Epilepsy is one of the most common neurological diseases in women of reproductive age. It is a truth that there may appear specific complaints in women with epilepsy during pregnancy, but despite this, the vast majority of women gives a birth to normal children, and the pregnancy has a little effect on the course of epilepsy. Thus, the paper explores the problem of epilepsy in our society and discusses all the components which make the topic as actual as it is nowadays. This research paper demonstrates several types of medications used in the course of treatment, explains their possible risks and benefits, proves the necessity of planning and argues possibility of nursing interventions.
The problem of pregnancy in women with epilepsy is multifaceted and actual nowadays, while its actuality greatly increases in connection with the democratization of the society, the availability of information (computer technology), the introduction of new antiepileptic drugs which significantly improves the quality of life of many patients, the development and provision of modern medical equipment that allows to monitor a set of objective indicators of pregnancy in non-invasive way. Every of the above numerated components leads to the fact that an increasing number of women with epilepsy seeks to have children. According to Mazzoni (2006), scientific observations indicate a 4-fold increase in the number of pregnancies and births to women with epilepsy in the past decade in comparison to 80s of twentieth century. Thus, we are going to discuss epilepsy in pregnancy, paying a specific attention to the definition of the concept, the medications used, the risk and benefits of the medications, the nursing interventions and planning.
First of all, it is necessary to define the term of epilepsy for the purpose to understand the topic better. Epilepsy is a chronic neurological disorder characterized by the emergence of local (partial) and generalized epileptic seizures. Treatment of epilepsy involves long-term (as often as not) use of antiepileptic drugs. The debut of epilepsy during pregnancy is a manifestation of symptoms of existing cerebral lesions. It can be associated not only with brain tumors, but also with cardiovascular disorders, connective tissue diseases, cerebral aneurysms, cavernous hemangioma, and arteriovenous malformations.
Thinking about possible risks which epilepsy can have in pregnancy, we need to mention that epileptic seizures should be distinguished from symptomatic seizures that conditioned by other nerve diseases (encephalitis, concussion, brain tumors, etc.), as well as seizures of eclampsia. An important point in the diagnosis is the presence of epileptic seizures in anamnesis. It is a well-proven fact that childbirth often occurs prematurely and runs quickly in patients with epilepsy. In connection with the disease it can be also important to speed up the second stage of childbirth by the use of forceps or perineotomy. Thus, both the epilepsy by itself and a treatment that carried out to fix the problem present the risk to pregnancy. Moreover, a significant impairment of blood circulation in the placenta is observed during generalized epileptic seizures, and therefore, the risk of having a child with a variety of developmental defects significantly increases in women suffering from frequent generalized epileptic seizures during pregnancy.
Epilepsy and antiepileptic treatment can significantly complicate the pregnancy, but in spite of this, most women with epilepsy have a chance to give a birth to healthy children safely. It is extremely important to implement a proper planning of pregnancy and treatment of epilepsy for women with epilepsy because many variations of treatment taken to stop and prevent further epileptic seizures can also have a detrimental effect on the child's development. Sometimes, high doses of antiepileptic drugs and combinations of several drugs are especially dangerous for the fetus. But good news is present in the fact that according to Chillemi (2005), the risk of transmission of hereditary epilepsy to a child usually does not exceed 10%.
Thinking about the question of epilepsy in pregnancy from historical perspective, we can mention that some years ago, women who had epilepsy were often discouraged from getting pregnant. Nowadays, however, it does not take a place to be. According to the Epilepsy Foundation research on this case, thanks to early and regular prenatal care, more than 90 percent of pregnant women with the epilepsy diagnosis, give birth to healthy babies. Having epilepsy should not prevent a woman from planning a family, but planning ahead is important. Recent reviews of the literature, outlined in the AAN Updated Practice Parameter Statements on Pregnancy in Women with Epilepsy , is very encouraging in the statement that the risks can now be minimized, especially by considering recent findings of differential risks between medications.
