History

Fact Explanation
Known personal history of epilepsy The aetiology is usually idiopathic while rarely a secondary aetiology predisposing seizure development may exist. Epilepsy affects about 0.5% of pregnant women.[1]
A diagnosed patient with epilepsy may present with a seizure episode. During the antenatal period the seizure frequency may increase/decrease or remain unchanged.[2] The patient may experience an alteration in the seizure frequency due to the physiological changes associated with pregnancy. Reduced drug absorption (due to nausea & vomiting), increase in plasma volume, changes in renal & hepatic metabolism may precipitate seizure attacks.
Newly diagnosed with epilepsy during pregnancy Majority of women have being diagnosed prior to conception. A wide differential diagnosis including Eclampsia, central nervous system infection, metabolic disturbances, epilepsy, stroke etc needs to be considered if the first seizure episode develops during pregnancy.[3]
References
  1. NULMAN I, LASLO D, KOREN G. Treatment of epilepsy in pregnancy. Drugs [online] 1999 Apr, 57(4):535-44 [viewed 10 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10235691
  2. The Management of Pregnancy in Women with Epilepsy. Scottish Obstetric Guidelines and Audit Project, December 1997 [Viewed on 8 May 2014]. Available from : http://www.drfogarty.co.uk/mat_epilepsy.pdf
  3. HART LA, SIBAI BM. Seizures in pregnancy: epilepsy, eclampsia, and stroke. Semin Perinatol [online] 2013 Aug, 37(4):207-24 [viewed 14 September 2014] Available from: doi:10.1053/j.semperi.2013.04.001

Examination

Fact Explanation
Usually unremarkable. Examination is usually normal in patients with idiopathic epilepsy. Patients with secondary epilepsy may exhibit neurological signs in accordance to the underlying aetiology.[1]
References
  1. The Management of Pregnancy in Women with Epilepsy. Scottish Obstetric Guidelines and Audit Project, December 1997 [Viewed on 8 May 2014]. Available from : http://www.drfogarty.co.uk/mat_epilepsy.pdf

Differential Diagnoses

Fact Explanation
Eclampsia Eclampsia is defined as the occurrence of a tonic clonic seizure in association with a diagnosis of pre-eclampsia.[1] This is an obstetric emergency. Eclampsia can occur in the antenatal, intrapartum and postpartum period. The patient usually has severe hypertension with significant proteinuria. The patient may also develop other associated complications such as renal failure, placental abruption, HELLP syndrome etc.
Syncope Syncope is the result of generalized reduced cerebral perfusion. The patient experiences blackening of the environment accompanied with sweating and paleness. Loss of consciousness is limited to a few seconds from which the patient rapidly recovers. Syncope is usually not associated with clonic limb movements & urine/fecal incontinence.[2] There is no amnesia for the event. Syncope is often triggered by events the subject fears, emotional stress etc. Differentiation from seizures depends on the clinical history.
Organic non-epileptic seizures Non-epileptic seizures (NES) are seizures that develop in the absence of excessive brain electrical activity.[3] Organic NES develop due to the presence of a physical cause such as metabolic imbalances (Renal failure, diabetic ketoacidosis), electrolyte imbalances (hypocalcaemia, hyponatriaemia), cerebrovasular disorders, CNS infection etc.
Psychogenic non Epileptic Seizures Psychogenic seizures include dissociative seizures, panic attacks & fastidious seizures. Dissociative seizures happen unconsciously without awareness of the patient. Panic attacks are episodes of extreme anxiety accompanied with sweating, palpitations,dyspnea which may progress to seizures. Features that support a diagnosis of factitious seizures include very prolonged seizures, very high frequency of seizures and occurrence of seizures only in public. Features such as incontinence, injuries are usually absent.[4] Clinical history is used to differentiate epileptic seizures from psycogenic non-epileptic seizures.[5]
References
  1. WALKER JJ. Pre-eclampsia. Lancet [online] 2000 Oct 7, 356(9237):1260-5 [viewed 14 September 2014] Available from: doi:10.1016/S0140-6736(00)02800-2
  2. Guidelines for the diagnosis and management of syncope (version 2009). [Online] The Task Force for the Diagnosis and Management of Syncope of the European Society of Cardiology, 2009 [Viewed on 9 May 2014]. Available from : http://www.escardio.org/guidelines-surveys/esc-guidelines/guidelinesdocuments/guidelines-syncope-ft.pdf
  3. LESSER RP. Treatment and Outcome of Psychogenic Nonepileptic Seizures Epilepsy Curr [online] 2003 Nov, 3(6):198-200 [viewed 11 May 2014] Available from: doi:10.1046/j.1535-7597.2003.03601.x
  4. LEMPERT T, SCHMIDT D. Natural history and outcome of psychogenic seizures: a clinical study in 50 patients. J Neurol [online] 1990 Feb, 237(1):35-8 [viewed 11 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/2319265
  5. ALSAADI T.M, MARQUEZ A.V. Psychogenic Nonepileptic Seizures. American Family Physician, 2005 Sep, 72(5), 849-856.

