Greater Manchester and Eastern Cheshire SCN Epilepsy in Pregnancy Guideline - FINAL v1.0 October 2019 - NHS England
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Greater Manchester and
Eastern Cheshire SCN
Epilepsy in Pregnancy
Guideline
FINAL v1.0
October 2019
GMEC Epilepsy in pregnancy guideline Final v1.0 October 2019 Issue Date October 2019 Version 1.0
Version Final Review Date October 2021 Page Page 1 of 15Document Control
Document title: GMEC Management of Epilepsy in Pregnancy Guideline
Ownership
Role Department Contact
Project Clinical Lead GMEC SCN Sarah.vause@mft.nhs.uk
Document author Mandira Hazra on behalf of mandira.hazra@nhs.net
the NW Maternal Medicine
Network Group
Project Manager GMEC SCN Sarah.west20@nhs.net
Version control
New Development commenced by Greater Manchester 05/06/18
and Eastern Cheshire Maternal Medicine Group
V0.1 Draft version circulated to Clinical Leads and 21/02/19
Heads of Midwifery across GM&EC
V0.2 Comments considered and amendments made by 04/04/19
MH. Revised version shared with Clinical Leads
and Heads of Midwifery for comments
V0.3 Comments considered by author and further 09/05/19
revisions made.
V0.4 Final revisions made and prepared for ratification 09/09/19
Signed off by Greater Manchester and Eastern Cheshire Maternity
Ratification process
Steering Group
Date of Ratification: 18/10/2019
Circulation 29/10/2019
Review Date: October 2021
Review
Responsibility of: GMEC SCN
Acknowledgements
On behalf of the Greater Manchester and Eastern Cheshire and Strategic Clinical
Networks, I would like to take this opportunity to thank the contributors for their
enthusiasm, motivation and dedication in the development of this Management of
Epilepsy in Pregnancy Guideline.
I would also like to acknowledge and thank the members of the Maternal Medicine Group
for their passion for the subject and their commitment throughout its development.
Dr Sarah Vause
Consultant in Fetal and Maternal Medicine
Chair of the Greater Manchester & Eastern Cheshire SCN Maternal Medicine Group
GMEC Epilepsy in pregnancy guideline Final v1.0 October 2019 Issue Date October 2019 Version 1.0
Version Final Review Date October 2021 Page Page 2 of 15Contents
1. Background ...................................................................................................... 4
1.1... Generic note............................................................................................... 4
2. Preconception .................................................................................................. 5
2.1... Information to mothers ............................................................................... 5
3. Antenatal ........................................................................................................... 6
3.1... Information giving ....................................................................................... 6
3.2... Monitoring of AED ...................................................................................... 7
3.3... Fetal monitoring ......................................................................................... 8
4. Labour ............................................................................................................... 8
5. Status Epilepticus (SE) .................................................................................... 9
6. Postnatal ......................................................................................................... 10
6.1... Maternal ................................................................................................... 10
6.2... Neonatal ................................................................................................... 10
7. Contraception ................................................................................................. 10
7.1... Lamotrigine .............................................................................................. 11
7.2... Non-enzyme inducing AEDs .................................................................... 11
7.3... Enzyme-inducing AEDs ........................................................................... 11
7.4... Emergency contraception and enzyme-inducing AEDs ........................... 12
7.5... WWE with long-term DMPA ..................................................................... 12
Appendix 1 Recommended methods of contraception in WWE taking AEDs .. 13
Appendix 2 (Clinical presentation of seizures, amended from NECN) .............. 14
References .............................................................................................................. 15
GMEC Epilepsy in pregnancy guideline Final v1.0 October 2019 Issue Date October 2019 Version 1.0
Version Final Review Date October 2021 Page Page 3 of 151. Background
Epilepsy is one of the commonest neurological conditions to affect pregnant women
and affects 1 in 200 (0.5 to 1%) women. This guideline uses the term “Women With
Epilepsy” or WWE throughout the document to refer to these women. Women with a
history of epilepsy who are not considered to have a high risk of unprovoked
seizures (fit-free for 12 months) can be managed as low-risk women in pregnancy at
district hospitals. High risk women with difficulty in controlling of seizure
refractory to anti-epileptic drugs (AED) should be referred for prompt review by
either their usual neurologist or epilepsy nurse specialist (ESN) or to a joint
obstetric-neurology clinic. This includes women with high risk of teratogenicity of
AEDs and who are inadequately medicated in pregnancy with risk of sudden
unexpected death in epilepsy (SUDEP). A detailed list of women needing referral
can be found at Epilepsies: diagnosis and management NICE guideline (CG137,
1.10.2) https://www.nice.org.uk/guidance/cg137/chapter/1-Guidance#referral-for-
complex-or-refractory-epilepsy
The aim of this guideline is to provide evidence on the optimum management of
women with epilepsy in managing their fertility and pregnancy including risks of anti-
epileptic drugs (AED), changes to AED and plans for delivery and contraceptive
options in women on AEDs.
