Delivery, breast feeding and child rearing in women with epilepsy

The occurrence of seizures during delivery is very low and convulsive status epilepticus is rare. Seizure freedom for at least 9 months prior to pregnancy is associated with a high likelihood of remaining seizure-free during pregnancy. Mode of delivery during pregnancy is most often based on obstetrical indications. Recent evidence shows good maternal and fetal outcome for pregnancy in women with epilepsy. Breastfeeding is encouraged for most mothers with epilepsy and is generally safe. There is a large knowledge gap on studies looking into the child rearing knowledge and practice of mothers with epilepsy. Neurology Asia 2013; 18 (Supplement 1) : 31 – 34 Address correspondence to: Leonor I. Cabral-Lim, Department of Neurosciences, College of Medicine-Philippine General Hospital, University of the Philippines, The Health Sciences Center, Manila, Philippines 1000. Tel: (632)5548462; Email: [email protected] SEIZURES DURING DELIVERY AND PREGNANCY On average, 5% women with epilepsy (WWE) have been reported to have seizures during labour, delivery, or the fi rst 24 perinatal hours. In the largest prospective study on seizure control throughout a complete pregnancy of 1,736 pregnant women with epilepsy, seizures occurred during delivery in 3.5%.Of these seizures, 1.6% were cases of single primary or secondary generalized tonic-clonic seizures and only one case (0.06 %) of convulsive status epilepticus. The only signifi cant factor associated with the risk of seizures during delivery was the occurrence of seizures earlier during pregnancy. No particular risk factor was identifi ed for the development of status epilepticus. Recent evidenced-based review from the American Academy of Neurology (AAN) from 1985 to February 2008 do not suggest high rates of seizure increase or status epilepticus during pregnancy or an increased risk of seizure relapse during pregnancy for WWE who are seizure-free. ”Seizure freedom for at least 9 months prior to pregnancy is probably associated with a high likelihood (84%–92%) of remaining seizure-free during pregnancy)”.2 The above data emphasizes the importance of achieving seizure freedom not only prior to pregnancy but also during pregnancy to decrease the chances of seizure recurrence during delivery. MODE OF DELIVERY Epilepsy per se is not an indication for elective caesarean section or induction of labor. Caesarean section is recommended if frequent tonic-clonic seizures or other seizures greatly impair cooperation in the forthcoming labour and delivery, and may be indicated if birth is excessively prolonged particularly in generalized epilepsy where sleep deprivation increases the risk of a seizure. A caesarean delivery may be necessary if a generalised tonic-clonic seizure occurs during labour or in refractory status epilepticus in the third trimester of pregnancy. These are unusual occurrences and most women with epilepsy have normal deliveries.3 MATERNAL AND FETAL OUTCOME The same AAN review also reported no conclusive evidence of an increased risk of many obstetrical complications often discussed as associated with WWE during pregnancy and further stated that this raises the possibility that there is no true difference in the rates of obstetrical complications in WWE compared to the general population. The report states “there is probably no substantially increased risk (greater than two times expected) of cesarean delivery or late pregnancy bleeding, and probably no moderately increased risk (greater than 1.5 times expected) of premature contractions or premature labor and delivery”. Neurology Asia 2013; 18 (Supplement 1) 32 A more recent population-based cohort study from Norway involving 2,805 pregnancies in women with a current or past history of epilepsy confi rms the low complication rate for pregnant women with epilepsy showing a slightly increased risk of induction, caesarean section and postpartum haemorrhage. (OR 1.3, 1.4, 1.2 respectively).5 Neonates of WWE taking antiepileptic drugs (AEDs) probably have an increased risk of being small for gestational age and possibly have an increased risk of a one-minute Apgar scores of < 7.( about 2x the expected rate).6 Lin et al reported that only approximately 14% of the WWE in a cohort of 1,182 women received AED treatment during gestation. They found no signifi cant difference in the risk of low birth weight infants, preterm births and small for gestational age babies between mothers with epilepsy receiving treatment during pregnancy and mothers without epilepsy. The adjusted odds of low birth weight, preterm births and small for gestational age babies for women with epilepsy not on AED treatment during pregnancy were 1.31,1.35 and 1.23 times than that of women without epilepsy.7