Guidelines on epilepsy management in
pregnancy
Epilepsy
is a common condition affecting many women in the reproductive age group. It is
estimated that about 1 million women with epilepsy in the United States are in
their reproductive years. Increased fetal and maternal risks in such patients
are well established. It is with this in mind that the American Academy of
Neurology (AAN) and the American Epilepsy Society (AES) published Practice
Parameter Updates on the pregnant woman with epilepsy in 2009. Following are
guidelines taken from that report.
The effect of antiepileptic drugs (AED)
The
general worldwide incidence of major structural and genetic birth anomalies is
estimated to be about 3% of births. Epileptic women taking AED during the first
trimester have registered a higher incidence of such defects. This becomes
quite apparent when we compare these women to those epileptics not on
medication, and when we consider the effects of AED on organogenesis. Valproic
acid (VPA) is shown to have a higher risk amongst the AED, with polytherapy
also increasing the risk compared to monotherapy.
It
is recommended that VPA be avoided especially during the first trimester, preferably
preconception, if not altogether during pregnancy. Patients desiring pregnancy
need to be changed to alternate therapy such as lamotrigine (LTG) or
levatiracetam (LVT), which happen to be 2 of the most studied AED in pregnancy.
Increased
surveillance involving detailed ultrasound scans and possibly amniocentesis are
essential for these patients.
The role of Folic acid (folate)
Higher
dose folic acid (about 5mg) is known to prevent neural tube defects in
pregnancy, if taken at least 3 months preconceptually. Certain AED such as
carbamazepine, phenytoin and even LTG lower folic acid levels and may increase
the risk of neural tube defects. Although no exact evidence exists regarding
the correct dosage in pregnancy, 5 mg/d of folic acid supplementation for women
with epilepsy of childbearing age for 3 months prior to conception and for at least
10- to 12-weeks postconception is now the standard recommendation.
The first convulsion in pregnancy
Firstly,
any convulsive event in pregnancy must be confirmed as such rather than loss of
consciousness or a shaking event. Differential diagnoses include metabolic
alterations and medications in the first trimester, low blood pressure and
syncope in the second, and eclampsia and stroke being of more dire consequence
in the third trimester and postpartum period. Mass lesions and infections can
occur throughout pregnancy.
Adequate
inpatient investigation includes laboratory tests, lumbar puncture,
electroencephalogram (EEG) and magnetic resonance imaging (MRI) of the brain.
Once
an unprovoked seizure is established, appropriate first line therapy should include
enough sleep and carbamazepine or LVT depending on the seizure type. Although
LTG is relatively safe, therapeutic levels are hard to achieve when started in
pregnancy.
The dose of medication during pregnancy
Almost
all AED levels drop during pregnancy due to increased renal clearance and
hepatic elimination, but return to baseline within a few weeks of delivery.
Thus, most medications require a slight dose increase once pregnancy is confirmed.
LTG especially undergoes a marked drop in serum levels. Monitoring of the
levels of AED should be considered.
Delivery and Postpartum
Women
with well-controlled epilepsy or those seizure-free for 1 year prior to
pregnancy have very little risk of a fit around the time of delivery and in the
immediate postpartum period. The highest risk is with those patients with
active epilepsy.
The
patient should be on regular medication throughout the peripartum period and
adequate rest has been shown to be beneficial. Tramadol, which is known to
provoke seizures, should be avoided to further decrease the risk of an
epileptic fit.
Since
AED levels gradually increase back to normal postpartum, it is recommended that
they be closely monitored during this period, especially in the case of LTG due
to the aforementioned reason.
References
- 1. Harden CL, Hopp J, Ting TY, et al. American Academy of Neurology; American Epilepsy Society. Practice parameter update: management issues for women with epilepsy—focus on pregnancy (an evidence-based review): obstetrical complications and change in seizure frequency: report of the Quality Standards Subcommittee and Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology and American Epilepsy Society. Neurology 2009;73(2).
- 2. Cunnington MC, Weil JG, Messenheimer JA et al. Final results from 18 years of the International Lamotrigine Pregnancy Registry. Neurology 2011;76(21):1817–1823
- 3. Tomson T, Battino D. Teratogenic effects of antiepileptic medications. Neurol Clin 2009;27(4):993–1002.
- 4. De Wals P, Tairou F, Van Allen MI, et al. Reduction in neural-tube defects after folic acid fortification in Canada. N Engl J Med 2007;357(2):135–142.