1.1 Generic note
Most women with epilepsy who are receiving optimal treatment for their
epilepsy have uncomplicated pregnancies. The diagnosis of epilepsy and
epileptiform seizures like psychogenic non-epileptiform seizures (PNES) or
pseudo-seizures should be made by a medical practitioner with expertise in
epilepsy, usually a neurologist.
There are a number of health‐related issues associated with the diagnosis of
epilepsy and the use of AEDs in women of child‐bearing age.
1.1.1 Generic preconception advice
• Both the disease and its treatment may alter the menstrual cycle and fertility.
• Problems with drug interactions - hormonal contraception are less effective
depending on type of AEDS. WWE well controlled with enzyme inducing
AEDs (see later) can use Copper intrauterine devices (IUDs) or the
levonorgestrel-releasing intrauterine system (LNG-IUS).
• Effective contraception avoids risks of AEDs on fetus in unplanned
pregnancy
• WWE on AEDs should be offered 5 mg/day of folic acid at least 3 months
prior to conception and to continue the intake until at least the end of the first
trimester to reduce the incidence of major congenital neural tube defect and
may be helpful in reducing the risk of AED-related cognitive deficits.
GMEC Epilepsy in pregnancy guideline Final v1.0 October 2019 Issue Date October 2019 Version 1.0
Version Final Review Date October 2021 Page Page 4 of 151.1.2 Generic antenatal advice
• Some AEDs (dependent on type, number and dose) are associated with
teratogenic effects.
• Uncontrolled seizures can cause adverse effects during pregnancy
• Pregnancy can hormonally induce alteration of the seizure threshold.
• Decisions around choice and dose of AEDs are based on the risk to the
fetus and control of seizures.
• WWE and their partners, as appropriate, should be given accurate
information and counselling about pregnancy, caring for children and
breastfeeding. This should be given tailored to their individual needs and
should be given, as needed, to people who are closely involved with women
and girls with epilepsy. These may include her family and/or carers. A
patient information leaflet can be obtained from the following link
(https://www.rcog.org.uk/en/patients/patient-leaflets/epilepsy-in-pregnancy/)
• WWE should be reassured that most mothers have normal healthy babies
and the risk of congenital malformations is low if they are not exposed to
AEDs in the peri-conception period.
2. Preconception
2.1 Information to mothers
• Women with epilepsy who are considering pregnancy should discuss their
medication with their neurologist and/or epilepsy specialist nurse (ESN) where
available
• Consider referral of high risk WWE who are considering pregnancy for further
preconception counselling to either a joint obstetric medicine clinic at the
tertiary referral centre for the trust or to the neurologist.
• The lowest effective dose of the most appropriate AED should be used.
• Valproate is contraindicated in women of childbearing potential unless
the conditions of “prevent” (valproate pregnancy prevention
programme) are fulfilled (www.medicines.org.uk , enter “valproate” and click
on “Risk Materials”; or search online for “MHRA valproate”) or look for
https://www.gov.uk/guidance/valproate-use-by-women-and-girls
• AED poly-therapy should be minimised by changing the medication prior to
conception
GMEC Epilepsy in pregnancy guideline Final v1.0 October 2019 Issue Date October 2019 Version 1.0
Version Final Review Date October 2021 Page Page 5 of 152.2 Risk of epilepsy for the baby
• Genetic counselling should be considered if one partner has idiopathic
epilepsy and a positive family history of epilepsy
• For idiopathic generalized epilepsy, the risk to the child developing epilepsy is
5–20% if one first degree relative is affected and over 25% if two first degree
relatives are affected.