With many other problems, which can be caused by epilepsy, a wrong use of medications can also affect pregnancy as well. Women who have this disease face a higher risk of pregnancy-related complications. These complications can, but not certainly, include severe morning sickness, premature separation of the placenta from the uterus, which is called placental abruption, anemia, failure to progress during labor and delivery, premature birth of the baby or a low birth weight, babies with congenital inherent anomalies, preeclampsia, which basically shows itself as a high blood pressure and excess protein in the urine after 20 weeks of pregnancy, vaginal bleeding during and after pregnancy. The development of the sickness can sometimes change during the pregnancy. It can be different to every other woman, due to personal different reactions on the pregnancy. For most of the women, who suffer from epilepsy, seizures can remain the same as before the baby. For some part of them, seizures can even become less frequent. Others, who particularly suffer from the poorly controlled sickness, will have to overcome the increasing number of the seizures during their pregnancy. Mothers should remember that seizures can be dangerous. But in the same way it does not mean that mothers who have seizures during pregnancy can not give a birth to healthy babies. It is only the question of everyday control. They need to report their care provider about this issue. This way, women can be provided with a special treatment, medications that can guarantee a prevention of other seizures in some way. According to The EURAP Study Group (2006), in a prospective international study of 1736 pregnancies, about 60% of women remained seizure free throughout pregnancy. The information given by The EURAP Study Group (2006) also mentioned that childbirth and all the period of pregnancy carry an increased risk because about 2-5% of women with epilepsy having the most hard seizures at these times.
According to the analysis of seizure control and treatment in pregnant women with epilepsy, which was made by The EURAP Study Group in Stockholm, Sweden, the majority of women with epilepsy preserved seizure control during their pregnancy. Women treated with the oxcarbazepine appeared to have higher risk of the seizures. Moreover, with the use of oxcarbazepine and lamotrigine the frequency of the seizures is even higher. In such a way, a variety of the above presented facts confirms that young women with the epilepsy are in the need of special care and counseling.
Being more specific and discussing the planning of pregnancy for women with epilepsy, we can said that patients can discuss all the problems during this period with their own doctor or seek assistance at the certain centers for pregnant women, which are dealing with these questions directly. It is important to remember that a sooner visit to the doctor gives better result than constant waiting of possible epileptic seizures and doing nothing in relate to the existing problem. Young mothers have to observe these problems in the right way before they contemplate their future pregnancy, and it should be made for the purpose to be out of the list exposed to higher risk later. Of course, on the one hand, there could be mentioned a certain list of problems, which have to be brought up during the consultation, but on the other hand, it will give a great opportunity to do everything in the right way and to protect the own health and the health of the future child from possible complication which can happen during pregnancy to a future mother.
There could be also mentioned the presence of the risk of inheriting epilepsy, which is low in the most types of it; possibility and necessity of increasing the drug doses in the cases of seizures to maintain adequate seizure control; but in this situation it is always very important to find the most normal balance between fetal and maternal risk. In this case tonic-clonic seizures have to be avoided, because they carry out a lot of risk to the mother and her baby.
The next important question to discuss is the fetal risk, which is connected to the antiepileptic drugs which can be used during the pregnancy period. It should be noticed that those drugs can slightly increase the probability of occurrence of the malformations. Some of the researches underline the unwelcome use of the Valproate. It is highly recommended to avoid it in cases when there can be used other kinds of drugs which can provide satisfactory epileptic seizure control. It is also highly recommended to refer to the ultrasonography. To explain the necessity of ultrasonography, it can be said that such test can detect most neural tube defects and almost all major anomalies. During the pregnancy, as it was above mentioned, woman should also discuss the principles of the drug treatment of her sickness with a group of competent specialists. According to Gabbe et al (2012), drugs should be given at the lowest effective dosage in essential compliance with the prescribed treatment. Women, who are taking antiepileptic drugs, are often recommended to take up to 5 mg/day of folate from the first days of impregnation to the end of the first trimester.
Chillemi (2005) stated that there are some medical advises of treating the epilepsy for women who are already pregnant. It is not necessary to change or withdraw the usage of antiepileptic drugs. It is not justified every single time if the seizures are well controlled. Normal treatment and care should be increased. The frequency of visits to the own doctor or clinical visits is highly recommended to do timely; drug should be set in order with a big impotency in patients who have tonic-clonic seizures during pregnancy period. The most important thing to notice is that the neurological and obstetric risks are low in the cases of adequate treatment.