- 5. Committee on Educational Bulletins of the American College of Obstetricians and Gynecologists. ACOG educational bulletin. Seizure disorders in pregnancy. Int J Gynaecol Obstet 1997;56(3):279-286.
- 6. EURAP Study Group. Seizure control and treatment in pregnancy: observations from the EURAP epilepsy pregnancy registry. Neurology 2006;66(3):354-360.
- 7. Meador KJ, Baker GA, Browning N, et al; NEAD Study Group. Effects of breastfeeding in children of women taking antiepileptic drugs. Neurology 2010;75(22):1954–1960.
Antimicrobial Prophylaxis for Cesarean Delivery
Antimicrobial prophylaxis for caesarean delivery has been a general practice for caesarean deliveries because it significantly reduces postoperative maternal infectious morbidity (1). These antibiotics have been administered intraoperatively after umbilical cord clamping for two theoretic concerns related to the fetus: 1) antibiotics in neonatal serum may mask newborn positive bacterial culture results; and 2) fetal antibiotic exposure could lead to an increase in newborn colonization or infection with antibiotic-resistant organisms. Surgical research data support antimicrobial prophylaxis administration, ideally within 30 minutes and certainly within 2 hours of the time of skin incision, to prevent surgical site infection (2). The infusion should be timed so that a bactericidal serum level is established by the time of skin incision, and to maintain therapeutic levels throughout the operation (3). For longer surgical procedures, readministration of the drug is indicated at intervals of one or two times the half-life of the drug (using the same dose) (4). Narrow spectrum antibiotics that are effective against gram-positive bacteria, gram-negative bacteria, and some anaerobic bacteria, such as a first-generation cephalosporin, are mainly used for prophylaxis for caesarean delivery. A larger dose may be indicated if a woman is obese. For women with a significant allergy to β-lactam antibiotics, such as cephalosporins and penicillins, clindamycin with gentamicin is a reasonable alternative. Preoperative administration significantly reduces endometritis and total maternal infectious morbidity compared with administration of antibiotics after umbilical cord clamping (5). These data further suggest that preoperative antimicrobial prophylaxis for caesarean delivery is not associated with an increase in neonatal infectious morbidity or the selection of antimicrobial resistant bacteria causing neonatal sepsis. The Committee on Obstetric Practice recommends antimicrobial prophylaxis for all cesarean deliveries unless the patient is already receiving appropriate antibiotics (eg, for chorioamnionitis) and that prophylaxis should be administered within 60 minutes of the start of the caesarean delivery. (6) When this is not possible (eg, need for emergent delivery), prophylaxis should be administered as soon as possible.
References
1. Smaill FM, Gyte GM. Antibiotic prophylaxis versus no prophylaxis for preventing infection after cesarean section. Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.: CD007482. DOI: 10.1002/14651858.CD007482.pub2.
2. Classen DC, Evans RS, Pestotnik SL, Horn SD, Menlove RL, Burke JP. The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. N Engl J Med 1992;326:281–6.
3. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1999;20:250-78; quiz 279–80.
4. Page CP, Bohnen JM, Fletcher JR, McManus AT, Solomkin JS, Wittmann DH. Antimicrobial prophylaxis for surgical wounds. Guidelines for clinical care [published erratum appears in Arch Surg 1993;128:410]. Arch Surg 1993;128:79–88.
5. Costantine MM, Rahman M, Ghulmiyah L, Byers BD, Longo M, Wen T, et al. Timing of perioperative antibiotics for cesarean delivery: a metaanalysis. Am J Obstet Gynecol 2008;199:301.
6. Antimicrobial Prophylaxis for Cesarean Delivery: Timing of Administration. The Committee on Obstetric Practice of the American College of Obstetricians and Gynecologists. Obstet Gynecol. 2010;116:791-792.
LATEST UPDATES ON OSTEOPOROSIS SCREENING
Previous recommendations for osteoporosis screening were based on indirect evidence mostly obtained from studies of women. In 2002, on the basis of results of a previous review, the US Preventive Services Task Force (USPSTF) recommended bone density screening for women 65 years or older and women aged 60 to 64 years at increased risk for osteoporotic fractures. They made no recommendations for or against screening postmenopausal women younger than 60 years or women aged 60 to 64 years without increased risk.
These recommendations have now been reviewed to evaluate the efficacy and harms of osteoporosis screening in decreasing fractures for men and for postmenopausal women with no previous history of fractures, the ability of risk assessment instruments and bone measurement tests to diagnose osteoporosis, optimal screening intervals, and effectiveness and harms of medications to reduce primary fractures. This was done by searching the Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews through the fourth quarter of 2009, MEDLINE from January 2001 to December 2009, bibliographies of retrieved articles, and Web of Science.