Investigations - for Diagnosis

Fact Explanation
The diagnosis of epilepsy is primarily based on history & an account of an eye witness. Patients presenting with their first seizure during pregnancy need to be evaluated with a thorough history. An eye witness account is essential to exclude other differential diagnoses. To exclude a secondary aetiology, brain imaging with CT scan, MRI etc may be required.[1]
Urine protein assessment Significant proteinuria (>300mg protein/ 24 hours) is seen in severe pre-eclampsia.[2]
Full blood count A full blood count is performed to help exclude eclampsia. Haemoconcentration, thrombocytopenia, haemolytic anemia may be seen in the presence of severe pre-eclampsia.[2]
Coagulation profile ( Prothrombin time test, APTT) Disseminated intravascular coagulopathy is a complication of severe pre-eclampsia.[2]
References
  1. The epilepsies: the diagnosis and management of the epilepsies in adults and children in primary and secondary care. National institute for health and care excellence, January 2012 [Viewed on 10 May 2014]. Available from : http://publications.nice.org.uk/the-epilepsies-the-diagnosis-and-management-of-the-epilepsies-in-adults-and-children-in-primary-and-cg137
  2. WALKER JJ. Pre-eclampsia. Lancet [online] 2000 Oct 7, 356(9237):1260-5 [viewed 14 September 2014] Available from: doi:10.1016/S0140-6736(00)02800-2

Investigations - Followup

Fact Explanation
Full blood count Anticonvulsants such as carbamazepine, sodium valproate may lead to blood disorders. [1]
Liver function tests Anticonvulsants such as sodium valproate, carbamazepine etc have hepatotoxic properties & need periodical liver function assessment.[1]
Serum anticonvulsant levels[1] Monitoring of drug levels is not recommended routinely and is performed in circumstances such as increased seizure frequency, polypharmacy, concern over drug side effects etc.
References
  1. ADAB N. Therapeutic monitoring of antiepileptic drugs during pregnancy and in the postpartum period: is it useful? CNS Drugs [online] 2006, 20(10):791-800 [viewed 11 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16999450

Investigations - Screening/Staging

Fact Explanation
Ultrasound scan A detailed anomaly scan needs to be performed since a majority of anticonvulsants are teratogenic. Common congenital anomalies seen are neural tube defects, facial clefts, cardiac anomalies & genitourinary anomalies.[1]
Fetal echocardiography Fetal echocardiography is considered at 22-24 weeks.[2] Use of sodium valproate, carbamazepine and phenytoin during pregnancy has being linked with fetal cardiac anomalies.
α fetoprotein Prenatal screening for neural tube defects.[1]
References
  1. The Management of Pregnancy in Women with Epilepsy. Scottish Obstetric Guidelines and Audit Project, December 1997 [Viewed on 8 May 2014]. Available from : http://www.drfogarty.co.uk/mat_epilepsy.pdf
  2. FETAL ECHOCARDIOGRAPHY (INCLUDING DOPPLER, PULSED WAVE AND COLOR FLOW MAPPING). Clinical Coverage Guideline, 2009 [Viewed on 11 May 2014]. Available from : https://www.wellcare.com/WCAssets/corporate/assets/ccg/ccg_fetal_echocardiography_08_2013.pdf

Management - General Measures

Fact Explanation
Patient education & counseling Patient education is paramount and should cover the following aspects : About the disease process, importance of compliance to treatment, drugs & their side effects, implications to the fetus, first aid measures in a seizure & about high risk situations such as bathing, driving etc. She should be advised to avoid seizure provoking factors such as sleep deprivation, extreme exhaustion, hypoglyceamia etc. The pregnant women should be counseled about fetal implications due to the disease itself and the anticonvulsant therapy. There is a higher risk of congenital anomalies even without anticonvulsant treatment which is further aggravated with the use of teratogenic drugs.[1][2] Sodium valproate is considered the most teratogenic anticonvulsant but is the most effective drug for seizure control.[3] Valproate use can lead to development of neural tube defects, genitourinary anomalies etc. There is a 4% risk of epilepsy in the child if one parent is affected & 15% if both parents are affected.
Involvement of the general practitioners in the management plan Care for the pregnant women with epilepsy should start pre-conceptually. General practitioners should optimize the drug regime and refer the patient for specialist assessment.[4]
References
  1. NULMAN I, LASLO D, KOREN G. Treatment of epilepsy in pregnancy. Drugs [online] 1999 Apr, 57(4):535-44 [viewed 10 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10235691
  2. The Management of Pregnancy in Women with Epilepsy. Scottish Obstetric Guidelines and Audit Project, December 1997 [Viewed on 8 May 2014]. Available from : http://www.drfogarty.co.uk/mat_epilepsy.pdf
  3. VAJDA FJ. Effect of anti-epileptic drug therapy on the unborn child. J Clin Neurosci [online] 2014 May, 21(5):716-721 [viewed 11 May 2014] Available from: doi:10.1016/j.jocn.2013.09.022
  4. AHMED R, APEN K, ENDEAN C. Epilepsy in pregnancy - a collaborative team effort of obstetricians, neurologists and primary care physicians for a successful outcome. Aust Fam Physician [online] 2014 Mar, 43(3):112-6 [viewed 11 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24600671

