( This is not my own notes, got from a friend)
A 21 year old woman who is an epileptic on medication is planning
a pregnancy. The couple come to you for advice
1. What important aspects of the disease you would consider before
advising on pregnancy?
*Disease
severity & control, when was the last fit
*What are the drugs
– valproate, carbamazapine, phenitoin or any other
*Single drug or
combination of drugs
*Type of seizer
(some types of seizers are best manage with certain drugs)
*Family, social
support and economic background
*Level of education
2. If not in good control,
how are you going to advice?
*delay the
pregnancy, have a good control
*prescribe a
reliable method of contraception
3. If in good control, what advice would you give?
*Need for referral
to a neurologist
*Consider
possibility of stopping medication – if long fit free interval
*possibility of
changing drug/s to less teratogenic drugs
*possibility to
manage with single drug with minimum effective dose
*Counselling
regarding the effects of disease/ drugs to the fetus
-
Increased risk of epilepsy two folds.
-
Major teratogenic effects –oro fascial
clefts, Ht disease, NTD
- minor
teratogenic effects- neuro development delay
To
mother-
-1/3
gets increased seizer frequency
-may
need increasing drug dose/ frequency
-drug
levels in blood to be monitored
-Need
frequent ANC visits, blood investigations
-Importance
of compliance
-High
dose folic acid (5mg/d) reduces the risk of NTD
4. How to minimize adverse outcomes due to drugs?
*If long fit
free period à stop mediation
*Pre pregnancy folic
acid
*manage on single
drug, minimum effective dose
*Change to a less
teratogenic agent
*Screaning for
diformitiesà USS – NTD, Ht
disease, orofascial clefts
àacetyle choline
esterase – open NTD
5. Why do some women experience increased seizer frequency in
pregnancy?
*Reduced compliance
*Increased plasma
volume reduces drug concentration
*Reduced plasma
proteinsà increased clearance
(due to reduced bound fraction)
6. What important steps would you consider during labor and
delivery?
*Continue
antiepileptic Rx
*Good pain relief –
epidural/ opioids
*one to one care
*Inform paediatric
team
*Maintain good
hydration
*None precipitous
labor environment
7. How do you manage status epilepticus?
*Call for help
*Patient put in
left lateral position, suck out secretions, and give O2
*IV line, medosolam
or diazepam iv, if not possible give rectally
*If no response paralyse
and ventilate
8. What is the importance of vit K within last 4 weeks of delivery?
*Reduces risk of
PPH
*Reduces risk of
haemorrhagic disease of new born
9. What advice would you give on discharge?
*Breast feeding not
contraindicated, some drugs excreat in breast milk, if the baby is excessively sleepy need medical
attention
*Breast feed before
taking drugs
*Stress and lack of
sleep can provoke fits
*Need help/
supervision at baby caring, bathing and breast feeding
*Drugs can be
changed to pre pregnancy drugs/ doses
10. What advice would you give regarding contraception?
*Enzyme inducing drugs increase metabolism
of hormonal contraception, reducing their efficacy
*If taking OCP need high dose pills, cannot
follow conventional missed pill rule
*DMPA- needs increased frequency
*IUCD good option
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