• The risk is 3% if one parent had cryptogenic (focal) seizures
3. Antenatal
3.1 Information giving
• WWE should be registered with the UK Epilepsy and Pregnancy Register
(www.epilepsyandpregnancy.co.uk)
• Verbal and written information (https://www.rcog.org.uk/en/patients/patient-
leaflets/epilepsy-in-pregnancy/) to be given at prenatal screening about AEDs
and its implications, the risks of self-discontinuation of AEDs and the effects
of seizures and AEDs on the fetus and on the pregnancy and breastfeeding.
• In utero exposure to sodium valproate may have adverse effect on
psychomotor or neurodevelopment in addition to increased risk of congenital
malformations.
• Based on limited evidence, in utero exposure to carbamazepine and
lamotrigine does not appear to adversely affect neurodevelopment of the
offspring.
• There is very little evidence on long-term outcomes on neurodevelopment of
the child for in utero-exposure to levetiracetam and phenytoin
• WWE should receive the same brand of AED and not a generic substitution
while in hospital. Please consult the unit pharmacist if the brand is
unavailable or for safe alternatives as per MHRA 2013 look at
https://www.epilepsy.org.uk/news/news/mhra-new-guidance-switching-meds-
63630
• The clinician should discuss with WWE the relative benefits and risks of
adjusting medication to enable her to make an informed decision. Where
appropriate, the neurologist should be consulted
• The possibility of status epilepticus and SUDEP should be discussed with
WWE.
• There is no evidence that focal, absence and myoclonic seizures affect the
pregnancy or developing fetus adversely, unless WWE falls and/or sustains
an injury
• The risk of a tonic–clonic seizure during the labour and the 24 hours after
birth is low (1−4%) and 2/3rd will not have seizure deterioration in pregnancy
and early puerperium
GMEC Epilepsy in pregnancy guideline Final v1.0 October 2019 Issue Date October 2019 Version 1.0
Version Final Review Date October 2021 Page Page 6 of 15• Delivery should take place in an obstetric unit with facilities for maternal and
neonatal resuscitation and treating maternal seizures.
• Provide a copy of the “Tips for looking after an infant when you have
epilepsy”. https://www.epilepsy.org.uk/info/caring-children and discuss the
epilepsy action checklist with the
kithttps://www.womenwithepilepsy.co.uk/pregnancy-toolkit/ including post-
partum safety advise on seizure deterioration and AED intake
3.2 Monitoring of AED
• WWE who have experienced seizures in the year prior to conception require
close monitoring for their epilepsy.
• WWE taking AEDs who become unexpectedly pregnant should be advised to
continue their AEDs and should be to contact their own neurologist, epilepsy
specialist nurse (ESN) or be seen in the local special interest AN clinic for
review of their medication.
• WWE who have had tonic-clonic seizures in the last 3 months, should be
seen in the next earliest available clinic by few weeks
• WWE should be under the care of a consultant obstetrician, neurologist /
medical-obstetric clinic and/or epilepsy specialist midwife/ nurse ( where
available) for regular follow-up
• Ensure compliance with routine antenatal care, including dating and anomaly
scans at 18-20 weeks in line with the NHS Fetal Anomaly Screening
Programme (FASP).
• Aim for seizure freedom during pregnancy but consider the risk of adverse
effects of AEDs and use the lowest effective dose of each AED, avoiding
polytherapy if possible.
• There is no clear-cut relationship between serum levels of AEDs and seizure
control in non-pregnant and pregnant women with epilepsy therefore
monitoring of serum AED levels in pregnancy is not routinely recommended.
• If seizures increase or are likely to increase, monitoring AED levels
(particularly levels of lamotrigine and phenytoin, which are particularly
affected in pregnancy) are useful for making dose adjustments.
• Indications for monitoring of AED blood levels are:
o Detection of non-adherence to the prescribed medication
o Suspected toxicity
o Adjustment of phenytoin dose
o Management of pharmacokinetic interactions (for example, changes in
bioavailability, changes in elimination, and co-medication with
interacting drugs)
o Specific clinical conditions, for example, status epilepticus and organ
failure
• Healthcare professionals should be alert to signs of depression, anxiety and
any neuropsychiatric symptoms in mothers exposed to AEDs.
GMEC Epilepsy in pregnancy guideline Final v1.0 October 2019 Issue Date October 2019 Version 1.0
Version Final Review Date October 2021 Page Page 7 of 15• WWE should be regularly assessed for the following: risk factors for seizures,
such as sleep deprivation and stress; adherence to AEDs; and seizure type
and frequency.
• WWE at reasonable risk of seizures should be accommodated in an
environment that allows for continuous observation by a care provider or
partner when in hospital.
