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ORIGINAL ARTICLE
Year : 2021  |  Volume : 48  |  Issue : 1  |  Page : 21-24

Fetomaternal outcome in epilepsy in pregnancy in a tertiary care hospital


Department of Gynae and Obstetrics, SKIMS, Soura, Srinagar, Jammu and Kashmir, India

Date of Submission17-Aug-2020
Date of Acceptance03-Dec-2020
Date of Web Publication5-May-2021

Correspondence Address:
Dr. Shaheera Ajaz
House No. 8 LD Colony Rawalpora, Srinagar - 190 005, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jss.JSS_82_20

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  Abstract 


Introduction: Epilepsy is one of the most common neurological disorders in obstetrics. Pregnancy with epilepsy is associated with increased risk of complications such as preeclampsia, antepartum hemorrhage, stillbirths, neonatal deaths, intrauterine growth restriction (IUGR), and preterm delivery. Aims and Objectives: To study the fetomaternal outcome of pregnancies complicated by epilepsy. Materials and Methods: This was a single center retrospective study conducted over a period of 27 months from March 2017 to June 2019. Maternal variables studied included baseline parameters such as age, parity, and mode of delivery. Other variables studied included duration of epilepsy, seizure during pregnancy, antiepileptic drug usage in pregnancy, and maternal complications. Fetal outcome variables analyzed were number of live birth, stillbirth, birth weight, Apgar score, congenital anomalies, and perinatal complications. Results: Out of 40 patients with epilepsy in pregnancy, 28 were on antiepileptic drugs (AEDs) during the current pregnancy. The cesarean section rate was 65% in these patients which were higher than in patients without epilepsy. Fourteen patients (35%) delivered vaginally out of which ten were induced. There were six patients who had convulsions four had convulsions in the antepartum period and two had convulsions in the postpartum period. Maternal outcome included gestational hypertension in 6 (15%), postpartum hemorrhage in 1 (2.5%), premature rupture of membranes in 2 (5%), hypothyroidism in 2 (5%), and no maternal death. Prematurity was observed in 10%, low birth weight in 22.5%, and IUGR in 15%. All the neonates received 1 mg of Vitamin K at birth liveborn infants were delivered in 36. Conclusion: There was no maternal mortality in our study. The good maternal outcome is because of early booking, regular antenatal visits and regular intake of folic acid, and appropriate number and dose of AEDs. Epilepsy in pregnancy is a high-risk factor which needs thorough evaluation and care from preconception to delivery. These women need delivery at a tertiary care center for the optimum outcome for the perinatal complications.

Keywords: Epilepsy, fetomaternal outcome, pregnancy


How to cite this article:
Khursheed R, Ajaz S, Jeelani B, Wani S, Ahmed A. Fetomaternal outcome in epilepsy in pregnancy in a tertiary care hospital. J Sci Soc 2021;48:21-4

How to cite this URL:
Khursheed R, Ajaz S, Jeelani B, Wani S, Ahmed A. Fetomaternal outcome in epilepsy in pregnancy in a tertiary care hospital. J Sci Soc [serial online] 2021 [cited 2021 Jun 17];48:21-4. Available from: https://www.jscisociety.com/text.asp?2021/48/1/21/315458




  Introduction Top


Epilepsy is one of the most common neurological disorders in obstetrics. The incidence of epilepsy in pregnancy is 0.3%–0.5% of all births.[1] An estimated 2.7 million women in India suffer from epilepsy, with 50% of them being in the reproductive age group.[2] Pregnancy with epilepsy is associated with increased risk of complications such as preeclampsia, antepartum hemorrhage, stillbirths, neonatal deaths, intrauterine growth restriction (IUGR), and preterm delivery. It is also complicated by the teratogenic potential of antiepileptic drugs (AEDs). However, some studies show no significant increase in these complications in pregnancy with epilepsy.[3],[4],[5] Exposure to AED has been associated with two to three times increase in major malformations in infants exposed in utero as compared to the general population. There is a paucity of data regarding fetomaternal outcome in epilepsy in pregnancy from our local population. With this background, we planned our study to analyze the fetomaternal outcome in these patients which in turn would help in improving their outcome.

Aims and objectives

This study aims to study the fetomaternal outcome of pregnancies complicated by epilepsy.