Moreover, it is extremely important to define what kind of medications to choose during the pregnancy. Patients should remember that any medication they take during pregnancy period can effect on their baby in some way. Drugs can cause some birth defects such as cleft palate, neural tube defects, skeletal abnormalities, and congenital heart and urinary tract defects. It is not clear estimated whether usage of the drugs can cause other problems which can be caused by seizure treatment and may include birth defects, affecting children's appearance. This can easily be wide set eyes or short upper lip. All these consequences are the main concern with the patients taking seizure medications.
According to Hill et al (2010), the risk of the birth defects for those babies, whose mothers take seizure treatment, is 4% to 8%. By taking more that one seizure medicine the risk can be increased, particularly with high doses. But it does not mean that mothers have to refuse from the treatment at all because uncontrolled seizures might sometimes deprive the baby of receiving the oxygen or increase the risk of stillbirth and miscarriage without medicine. In some cases, it is possible for women to decrease the usage of medications during the pregnancy period, but it does not work in all the cases. Sometimes it is obliged to continue treatment to minimize the risk for the health of the mother and hew baby. Patients have to keep in mind that one kind of medicine can not work in the best way for every single mother. There is a great possibility of epileptic seizures after birth due to the high level of concentration of seizure medications in blood. To avoid such an effect, mothers should consult with their doctors about the necessity of the dosage change.
Basing on the recent researchers, it is considered that there exist four most commonly used drugs (the speech is going about the period of pregnancy) for those women who have epilepsy. They are carbamazepine (Tegretol or Carbatrol), phenytoin (Dilantin or Phenytek), valproate (Depakote or Depakene), and lamotrigine (Lamictal). In addition to these names, there also exist several genetic versions of them. Describing the drugs, we need to state that carbamazepine has been used for quite a long time. It is one of the most used medicines for pregnant women with the epilepsy, because it is considered to be the safest antiepileptic drug in pregnancy. The chance of abnormality during taking this drug is very low. Complications can include neural tube defects, which is 1% risk, hypospadias.
To continue, we are going to dwell with all the possible details on the treatment with the use of phenytoin because it is the oldest of these kinds of drugs. It has been in use more than 70 years. In 1938 this drug was invented as a treatment of partial and generalized tonic-clonic seizures. It had no sedative effects, which helped the drug to become one of the most commonly used drugs for the treatment of epileptic seizures. The normal dosage of this drug is 300 mg daily. The dose can be given orally or intravenously. It is better to use the drug in intravenous way during convulsion, with the dosage of 10 to 15 mg/kg. A very important detail is hidden in the fact that it also should be given slowly for the purpose not to exceed 50 mg/min. This way of the drug's use helps to decrease the risk of hypotension and cardiac arrhythmia. Drug absorption occurs very little in the stomach, and it happens due to an acidic medium and poor soluble in the water. Phenytoin is basically bound to albumin in a part of intestine. Patients who have renal failure have to use the drug under careful control of the doctor. It is very important due to the affect of this condition; the drug consecration should be changed.
According to Pandey & Gupta (2012), "phenytoin is eliminated primarily by hepatic metabolism and is excreted in urine. Doses of phenytoin must be carefully adjusted. The ability of the liver to metabolize the drug tends to reach maximum capacity close to the therapeutic level. At therapeutic levels, phenytoin is safe, with relatively few adverse effects. If more drugs is given than it is needed, the maximal capacity for phenytoin metabolism can be approached, causing plasma levels to increase dramatically, resulting in toxic effects such as ataxia, nausea, vomiting, hypotension, motor restlessness, dizziness, and fatigue. Deep coma may also result". Of course, there is the certain time at which women can metabolize the drug. It is extremely important in attaining a state level of phenytoin. The life of phenytoin can be different among patients. Usually it is from 8 to 64 hours. Every month women during pregnancy period have to take therapeutic drug monitoring. When there are some cases of more often seizures, this monitoring can be taken more than every 2 months. It is necessary to monitor after delivery period, the level of phenytoin in blood. Very often it can be increased, which can lead to toxic effects. Explaining the necessity of monitoring in the case, we can state that just a careful monitoring can prevent bad outcomes by adjusting the dosage as needed. There are some general effects of this drug being explored in medical purposes. It can include dysmorphic changes such as acne and hirsutism. They can occur in the brow, nose, lips and other facial parts. Another common adverse effect is gingival hyperplasia. It is the dose-related effect that often begins within the first 3 months of therapy. By its progressing it can last through the whole year. It commonly appears within more than 45% of people who take this kind of medicine. There is an understandable need for frequent oral care and regular dental checkups.
