LA CONSULTA SEMANAL

MAYO 2000

CONSULTA:

Lancet 1999 Oct 30;354(9189):1522 [Texto completo]

Intractable seizures in pregnancy. 

Smith PE, Saunders J, Dawson A, Kerr MP 

Epilepsy Unit, University Hospital of Wales, Cardiff, UK. SmithPE@cardiff.ac.uk 

Epilepsia 1999 Sep;40(9):1237-43 

Long-term neuropsychological consequences of maternal epilepsy and anticonvulsant treatment during pregnancy for school-age children and adolescents. 

Koch S, Titze K, Zimmermann RB, Schroder M, Lehmkuhl U, Rauh H 

Department of Pediatrics, Humboldt University, Berlin, Germany. 

PURPOSE: Antiepileptic drugs (AEDs) are potential teratogenic agents. The purpose of this study was to examine the long-term effects of intrauterine AED exposure on neurologic and psychological functioning. METHODS: Of a prospective study, "Epilepsy, pregnancy, and child development," children could be retraced at school age and adolescence. Sixty-seven were born to mothers with epilepsy [no drugs during pregnancy (n = 13), monotherapy (n = 31), polytherapy (n = 23)]; 49 were nonafflicted control children. Assessments included an intelligence test (Wechsler), a neurologic examination (Touwen), and an EEG. Data analyses were performed, controlling for parental social status, type of maternal drug therapy and drug dosage, type of epilepsy, frequency of seizures during pregnancy, the original subgroups, and specific drug effects. RESULTS: Type of maternal epilepsy and type and kind of AED therapy, but not maternal seizures during pregnancy correlated with an increase in abnormal EEG patterns. Minor neurologic dysfunction was diagnosed, with increased frequency from the control to the risk/no drug or monotherapy to the polytherapy group. The compromised intelligence score of the polytherapy group was primarily due to those children who had been exposed to primidone (PRM). Level of IQ was negatively associated with PRM dosage. CONCLUSIONS: Maternal epilepsy and AED therapy during pregnancy appear to have long-term effects on the offspring well into adolescence, as evinced in EEG patterns, minor neurologic dysfunction, and intellectual performance. Severity of effects increased from control group to epilepsy/no-drug group to monotherapy group and was most marked in the polytherapy group. These group differences are assumed to reflect differential neural vulnerability to social and family factors. 

Rev Neurol 1999 May 1-15;28(9):916-24 [Texto completo en formato PDF]

[The treatment of epilepsy in medical conditions, geriatric and pregnant patients]. 

[Article in Spanish] 

Arroyo S 

Unidad de Epilepsia, Hospital Clinic, Barcelona, Espana. sarroyos@meditex.es 

INTRODUCTION: Treatment with antiepileptic drugs in patients with medical conditions, old age or pregnancy is associated with concomitant pathology and the specific physiopathological changes of age or pregnancy. DEVELOPMENT: The difficulties of treatment in special conditions are related to changes in the pharmacokinetics of antiepileptic drugs, interaction with other medication and with concomitant treatment with drugs which may potentially cause convulsions. Also, the occurrence of a particular disorder or of pregnancy may lead to changes in the frequency of crises. Besides this, the side-effects of antiepileptic drugs may be more marked or more frequent in patients with several other conditions or in the elderly. CONCLUSION: The treatment of epilepsy in patients with associated medical disorders, old age or pregnancy requires knowledge of the behaviour of antiepileptic drugs and the physiopathology of these conditions.  

Publication Types: 

· Review 

· Review, tutorial 

Comments: 

· Comment in: Rev Neurol 1999 Dec 16-31;29(12):1352 

BMJ 1999 May 22;318(7195):1374 [Texto completo] 

Women with epilepsy are not getting pregnancy advice. 

Madden V 

Publication Types: 

· News 

Am Fam Physician 1999 Mar 15;59(6):1681-2 [Texto completo] 

New guidelines offer recommendations for women with epilepsy. 

Rose VL 

Lancet 1998 Dec 19-26;352(9145):1952-3 

Infertility and pregnancy in epileptic women. 

Schwartz LB 

Department of Obstetrics and Gynecology, New York University Medical Center, NY 10016, USA. 

Publication Types: 

· Comment 

Comments: 

· Comment on: Lancet 1998 Dec 19-26;352(9145):1970-3 

Neurology 1998 Oct;51(4):1039-45 

Analysis of prenatal and gestational care given to women with epilepsy. 