  Materials and Methods Top


This was a single center retrospective study conducted in the Department of Gynaecology and Obstetrics, SKIMS, Soura, J and K over a period of 27 months from March 2017 to June 2019. Maternal variables studied included baseline parameters such as age, parity, and mode of delivery. Other variables studied included were age, parity, duration of epilepsy, seizure during pregnancy, antiepileptic drug usage in pregnancy, and maternal complications. Fetal outcome variables analyzed were number of live birth, stillbirth, birth weight, Apgar score, congenital anomalies, and perinatal complications.


  Results Top


Out of 40 patients with epilepsy in pregnancy, 28 were on AEDs during the current pregnancy. Twelve patients were not on any AEDs as per treating neurologist's advice (these patients were seizure-free for >5 years). Liveborn infants were delivered in 36. There were four fetal losses. One fetus was stillborn, one had term intrauterine death (IUD), two had preterm IUD of the fetus at 28 and 32 weeks. Out of 36 liveborn infants, two had congenital anomaly – one major and one minor. [Table 1] shows the baseline characteristics of epileptic pregnant women in our study.
Table 1: Baseline characteristics of women with seizure disorder in pregnancy

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The dosage and number of AEDs used are correlated to the incidence of congenital malformations and fetal outcome in these women. [Table 2] shows whether the epileptic women were on treatment and the AEDs used. The patient who delivered a baby with multiple congenital malformations (Meningomyelocele and limb defects) was on multiple drug therapy (Phenytoin + Levetiracetam + Sodium valproate).
Table 2: Antiepileptic drug use in pregnancy

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The cesarean section rate was 65% in these patients which were higher than in patients without epilepsy. Fourteen patients (35%) delivered vaginally out of which ten were induced.

[Table 3] shows the fetomaternal outcome in women with epilepsy in pregnancy. There were six patients who had convulsions four had convulsions in the antepartum period and two had convulsions in the postpartum period. One patient who had convulsion in postpartum period had status epilepticus. Maternal outcome included gestational hypertension in 6 (15%), postpartum hemorrhage in 1 (2.5%), premature rupture of membranes in 2 (5%), hypothyroidism in 2 (5%), and no maternal death. Prematurity was observed in 10%, low birth weight in 22.5%, and IUGR in 15%. Out of the four patients who had IUDs, the causes included two deaths because of gestational hypertension, and in two other cases the cause of IUD could not be ascertained, however, they were morphologically normal fetuses. All the neonates received 1 mg of Vitamin K at birth. Thirty-six out of 40 (90%) of these women were on regular folic acid supplementation throughout pregnancy starting from the day of confirmation of pregnancy. The dose was 5 mg OD.
Table 3: Fetomaternal outcome in women with epilepsy in pregnancy

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  Discussion Top


In patients with epilepsy, the majority of cases are uncomplicated, but there is increased risk of adverse obstetrical and neonatal outcomes than the general population.

In our study, all patients (n = 40) were booked in the first or early second trimester. Neurological consultation was sought at the first visit. Seizure disorder in pregnancy is associated with concerns of seizure aggravation because of altered pharmacokinetics and hence changes in the drug levels and AED-associated potential teratogenic effects. Pregnant women with epilepsy had 4%–8% chance of major congenital malformation. Polytherapy has been found to be one of the risk factors for malformations in other studies. In our study, only one patient who was on polytherapy had major congenital malformations. Preconceptional counseling and planning the pregnancy after optimization of drug dosage levels with preferable change from polytherapy to monotherapy can decrease the chances of developing congenital malformation in these patients. The AEDs cause malformation by folate deficiency and free radical generation and risk are further increased in women receiving polytherapy. In our study, 28 patients (70%) were on AEDs. Among these 21 patients (75%) were on monotherapy and 7 (25%) were on combined AEDs. This was comparable to Thomas.[2]

Since our patients were registered in the first or early second trimester, they had better antenatal counseling and earlier neurological consultation. Thirty-six out of 40 (90%) of these women were on regular folic acid supplementation throughout pregnancy. Further, only seven patients (17.5%) were on polytherapy. This might have been the reason for lesser incidence of major congenital malformation in comparison to other studies.

There was no maternal death in our study which is comparable to other studies. In our study, 34 (85%) patients were seizure-free during pregnancy and in the postpartum period. This is comparable to study by Malik et al.[6] and Raji and Sekar.[7] In the present study, the cesarean section rate is 65% which is comparable to Raji and Sekar et al [7]. Eleven cases had maternal complications of pregnancy among which the commonest was gestational hypertension in six patients (15%). These findings were comparable to other studies.[8],[9],[10],[11] Hypothyroidism was present in 2 (5%) patients. AEDs can lead to hypothyroidism and possible mechanisms include hepatic CYP450 enzyme induction by AEDS with consequent accelerated thyroid hormone metabolism, thereby decreasing its serum concentration, interference with hypothalamic-pituitary axis regulation of thyroid hormone production and iodine uptake inhibition by the thyroid gland.