As all drugs, taken during pregnancy, phenytoin has its effects on the fetus and newborn infant. The maternal seizures are the biggest risk for the fetus. For instance, the so called apnea can cause transient hypoxia and acidosis in the baby. Pandey & Gupta (2012) said that "the neonates have an increased risk for stillbirths, congenital malformations, hemorrhagic disease, and hypocalcemia". The long-term cognitive function of children of pregnant women who take antiepileptic drugs is also in a concern.
For a great regret, the number of congenital malformations can be increased in pregnancy due to the maternal epilepsy. This occurs than the frequency of the seizures is uncontrolled during the first trimester of pregnancy. By the time of the third trimester often epileptic seizures can cause the hypoxic episodes. Fetal malformations occur in about 10% of pregnant women with epilepsy. According to Gabbe et al (2012), "there is little doubt that anticonvulsant medications are associated with an increase in congenital malformations, but the magnitude of this risk and the association of certain anomalies with specific drugs remain debatable." Women who take the anticonvulsant medications are imperilment to have neural tube defects. Phenytoin can also cause a decreased folate concentration in plasma. It can happen when the phenytoin is taken in the same time with the absence of folic acid supplements. The best way in this case, is to start taking the folic acid supplements before the pregnancy and to continue taking of folic acid during the pregnancy till the end of the first trimester. This way of the drugs taking allows to reduce the risk of the neural tube defects.
In addition, taking phenytoin can also cause the hemorrhagic disease of the newborn. Patients have to take does of phenytoin early to reduce bleeding tendencies in the newborn. Immediately after birth (usually within 24 hours) child should receive another injection, otherwise the newborn is in the risk for vitamin K deficiency and hemorrhage. The hemorrhage can appear on the skin, liver, gastrointestinal tract, intracranial sites, and thorax. In 25% of the cases intracranial hemorrhage can take its place. Mazzoni (2006) emphasized on the fact that 40% of the infants who have intracranial hemorrhage die. This is the main reason why the infants should be under good monitoring of bleeding signs. Usage of the phenytoin can also cause neonatal hypocalcemia. This drug contains vitamin D. Decreased level of it in the maternal system can cause its low level in fetus.
Thinking about additional possible risks of medications use, we need to stress that it can lead to the increasing risk for the neonatal hypocalcemia. Another outcome of the usage of this drug is its influence on the intellectual intelligence, and can cause the defection of cognitive function. Infants, whose mothers take antiepileptic medications, are observed to have smaller head size.
However, despite all the possible bad after-effect of taking phenytoin, it is considered to be a very good working drug for pregnant women, who have epilepsy. It is important to follow some guidelines to prevent the bad causes. Counseling about the risk of treatment of epilepsy by this drug should be provided before pregnancy. Also there can be taken an attempt to withdraw antiepileptic drugs from those women who have no epileptic seizures during past two years. Many physicians believe that it is important to make attempts, where it is possible, to use only one antiepileptic drug for the purpose to minimize the risk of the neural tube defects in a case when women take a folic acid supplement. The dose of the medications should be strictly defined by the doctor. To minimize the risk of neonatal hypocalcemia, pregnant women have to take a cholecalciferol supplement, which is vitamin D. There should be present oral care and regular dental checkups. Regular fetal ultrasound examinations to monitor fetal growth and detect malformations should be scheduled as well. Thus, phenytoin is recommended to all newborns in the frames of the above mentioned information.