• There is insufficient evidence to recommend giving vitamin K to WWE to
prevent postpartum haemorrhage.
3.3 Fetal monitoring
• WWE on AED need serial growth scans for detection of small-for-gestational-
age babies
• There is no role for routine antepartum fetal surveillance with
cardiotocography
• Epilepsy is rarely an indication for induction of labour or caesarean section
unless tonic-clonic seizures are poorly controlled while there is no known
contraindications to use of any induction agents in WWE taking AEDs if
needed for other obstetric reasons
• WWE taking enzyme-inducing AEDs who are at risk of preterm delivery can
be given antenatal corticosteroid dose for prophylaxis against respiratory
distress syndrome in line with pre-term labour guideline
• There is insufficient evidence to recommend routine maternal use of oral
vitamin K to prevent haemorrhagic disease of the new-born in WWE taking
enzyme-inducing AEDs.
4. Labour
• Risk of seizures in labour is low
• Delivery should be at consultant obstetrician led unit, homebirth not
recommended
• IV access should be obtained at the onset of labour if required for other
obstetric indication
• AED intake should be continued during labour. Use parenteral route if needed
• In individual cases if labour is thought to be likely to precipitate a major
seizure, the care plan may include use of clobazam 10-20mg orally 12 hourly
to reduce the risk
• Adequate analgesia and appropriate care in labour should be provided to
minimise risk factors for seizures such as insomnia, stress and dehydration.
• TENS machines, epidurals and spinals are suitable for use in WWE.
Anaesthetists involved in the woman’s care should be informed about her
epilepsy and AEDs prior to anaesthesia
GMEC Epilepsy in pregnancy guideline Final v1.0 October 2019 Issue Date October 2019 Version 1.0
Version Final Review Date October 2021 Page Page 8 of 15• The decision to use water birth should be made on an individual basis. WWE
who are not taking AEDs and who have been seizure free for a significant
period may be offered a water birth after discussion with their epilepsy
specialist.
• Pethidine is known to decrease seizure threshold and should be
avoided, diamorphine can be used as an alternative.
• If a seizure occurs, maternal airway and oxygenation should be maintained
• Seizures during labour should be treated with intravenous lorazepam (0.1
mg/kg (usually a 4 mg bolus, with a further dose after 10−20 minutes) is
preferred. Alternately, Diazepam 5–10 mg administered slowly intravenously
at 2mg/min. If no intravenous access, Diazepam (10-20mg rectal gel repeated
once 15 minutes later if there is a continued risk of status epilepticus.
• If there is doubt whether a seizure if due to epilepsy or eclampsia, then in
addition to intravenous diazepam, the trust guideline on eclampsia should
also be followed
• Continuous fetal monitoring is recommended in women at high risk of a
seizure in labour, and following an intrapartum seizure
5. Status Epilepticus (SE)
• SE is defined as convulsive seizures lasting 5 minutes or more, two or more
sequential seizures without full recovery of consciousness between seizures
or three or more seizures in an hour.
• Call for help (Labour ward Co-ordinator, ST5 or equivalent grade on-call
obstetrician, Anaesthetist, and Operating Department Assistant. Ensure the
Consultant Obstetrician on call is aware. Contact the General Medicine middle
grade on-call for on-going support and advice.
• Assess respiratory and cardiac function using the maternal/obstetric early
warning score (MOEWS)
• Secure the airway
• Aseptically insert a 16g Venflon if not already done so.
• Give Lorazepam or Diazepam as in chapter 4
• If seizures are not controlled, consider administration of phenytoin or
fosphenytoin. The loading dose of phenytoin is 10–15 mg/kg by intravenous
infusion, with the usual dosage for an adult of about 1000 mg (
https://www.nice.org.uk/guidance/cg137) https://www.sps.nhs.uk/articles/how-
can-we-minimise-the-risks-to-patients-when-using-intravenous-phenytoin-in-
status-epilepticus-se/
• Give usual AED medication if already on treatment.
• Once seizure control is secured commence cardiotocography (CTG)
monitoring of the fetus if suspected or known to be above local gestation
threshold
•
GMEC Epilepsy in pregnancy guideline Final v1.0 October 2019 Issue Date October 2019 Version 1.0
Version Final Review Date October 2021 Page Page 9 of 156. Postnatal
6.1 Maternal
• Do not nurse in a single room
• Postnatal WWE at reasonable risk of seizures should be accommodated in
single rooms only when there is provision for continuous observation by a
carer or partner or nursing staff.