Inclusion criteria were English-language publications of randomized controlled trials of screening or medications with fracture outcomes, performance studies of validated risk-assessment instruments, and systematic reviews and population-based studies of tests for bone measurement or of harms from medication. Using established criteria, the reviewers rated and abstracted data on patient populations, study design, analysis, and follow-up. This review of studies published from January 2001 to December 2009 regarding osteoporosis screening found no trials of screening.
There were 14 risk-assessment instruments identified, which modestly predicted low bone density (area under the curve [AUC], 0.13 - 0.87), and 11 that modestly predicted fractures (AUC, 0.48 - 0.89). Performance of simple and complex instruments was not significantly different.
Highlights of the study are:
Dual energy x-ray absorptiometry appeared to be similarly effective in predicting the risk for fracture among women and men. Although calcaneal quantitative ultrasonography can predict fractures, it has only fair correlation with the results of dual-energy x-ray absorptiometry. A large trial of women addressed the issue of the screening interval for multiple studies for osteoporosis. A second measurement of bone mineral density up to 8 years after an initial study did not add to the risk ratio estimates for fracture. Multiple medications were demonstrated to reduce the risk for vertebral fractures among women with osteoporosis. These medications, and their associated relative risks for vertebral fracture, are:
o Bisphosphonates: 0.66
o Parathyroid hormone: 0.32
o Raloxifene: 0.61
o Estrogen: 0.62
There was less evidence that these treatments improved the risk for nonvertebral fractures. When results for bisphosphonates were analyzed using alternative pooling methods, this class of medications was significantly associated with a lower risk for nonvertebral fracture. Only parathyroid hormone has been tested as primary prevention for fracture among men with low bone density. It was associated with a trend toward a lower incidence of fracture in one study. Bisphosphonates are generally free of serious adverse events when used as directed. Raloxifene and estrogen increase the risk for thromboembolic events, and estrogen, with or without progestin, has also been associated with a higher risk for cardiovascular events. A lack of trial data limits the knowledge regarding the potential adverse events of parathyroid hormone and calcitonin.
Clinical Implications
In 2002, the USPSTF recommended routine screening for bone mineral density among women at age 65 years or older or among high-risk women between the ages of 60 and 64 years. There were no recommendations made regarding screening among women younger than 60 years or among men. The current update from the USPSTF concludes that although there are effective means to screen for osteoporosis and prevent fractures, there remains no direct evidence to evaluate the potential benefits and harms of primary screening for osteoporosis.
Guidelines for Diagnosis and Classification of Hyperglycemia in Pregnancy
March 1, 2010 — The International Association of Diabetes and Pregnancy Study Groups (IADPSG) has issued recommendations on the diagnosis and classification of hyperglycemia in pregnancy. The new guidelines for gestational diabetes mellitus (GDM) are published in the March issue of Diabetes Care.
The effects of overt diabetes on pregnant women and their fetuses have been well documented. What was poorly understood was the effect of less severe degrees of hyperglycaemia on adverse outcomes. The HAPO [Hyperglycemia and Adverse Pregnancy Outcome] study was designed to clarify risks of adverse outcome associated with degrees of maternal glucose intolerance less severe than those with overt diabetes during pregnancy. Continuous graded relationships with increasing maternal hyperglycaemia were studied for primary outcomes of birth weight greater than the 90th percentile, caesarean delivery, neonatal hypoglycemia, and cord C-peptide (as a proxy for fetal insulin) greater than the 90th percentile.
This study, for the first time, conclusively identified strong continuous associations of maternal glucose levels below those diagnostic of diabetes with several perinatal outcomes.
The significant associations between adverse outcomes and higher levels of maternal glucose within what is at present considered a nondiabetic range indicated the need to reconsider current criteria for diagnosing and treating hyperglycemia during pregnancy.
As a result of the extensive efforts used to standardize procedures for participant enrolment, laboratory analyses, data collection and analysis of results, HAPO data have been used as the basis for the new GDM diagnostic thresholds recommendations by the IADPSG.