Seale CG, Morrell MJ, Nelson L, Druzin ML 

Department of Neurology and Neurological Sciences and Stanford Comprehensive Epilepsy Center,CA, USA. 

OBJECTIVE: To assess past care practices of neurologists and obstetricians to identify areas in which practice patterns differ from currently accepted optimal care. METHODS: Retrospective chart review of 155 women identified as having a diagnosis of epilepsy (or seizure disorder) who had been pregnant any time between January 1988 and December 1995 and were admitted to Stanford University Hospital for delivery. A total of 161 pregnancies (132 women) were selected for study. RESULTS: An obstetrician was seen at some point during the pregnancy in 99% of the pregnancies, whereas a neurologist was seen at least once in only 64% of the pregnancies. In the 3 months before conception, an obstetrician was seen in 5% of the pregnancies and a neurologist was seen in 15%. Seventy-five percent of the patients taking antiepileptic medication and 65% of the untreated patients had documentation of folate supplementation at any time during pregnancy. Vitamin K supplementation in the final month of pregnancy was documented for only 41% of those receiving antiepileptic drugs. In over one-third of the pregnancies the mother did not have a maternal serum alpha-fetoprotein measure documented and a similar percentage did not receive genetic counseling. Monitoring of the maternal serum concentration of the non-protein-bound fraction of the prescribed antiepileptic drugs was not documented. CONCLUSIONS: We identified specific omissions of appropriate vitamin supplementation, genetic counseling, and drug level monitoring. Educational efforts should be targeted to improve the management of pregnancy in women with epilepsy.  

Epilepsia 1998 Aug;39(8):887-92 

Pregnancies of women with epilepsy: a population-based study in Iceland.  

Olafsson E, Hallgrimsson JT, Hauser WA, Ludvigsson P, Gudmundsson G 

Department of Neurology, National University Hospital, Reykjavik, Iceland. 

PURPOSE: Women with epilepsy who become pregnant are commonly considered to be at high risk for complications during pregnancy or delivery. The offspring are also considered to have increased risk of perinatal mortality, congenital malformations, and maturational delay. Because few of these studies are population based, potential bias exists because of selection. METHODS: We performed a historical population-based cohort study in Iceland to determine the prevalence of epilepsy among pregnant women, to identify pregnancy and delivery complications in women with epilepsy, and to determine the outcome of their pregnancies as compared with that in the general population of Iceland. We identified all women with active epilepsy who gave birth during a 19-year period in Iceland. RESULTS: In this population, 3.3 in 1,000 pregnancies involve mothers with active epilepsy. The frequency of adverse events (AE) during pregnancy in the women with epilepsy is similar to that observed among all live births in the population, but cesarean section was performed twice as frequently as in the general population. Perinatal mortality rate and mean birth weight are not significantly different in the offspring of women with epilepsy as compared with rest of the population. The risk of major congenital malformations (MGM) is increased 2.7-fold over that expected when a mother is treated with antiepileptic drugs (AEDs) during a pregnancy. CONCLUSIONS: Our study indicates that the rate of complications of pregnancy in mothers with active epilepsy is low and similar to that of the general population with epilepsy. Use of AEDs by the mother during pregnancy significantly increases the risk of MGM in the offspring. 

Neurol Clin 1998 Feb;16(1):189-206  

Medication use during pregnancy for neurologic conditions. 

Gilmore J, Pennell PB, Stern BJ 

Department of Neurology, Emory University, Atlanta, Georgia 30322, USA. 

Care of the pregnant patient is challenging because of the multiple physiologic changes associated with pregnancy and the need to consider the impact of any intervention on the fetus. This article addresses management issues that arise while caring for patients with epilepsy, eclampsia, stroke, multiple sclerosis, and headache. An emphasis is placed on considerations involving medication use and approaches to patient care are suggested. 

Publication Types: 

· Review 

· Review, tutorial 

Am Fam Physician 1997 Oct 15;56(6):1631-6, 1638 [Texto completo] 

Epilepsy in pregnancy. 

Rochester JA, Kirchner JT 

Lancaster General Hospital, Pennsylvania, USA. 