• Although the overall chance of seizures during and immediately after delivery
is low, it is relatively higher than during pregnancy. Mothers should be well
supported in the postnatal period to ensure that triggers of seizure
deterioration such as sleep deprivation, stress and pain are minimised.
• Any woman who had a seizure 1 month prior to pregnancy or during labour
should be observed closely for the next 72 hours.
• Any increase in drugs during pregnancy will need to be decreased to pre
pregnancy levels over the next 3-4 weeks to avoid toxicity.
• Ensure the same brand of AED is provided at discharge and advice from
pharmacist is taken for changing brand as mentioned above
6.2 Neonatal
• All babies born to WWE taking enzyme-inducing AEDs should be offered 1
mg of intramuscular vitamin K to prevent haemorrhagic disease of the
newborn
• Babies of WWE on phenobarbitone often experience withdrawal; they are
jittery and irritable and should be monitored for fits.
• Leaflet: “Tips for looking after a baby or young child when you have epilepsy”;
Epilepsy action ( https://www.epilepsy.org.uk/info/caring-children) can be
provided
• WWE who are taking AEDs in pregnancy should be encouraged to
breastfeed, as based on current evidence; the risk of adverse cognitive
outcomes is not increased in children exposed to AEDs through breast milk.
Prescribers should consult individual drug advice in the SPC and the BNF
(available at http://bnf.org) when prescribing AEDs to breastfeeding women.
The SPC (www.medicines.org.uk ) and Lactmed (available at
https://toxnet.nlm.nih.gov/newtoxnet/lactmed.htm for relevant information.
7. Contraception
• WWE should be offered effective contraception to avoid unplanned
pregnancies. The risks of contraceptive failure and the short- and long-term
adverse effects of each contraceptive method should be carefully explained to
the woman. Useful advice can be found at this link
https://www.gov.uk/guidance/valproate-use-by-women-and-girls
GMEC Epilepsy in pregnancy guideline Final v1.0 October 2019 Issue Date October 2019 Version 1.0
Version Final Review Date October 2021 Page Page 10 of 15• Copper intrauterine devices (IUDs), the levonorgestrel-releasing intrauterine
system (LNG-IUS) and Depo-medroxyprogesterone acetate injections
(DMPA) should be promoted as reliable long-acting reversible contraceptive
(LARC) methods that are not affected by enzyme-inducing AEDs.
• True contraceptive failures have been reported with the progesterone-only
implant and if women choose this method consistent use of condoms is
recommended.
• WWE taking enzyme-inducing AEDs who choose to take the combined oral
contraceptive pill, guidance about dosage should be sought from the faculty of
reproductive and sexual health (FRSH) and current edition of the BNF
(available at http://bnf.org.
• The use of additional barrier methods should be discussed with enzyme-
inducing AEDs and oral contraception or DMPA.
7.1 Lamotrigine
• For women taking lamotrigine, COC (combined oral contraceptives) are not
recommended; progesterone only methods (FSRH has added caution as
progesterone can increase AED level), the copper coil and LNG-IUS are
recommended.
• WWE taking lamotrigine with simultaneous use of any oestrogen-based
contraceptive can result in a significant reduction of lamotrigine levels and
lead to loss of seizure control.
• When WWE stops taking these contraceptives, the dose of lamotrigine may
need to be adjusted.
7.2 Non-enzyme inducing AEDs
• All methods of contraception may be offered to women taking non-enzyme-
inducing AEDs (e.g. sodium valproate, levetiracetam, gabapentin, vigabatrin,
tiagabine, zonisamide, gabapentin and pregabalin).
7.3 Enzyme-inducing AEDs
• Women taking enzyme-inducing AEDs (carbamazepine, phenytoin,
phenobarbital, primidone, oxcarbazepine, topiramate and eslicarbazepine)
should be counselled about the risk of failure with some hormonal
contraceptives (COC, progestogen-only pills), transdermal patches, vaginal
ring and progestogen-only implants.
• WWE who wish to have COC as hormonal contraception, a minimum of 50
(30 micrograms +20 micrograms) micrograms of ethnyloestradiol (EE) pill
should be used during treatment with enzyme inducing AEDs and for a further
28 days with a continuous or tricycling regimen plus pill-free interval of 4 days.