Management - Specific Treatments

Fact Explanation
Pre-pregnancy management The main objectives during the preconceptual period are to optimization the treatment, achieve good seizure control and patient education.[1] The obstetrician should liaise with a neurologist for optimal care.[2] Efforts should be made to maximize seizure control on the least tetatogenic monotherapy.[3] The lowest effective drug doses should be used in divided doses. Consider stopping the anticonvulsant therapy if the patient was seizure free for more than two years. All women should be advised to take folic acid 5mg daily for at least 12 weeks prior to conception and continue to do so until delivery.[4][5]
Antenatal management The patient's drug regime is continued if epilepsy is well controlled. The patient should be stressed about the importance of compliance to treatment during the antenatal period. If epilepsy is diagnosed during pregnancy lamotrigine and carbamazepine are the drugs of choice.[6] To avoid neonatal coagulopathy due to administration of enzyme inducing drugs, vitamin K 10mg/day is administered for the last 4 weeks of pregnancy.
Intrapartum care A diagnosis of epilepsy alone is not a contraindication for vaginal delivery. Vaginal delivery may precipitate seizure attacks due to maternal dehydraion, electrolyte changes, hypoglycaemia, exhaustion and pain.[7] Caesarian section is reserved for usual obstetric indications and in the circumstance of status epilepticus. Anticonvulsant treatment should be continued during the intrapartum period. Labor may precipitate seizure episodes due to sleep deprivation, poor drug absorption etc which should be controlled with benzodiazepines (diazepam/lorazepam). Monitor fetal parameters to identify fetal compromise.
Postpartum management The neonate should receive intramuscular vitamin K to reduce the risk of neonatal coagulopathy. Breast feeding is not contraindicated since the dose passed over to the fetus is low.[8] Drug dose changes made during the antenatal period are converted back to pre-pregnancy levels gradually. The women should be educated on an appropriate contraceptive method.
References
  1. EADIE MJ. Treating epilepsy in pregnant women. Expert Opin Pharmacother [online] 2014 Apr, 15(6):841-50 [viewed 11 May 2014] Available from: doi:10.1517/14656566.2014.896902
  2. THOMAS SV. Managing epilepsy in pregnancy. Neurol India [online] 2011 Jan-Feb, 59(1):59-65 [viewed 10 May 2014] Available from: doi:10.4103/0028-3886.76860
  3. KAMYAR M, VARNER M. Epilepsy in pregnancy. Clin Obstet Gynecol [online] 2013 Jun, 56(2):330-41 [viewed 10 May 2014] Available from: doi:10.1097/GRF.0b013e31828f2436
  4. NULMAN I, LASLO D, KOREN G. Treatment of epilepsy in pregnancy. Drugs [online] 1999 Apr, 57(4):535-44 [viewed 10 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10235691
  5. HARDEN CL. Pregnancy and epilepsy. Continuum (Minneap Minn) [online] 2014 Feb, 20(1 Neurology of Pregnancy):60-79 [viewed 11 May 2014] Available from: doi:10.1212/01.CON.0000443837.95260.af
  6. SABERS A, DAM M, A-ROGVI-HANSEN B, BOAS J, SIDENIUS P, LAUE FRIIS M, ALVING J, DAHL M, ANKERHUS J, MOURITZEN DAM A. Epilepsy and pregnancy: lamotrigine as main drug used. Acta Neurol Scand [online] 2004 Jan, 109(1):9-13 [viewed 10 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/14653845
  7. BARDY AH. Incidence of seizures during pregnancy, labor and puerperium in epileptic women: a prospective study. Acta Neurol Scand [online] 1987 May, 75(5):356-60 [viewed 14 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/3618113
  8. CRAWFORD P. Best practice guidelines for the management of women with epilepsy. Epilepsia [online] 2005:117-24 [viewed 10 May 2014] Available from: doi:10.1111/j.1528-1167.2005.00323.x