Women should be taught that even without taking antiepileptic medicine they are still under the higher risk of delivering an infant with congenital malformation and cognitive impairment. But it is also important, and moreover, should be explained to these patients that more than 90% of the babies born by women who have epilepsy are born without any of those malformations or other major problems nowadays. It is long estimated that the risk for the infant of taking antiepileptic medicine is much less than in cases where epileptic seizures activity and frequency is uncontrolled.
Exploring other drugs, we need to demonstrate the necessity of valproate use. Mazzoni (2006) mentioned that "valproate is the sodium salt of valproic acid, and it is an anticonvulsant used in the treatment of epilepsy". Researches estimate that the risk of birth defects from mothers who used valproate is in five times higher that any other antiepileptic drugs, and this can be rated to 11%. Also it was proved that those children have lower IQ. The level of IQ of those children was eight points lower than of those, whose mothers took others antiepileptic drugs.
Doctors highly recommend to go to another kind of drug which as well prevents seizures during the period of pregnancy. If the woman is still taking valproate during pregnancy period, she is highly recommended to lower its doses. Valproate was also estimated to cause a specific facial change, which even has its specific name as "fetal valproate syndrome". Moreover, Hill (2010) found that the level of autism before birth was 8.9% in children, whose mothers took valproate during their pregnancy, while the normal frequency of autism is estimated to happen less than in 1 % of born children.
Lamotrigine is used to treat epileptic seizures of partial and generalized epilepsy syndromes. It is also one of the few medications to be approved by the FDA for Lennox-Gastaut syndrome. According to Pennell et al (2008), women treated with lamotrigine had a risk of malformations of 2 % compared to 6.7% in women treated with valproate. It is estimated that about 50% of lamotrigine passes through breast milk in the mother's blood, however it is not known how much of the drug's mass actually enters the child's bloodstream. In such a way, taking into account a low research of the drug, the ways how lamotrigine affects the baby is unknown as well. Despite the fact that antiepileptic drugs enters into breast milk, breast-feeding is encouraged. In most cases, breast-feeding is safe, as the child has been exposed to antiepileptic drugs during pregnancy, and the absolute amount of drug is small in milk. Strategies such as receiving antiepileptic drugs immediately after a feed are designed to minimize the amount of drug while nursing. Breastfeeding is generally safe and recommended in view of its high value for the child.
Observing nursing interventions, specificity of childbirth and postpartum in women with epilepsy, it is important to remember that pregnancy in women with epilepsy may be resolved by natural childbirth with stable epilepsy, good control of the disease by prescribed medicines and lack of abnormalities in the development of the fetus. Cesarean section in women with epilepsy is applicable only in the case of increased frequency of epileptic seizures at the end of pregnancy or some problems in intrauterine fetal condition. Moreover, it is also necessary not to neglect the process of planning because the role of the neurologist in the planning of pregnancy in women with epilepsy is hard to overestimate. Neurologist should help a woman who wants to become pregnant to achieve a stable remission of epilepsy. By the way, the role of gynecologists in the planning of pregnancy in women with epilepsy is reduced to the correction of the menstrual cycle, which is often seen in women with epilepsy and can prevent conception and monitoring of the development of the fetus. In addition, all women with epilepsy should consult a geneticist relative risk of having a child with epilepsy.
In conclusion, epilepsy, of course, complicates the planning of pregnancy and its flow, but at the same time, the chances of having a healthy baby are great enough, especially with the right preparation to the desired event. Taking into a consideration everything of the above said, we have realized that since epilepsy is quite a serious disease of the brain, then its treatment lasts for years. Unfortunately, the process goes not without exacerbations. Therefore, planning a baby, every woman has to choose the best time when the pregnancy and epilepsy are not explicitly contradictory. We have also realized the necessity to use medications in a proper way, and explained the necessity not to interrupt the treatment during the pregnancy by the presence of large seizures, since the risk associated with the occurrence of seizures is greater than the risk of malformations due to the treatment. Thus, epilepsy in pregnancy is an uncommon, but serious problem in modern medicine. Often practical neurologists and gynecologists feel a lack of information regarding this category of patients, and the question needs further discussion and researchers by this reason.