Recommendations for Hyperglycemia in Pregnancy
Specific recommendations for identifying and diagnosing hyperglycaemic disorders in pregnancy include the following:
· 1st antenatal visit - all or only high-risk women should undergo testing of
§ fasting plasma glucose (FPG),
§ hemoglobin A1c,
§ or random plasma glucose
o Thresholds for diagnosis of overt diabetes during pregnancy are
§ FPG ≥ 7.0 mmol/L (126 mg/dL);
§ hemoglobin A1c ≥ 6.5% (Diabetes Control and Complications Trial/UK Prospective Diabetes Study standardized);
§ or random plasma glucose ≥ 11.1 mmol/L (200 mg/dL), plus confirmation
§ If this testing result indicates overt diabetes, treatment and follow-up should be the same as for preexisting diabetes
o GDM should be diagnosed if FPG is 5.1 mmol/L (92 mg/dL) - 7.0 mmol/L (126 mg/dL),
o If FPG is ≤ 5.1 mmol/L (92 mg/dL), the patient should be tested for GDM from 24 - 28 weeks of gestation with a 75-g oral glucose tolerance test (OGTT)
· At 24 - 28 weeks of gestation, a 2-hour, 75-g OGTT should be performed after overnight fast on all women not previously found to have overt diabetes or GDM during testing earlier in this pregnancy
o Overt diabetes is diagnosed if FPG is ≥ 7.0 mmol/L (126 mg/dL)
o GDM is diagnosed if 1 or more values ≥
§ FPG of 5.1 mmol/L (92 mg/dL),
§ 1-hour plasma glucose level of 10.0 mmol/L (180 mg/dL),
§ and/or a 2-hour plasma glucose level of 8.5 mmol/L (153 mg/dL)
o Normal test results are defined as all values on OGTT less than these thresholds.
· The panel concluded that insufficient studies have been done to determine whether there is a benefit of generalized testing to diagnose and treat GDM before the usual window of 24 to 28 weeks of gestation.
· All women diagnosed with GDM or overt diabetes during pregnancy should undergo postpartum glucose testing
Guidelines for Oral Presentations
Hanifullah Khan
Women’s Health and Endometriosis Care Centre Lumut, Malaysia
ABSTRACT
Most people attend a conference in order to listen to learn something. A good quality presentation goes a long way towards enhancing the conference experience and take home message. On this score, it is the responsibility of every presenter to give as well as they can. Issues at hand that need to be addressed in order to give a good presentation include proper research and preparation, employing effective visual aids, maintaining a professional conduct during the talk and being familiar with the audience, equipment and site. Knowledge of the assessment procedure also allows for more effective communication and preparedness. It is the responsibility of a presenter and the right of the audience to experience a good quality presentation.
Keywords – oral presentation; guidelines
Introduction
Attending a conference nowadays is an expensive hobby. A conference can be used for many purposes such as a means of networking, for sight-seeing, for meeting people and for renewing acquaintances. But to most people, conferences serve as a means of gaining and imparting knowledge and stimulating discussion. All this is usually conveyed via the medium of the presentation, which is a brief discussion of a focussed topic delivered to a group of listeners. The ability to give brief and effective presentations is a learned skill that does not come easy and requires lots of practice. Once a decent level is achieved, the presentation becomes an mportant tool for achieving effective communication.
Gone are the days of transparencies and flip charts. In their place is the ubiquitous PowerPoint. We are now so enamoured with our PowerPoint presentations that we sometimes forget the message that we intend to impart. The following is a not too exhaustive description of what makes a good presentation and some guidelines on how to go about preparing one.
Preparation
Preparation is the key to giving an effective presentation. It is wise to know your topic well and adequate research will do you no harm. If this is carried out well, you will realize that you know more than you can hope to impart. Thus it is important to determine your topic and decide what you will cover. Brainstorming and organization not only help boost self-confidence but also order your thoughts, allowing you to compose a good introduction, classify the important elements of your presentation and finish with a strong conclusion.
Know your topic – research adequately Determine what you will cover during your talk – set your goals Organize and brainstorm Compose a good introduction Classify the important elements of your presentation Write an effective conclusion
o Summarize the key points of your presentation
o Summarize how to implement solutions
o Summarize future predictions
Practice
o Practice giving the presentation to yourself
o Speak out loud and time yourself – it is absolutely important that you do not go over the limit
o Practice using your visual aids
o Your goal is to inform, not overwhelm - less can be more
Find out the background of your audience to determine the amount of detail and definition required Nervousness and fear
o Accept nervousness for what it is, part of the preparation for speaking
o It may be a good thing as it heightens your senses
o Everyone feels nervous – a good preparation increases self-confidence
Visual aids such as photos, film clips, graphs, diagrams, and charts enhance the understanding of a topic. Slides serve to save time, increase attentiveness and interest, and increase audience recall of the presented information.