Family physicians who provide obstetric care may periodically encounter a patient with a history of epilepsy, which may manifest before or after pregnancy. In either case, several issues need to be addressed. Pregnant women with epilepsy may have an increased frequency of seizures, with the potential for resultant maternal and fetal morbidity and mortality. Teratogenic effects of antiepileptic drugs include craniofacial abnormalities and neural tube defects. Management strategies include the prenatal use of folic acid and vitamin K, monotherapy with a single antiepileptic drug, and obtaining at least monthly free serum drug levels. Fortunately, with close monitoring and proper management, more than 90 percent of pregnancies in women with epilepsy will be uncomplicated.  

Publication Types: 

· Review 

· Review, tutorial 

Neurol Clin 1994 Nov;12(4):749-71 

Pregnancy, teratogenesis, and epilepsy. 

Yerby MS 

Oregon Comprehensive Epilepsy Program, Portland. 

Women with epilepsy who are of childbearing age need to understand what the risks of pregnancy are. These women have a 33% risk of increased seizures, a twofold increase in risk of hemorrhage, eclampsia, premature labor, and an increased need for cesarean sections. Babies born to women with epilepsy face a higher risk of miscarriage, stillbirth, prematurity, developmental delay, and major malformations. Seizure control should be obtained without clinical toxicity. Monotherapy reduces the risk of adverse outcomes. 

Publication Types: 

· Review 

· Review, academic 

Neurol Clin 1994 Aug;12(3):479-95 

Women with epilepsy. Reproduction and effects of pregnancy on epilepsy. 

Devinsky O, Yerby MS 

Department of Neurology, New York University Medical Center, Hospital for Joint Diseases, New York.

Conventional wisdom and prevailing medical practice strongly support the belief that medication should be avoided during pregnancy. For the nearly one million women of childbearing age with epilepsy in the United States this is often difficult, if not impossible, and for many of these women becoming pregnant raises many conflicting issues. Women with epilepsy may face a possible increase in the frequency and severity of seizures, and in generalized tonic-clonic seizures there is a small but increased risk of miscarriage. 

Publication Types: 

· Review 

· Review, tutorial 

Arch Neurol 1994 Mar;51(3):250-3 

Outcomes of pregnancy associated with antiepileptic drugs. 

Waters CH, Belai Y, Gott PS, Shen P, De Giorgio CM 

Department of Neurology, University of Southern California, School of Medicine, Los Angeles. 

OBJECTIVE: To determine whether exposure to antiepileptic drugs during pregnancy is associated with poor fetal outcomes (anomalies and death) and to assess the relative risks with phenobarbital, phenytoin sodium, and carbamazepine. DESIGN: The design was a prospective case-control cohort study of pregnant women with epilepsy and their offspring. Outcomes were compared with those of a control group of 355 healthy women and their offspring. SETTING: The obstetrics service at Los Angeles County/University of Southern California Medical Center, Los Angeles, a large, inner-city, teaching hospital. PATIENTS: Two hundred eleven subjects who were pregnant during the years 1987 through 1990, 174 of whom were delivered of infants, were available for analysis. A control group of 355 healthy women and their offspring from the same hospital were randomly selected from a computerized database. INTERVENTION: None. MAIN OUTCOME MEASURE: Anomalies and fetal death were the primary outcome measures. RESULTS: Offspring of women with epilepsy who were exposed to antiepileptic drugs had a higher rate of fetal death and anomalies than did the control population (P = .001). Abnormal outcomes were associated with the three major antiepileptic drugs (carbamazepine, phenytoin, and phenobarbital). In terms of abnormal outcome (death and anomalies), phenobarbital was associated with the highest relative risk, phenytoin with intermediate relative risk, and carbamazepine with the lowest relative risk (P = .019). Numbers were insufficient for assessment of risk associated with valproic acid. CONCLUSION: All three major antiepileptic drugs (phenobarbital, phenytoin, and carbamazepine) are associated with an increased risk of fetal death and anomalies. We found phenobarbital to be most associated with poor pregnancy outcome. 

BMJ 1993 Oct 9;307(6909):937 

Epilepsy and pregnancy. Emphasise the importance of extra folate. 

Girling JC, Shennan AH 

Publication Types: 

· Comment 

· Letter 

Comments: 

· Comment on: BMJ 1993 Aug 21;307(6902):492-5 

BMJ 1993 Aug 21;307(6902):492-5 

Epilepsy and pregnancy. 

O'Brien MD, Gilmour-White S 

Guy's Hospital, London. 

Publication Types: 

· Review 

· Review, tutorial 

Comments: 

· Comment in: BMJ 1993 Oct 9;307(6909):937