the consequences, both for the individual child and for the community. Where there is doubt, advice should be sought from a Consultant Paediatrician, District (Health Board) Immunisation Co-ordinator, or Consultant in Communicable Disease Control”. Immunisation Against Infectious Disease 2006 - "The Green Book" (opens new window)
UK Epilepsy Helpline: 01494 601400 Monday - Friday 10am - 4pm
© The National Society for Epilepsy April 2007
http://www.epilepsynse.org.uk/pages/info/leaflets/preg.cfm