In the present study, among total of forty patients, 36 (90%) had live birth and 4 (10%) had intrauterine fetal death. This was comparable to various other studies. In our study, prematurity was seen in 10% of the patients which was comparable to Raji and Sekar[7] and Nibedita et al.[10] six patients (15%) had intrauterine growth retardation which was comparable to study by SV Thomas et al. Low birth weight because of prematurity and IUGR was seen in 22.5% which was comparable to various studies.[12],[13],[14]

Thus good seizure control, high definition anomaly scan, and mandatory folate supplementation are the prerequisites of antenatal care in pregnancy with epilepsy. Further perinatal complications can be decreased if these patients are followed and delivered in well-equipped tertiary care centers with good coordination between an obstetrician, neurologist, and neonatologist.


  Conclusion Top


There was no maternal mortality in our study. The good maternal outcome is because of early booking, regular antenatal visits and regular intake of folic acid, and appropriate number and dose of AEDs. Epilepsy in pregnancy is a high-risk factor which needs thorough evaluation and care from preconception to delivery. These women need delivery at a tertiary care center for optimum outcome for the perinatal complications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Practice Parameter; Management Issue for Women with Epilepsy (Summary statement)-Report of the Quality Standards Subcommittee of American Academy of Neurology. Neurology 1998;51:944-8.  Back to cited text no. 1
    
2.
Thomas SV. Managing epilepsy in pregnancy. Neurol India 2011;59:59-65.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Yerby M, Kogpsell T, Daling J. Pregnancy complications and outcomes in a cohort of women with epilepsy. Epilepsia 1985;26:631-5.  Back to cited text no. 3
    
4.
Richmond JR, Krishnamoorthy P, Andermann E, Benjamin A. Epilepsy and pregnancy. An obstetric perspective. Am J Obstet Gynecol 2004;190:371-9.  Back to cited text no. 4
    
5.
Sawhney H, Vashishta K, Suri V, Khunnu B, Goel P, Sawhney IM. Pregnancy with epilepsy-a retrospective analysis. Int J Gynecol Obstet 1996;54:17-22.  Back to cited text no. 5
    
6.
Malik R, Kumar V, Chaudhary S, Duhan N. Obstetric and neonatal outcome in women with epilepsy. Int J Reprod Contracept Obstet Gynecol 2017;6:2593-6.  Back to cited text no. 6
    
7.
Raji C, Sekar D. Prospective study of fetomaternal outcome in epilepsy in pregnancy in a tertiary care hospital. Int J Reprod Contracept Obstet Gynecol 2017;6:5055-9.  Back to cited text no. 7
    
8.
Jeyrani P, Indumathi S. Maternal outcome in epilepsy complicating pregnancy. Int J Res Health Sci 2014;2:488-93.  Back to cited text no. 8
    
9.
Goel P, Devi L, Saha PK, Takkar N, Huria A, Dua D. Maternal and perinatal outcome in pregnancy with epilepsy. Internet J Gynecol Obstet 2005;5:478-82.  Back to cited text no. 9
    
10.
Nibedita C, Amitava M, Shyamapada P, Partha M, Dipankar G, Gautam G. Feto-maternal outcome in pregnancy with epilepsy in a tertiary care hospital. J Obstet Gynecol India 2008;58:406-9.  Back to cited text no. 10
    
11.
Tanganelli P, Regesta G. Epilepsy, pregnancy and major birth anomalies; an Italian prospective, controlled study. Neurology 1992;42:89-93.  Back to cited text no. 11
    
12.
Meador KJ, Zupanc ML. Neurodevelopmental outcomes of children born to mothers with epilepsy. Cleve Clin J Med 2004;71:S38-41.  Back to cited text no. 12
    
13.
Yerby MS, Kaplan P, Tran T. Risks and management of pregnancy in women with epilepsy. Cleve Clin J Med 2004;71:S25-37.  Back to cited text no. 13
    
14.
Saleh AM, Abotalib ZM, Al-Ibrahim AA, Al-Sultan SM. Comparison of maternal and fetal outcomes in epileptic and non-epileptic women. Saudi Med J 2008;29:261-6.  Back to cited text no. 14
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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