Use simple visual aids where possible Do not overcrowd a slide
o Try to use less than 8 lines of text per slide and less than 8 words per line
o Convey only 1 idea per slide
o In case extensive detail is required, consider providing a handout whilst keeping the slide simple
o Minimize clutter
Tables and graphs
o Restrict content
o There should only be 1 graph per slide
o There should only be 3 lines or bars per graph
o Do not overdo the amount of numbers or figures
Avoid colour clashes in a slide – use complimentary colours Colour may be utilized for emphasis but be moderate Dramatic slide transitions, artistry and sound may be exciting but do not substitute for content and can be distracting Fonts
o Use Times New Roman or Arial
o Size of Titles, Subtitles and body should be 48, 36 and 28 pt respectively
o Maintain uniformity of style, font and size
As a guide, an 8-10 minute talk should use no more than 10 slides Photographs Slides Graphs & charts Sketches Maps Posters Models | Videos Audio Handouts & brochures Audiovisual equipment PowerPoint presentations CD-Roms & iPods |
Conduct during presentation
Having spent so much time and effort preparing for the big day, it is finally time to confront the crowd and perform. This can be an intimidating exercise and many an experienced speaker have fallen flat because they have ignored some basic rules involving public speaking.
Be punctual Dress
o Dress smartly and neatly
o Convey a professional appearance
o Whatever you do, don’t wear a hat
In the beginning
o Begin with a smile and speak in a conversational tone
o Greet your audience
o Maintaining eye contact to all sides of the room - keeps the audience focussed on you and impresses upon them that you are in charge
Voice
o Speak clearly and be audible enough to the back row if no microphone is used
o Do not mumble or speak in a monotone
o Show some enthusiasm
o Do not use repetitive sounds and fillers such as “ah”, “and”, “um”
Posture
o Stand up straight and do not slouch.
o Keep your hands in front of you and do not drape yourself around the podium.
o If possible, move around as it captures the audience’s attention
o Never turn your back on the audience
o Do not walk in front of the projector
o Avoid distractions such as tapping a pencil or playing with the pointer
Begin by telling your audience what your topic is and what you will be covering Never apologize to your audience for any perceived lack of preparation or knowledge as this maintains your authority and confidence with the audience Avoid reading your remarks or speaking to the screen instead of to the audience
o Be so familiar with your visual aids that the only reason you look at them is to point something out.
The closing should be effective.
o Summarize your main points
o Give a strong concluding remark that reinforces why your information is of value
o Encourage questions with your eyes and your body language
Equipment tips
Most conferences employ professionals to manage their audiovisual aids, so this is not really an issue unless you are using your own projector. In this case, it serves to be familiar on the intricacies of using such a device. In this age, online connections and videoconferencing are increasingly being used during presentations. However, you are only as good as your internet connection, as they say, so a lot depends on the service available on site. At the same time, you need to be comfortable and familiar with the lecture room or hall.
Always have a backup copy of your presentation on a disk or flash drive Be careful when using the internet
o Do not expect a network connection to work when you need it
o If you intend to show any web sites keep them as offline copies on a portable media
Know the room
o Visit the room and be familiar with the layout
o Arrive early
o Feel comfortable and visualize yourself presenting in your mind
Handouts
Handouts are not mandatory but may be a good addendum to your presentation. They serve to provide structure to your talk and can be used by the audience as a record of the presentation. They can also provide supplemental material, references and a glossary of terms. A good handout should be attractively laid out with enough space for the listener to take notes.
Information deemed necessary on the handout:
Your name Title of course Date of presentation Title of your presentation Brief abstract (50 word summary of your presentation) A brief outline of your presentation including the major points A bibliography of references used to inform the presentation
The role of the audience
Whilst audiences vary in number and response, most will maintain a professional posture and are usually subservient to the speaker or chairperson. Presentations involve both a speaker and the audience. People in the audience play a role in how well a presentation goes. People in the audience have an obligation to:
Listen politely Make occasional eye contact with speaker Take notes or jot down interesting facts Control negative facial expressions Control bored body language Do not put your head down on the desk or tilt your head back to sleep Control the impulse to constantly check watch Expect a Question & Answer period to be part of the presentation Participate in Question & Answer period, either by listening or by posing a question. Prepare to remain attentive throughout the Q&A Remain seated until the speaker is finished
Evaluation
Most presentations undergo some type of evaluation and there is usually a prize at the end of a conference. It may be wise to know the evaluation criteria used in order to come across more effectively. Though the ultimate goal of any presentation is not to just win a prize, keeping this criteria in mind allows you to prepare your presentation better and measure your effectiveness. The following is a set of evaluation criteria (D'Arcy, 1998) that are commonly used.
A. Organization and Development of Content
Opening statement gained immediate attention? Purpose of presentation made clear? Previewed contents of speech? Main ideas stated clearly and logically? Organizational pattern easy to follow? Main points explained or proved by supporting points? Variety of supporting points (testimony, statistics, etc.) Conclusion adequately summed up main points, purpose?
B. Delivery
Presenter - owned the space, and was in control? Held rapport with audience throughout speech? Eye contact to everyone in audience? Strong posture and meaningful gestures?
C. Visuals
Visuals clear and visible to entire audience? Creative and emphasized main points? Presenter handled unobtrusively and focused on audience?
D. Voice
Volume Rate (pacing) Pitch Quality Energetic and included everyone in dialogue?
E. Comments
Conclusion
Everyone aspires to give as good a presentation as possible. Though we may be technical or professional whizz-kids, we are usually not trained in the art of public speaking. The guidelines provided above will go a long way towards improving one’s self-confidence and ability to impart knowledge to a gathering using the medium of multimedia. Remember, the audience has a right to expect quality presentations from speakers.
Reference
1. D'Arcy, Jan. 1998. Technically speaking: a guide for communicating complex information. Columbus: Battelle Press, p. 160.
Disclosure
Nothing to disclose
Which Antiepileptic Drug Is Safest in Pregnancy?
The need for antiepileptic drug treatment should be reassessed in all women with epilepsy who are considering pregnancy. Women may have epilepsy that is sufficiently controlled (ie, they have been seizure-free for several years) to warrant a trial off medication before conception.
1. The first priority is to select the right drug for the particular seizure type. In terms of efficacy, valproic acid and lamotrigine should be considered for women with idiopathic (primary) generalized epilepsy. The other antiepileptic drugs are appropriate for women with localization-related (partial) seizures.
2. Tolerability is the next consideration. Patients are unlikely to take a drug that makes them miserable.
3. Fetal effects. Current evidence suggests that women taking valproate in the first trimester run the highest risk for congenital malformations, an effect that is probably dose-related.[1] Furthermore, children who are exposed to valproate prenatally had impaired fluency and originality compared with children who were exposed to carbamazepine and lamotrigine.[2] Phenytoin and phenobarbital should also be avoided to prevent adverse cognitive outcomes.[1]
4. With respect to teratogenesis, monotherapy is safer than polytherapy. Consequently, if a woman with well-controlled seizures is taking 3 drugs, consider a trial of 2 drugs. If she is taking 2 drugs, try 1. As always, the lowest effective dose should be prescribed. These interventions are best implemented before pregnancy in case seizures recur, which could be harmful to the fetus.
5. It is important to monitor antiepileptic drug levels at regular intervals because dosage adjustment may be required as a result of the altered pharmacokinetics of pregnancy. This is particularly true with lamotrigine, levetiracetam, and oxcarbazepine.[3]
6. Although the newer antiepileptic drugs may appear safer with respect to teratogenicity, this perception is influenced by a relative lack of data.
Recommendations in Brief
Make sure the patient really needs antiepileptic treatment
Choose the drug that controls the seizures and is well tolerated (but avoid valproate).
Use as few drugs as possible at the lowest effective dose.
Monitor drug levels during pregnancy.
Conclusions
To date, no antiepileptic drug has proven safe in pregnancy in terms of teratogenesis. Treatment must be individualized for all patients.
References
Harden CL, Meador KJ, Pennell PB, et al. Practice parameter update: management issues for women with epilepsy-focus on pregnancy (an evidence-based review): teratogenesis and perinatal outcomes. Neurology. 2009;73:133-141.Abstract
McVearry KM, Gaillard WD, VanMeter J, Meador KJ. A prospective study of cognitive fluency and originality in children exposed in utero to carbamazepine, lamotrigine, or valproate monotherapy. Epilepsy Behav. 2009;16:609-616. Abstract
Patsalos PN, Berry DJ, Bourgeois BFD, et al. Antiepileptic drugs-best practice guidelines for therapeutic drug monitoring: a position paper by the subcommission on therapeutic drug monitoring, ILAE Commission on Therapeutic Strategies. Epilepsia. 2008;49:1239-1276.
Edited from an article by Andrew A. Wilner, MD published on Medscape 19 April 2010.