Breakthrough bleeding may indicate low serum EE concentrations. Exclude
GMEC Epilepsy in pregnancy guideline Final v1.0 October 2019 Issue Date October 2019 Version 1.0
Version Final Review Date October 2021 Page Page 11 of 15other causes (e.g. chlamydia) and dose of EE can exceptionally be increased
up to a maximum of 70 μg EE after specialist advice from sexual health.
• Use of two patches or two rings is not recommended
7.4 Emergency contraception and enzyme-inducing AEDs
• WWE taking enzyme-inducing AEDs should be informed that a copper IUD is
the preferred choice for emergency contraception. Emergency contraception
pills with levonorgestrel and ulipristal acetate are affected by enzyme-inducing
AEDs.
7.5 WWE with long-term DMPA
• Long-term treatment with carbamazepine, phenytoin, and primidone and
sodium valproate is associated with loss of bone mineral density (BMD) and
fracture. Whether concomitant use of DMPA leads to further loss of BMD or
increases the risk of fracture is unclear.
• Women with developmental disabilities may be poor candidates for DMPA.
Other women should be informed about the potential effect of both drugs, and
strategies to minimise BMD loss. Refer to the SPC and BNF (available at
http://www.bnf.org) for individual drug advice on the interactions between
AEDs and hormonal replacement and contraception.
GMEC Epilepsy in pregnancy guideline Final v1.0 October 2019 Issue Date October 2019 Version 1.0
Version Final Review Date October 2021 Page Page 12 of 15Appendix 1 Recommended methods of contraception in WWE taking
AEDs
Recommended methods of contraception in WWE taking AEDs (Clinical Guidance:
Drug Interactions with Hormonal Contraception,2017; UKMEC,2017)
UK Medical Eligibility Criteria (UKMEC):
UKMEC 1 – no restriction for the use of contraceptive method
UKMEC 2 – advantages of using the contraceptive method generally outweighs the
risks of the condition
UKMEC 3 – theoretical or proven risks generally outweigh the advantages of using
the method of contraception
UKMEC 4 – unacceptable health risk if used
AEDs CO POP Progesteron Progesterone LNG-
C e only only IUS
implant injectable And
Coppe
r IUD
Enzyme inducing 3 3 2 Depo-Provera 1
AEDs: carbamazepine, — 1
topiramate, Norethisterone
oxcarbazepine, Enanthate
— 2
phenytoin,
phenobarbitone,
primidone
Non-enzyme 1 1 1 1 1
inducing AEDs:
Benzodiazepines,
ethosuxamide,
gabapentin,
lacosamide,
Levetiracetam,
valproate, tiagabine,
vigabatrin, zonisamide
Lamotrigine (Non-enzyme 3 1 1 1 1
inducing AED)
GMEC Epilepsy in pregnancy guideline Final v1.0 October 2019 Issue Date October 2019 Version 1.0
Version Final Review Date October 2021 Page Page 13 of 15Appendix 2 (Clinical presentation of seizures, amended from NECN)
Clinical presentation of seizures and their effect on the mother and baby
Common types of Presentation Effects on mother and
seizures baby
Tonic-clonic seizures Dramatic events with Sudden loss of
stiffening, then bilateral consciousness,
jerking and a post- uncontrolled fall, without
seizure state of warning. Associated with
confusion and variable period of fetal
sleepiness. hypoxia. Highest risk of
SUDEP.
Focal seizures Symptoms are variable Impairment of
depending, depending consciousness increases
on risk of injury (fracture,
Areas of the brain injury, burns). Can have
affected. The attacks are “epileptic aura” while
remaining conscious.
recognisable and Can be associated with
stereotypical on a typical a variable period of
individual. hypoxia and risk of
May impair SUDEP.
consciousness.
Juvenile myoclonic epilepsy Myoclonic jerks (sudden Occurs more frequently
(JME) unpredictable after sleep deprivation,
movements) often tiredness and soon after
precede a generalised awakening. Sudden
tonic-clonic convulsion. jerky movements may
lead to falls or to
dropping
of objects including the
baby.
Absence seizures Generalised seizures Effects mediated through
that consist of brief blank brief loss of awareness
spells associated with of surroundings (like a
unresponsiveness, burning flame).
followed by rapid Worsening absence
recovery. seizures places the
women at high risk of
tonic-clonic seizures
GMEC Epilepsy in pregnancy guideline Final v1.0 October 2019 Issue Date October 2019 Version 1.0
Version Final Review Date October 2021 Page Page 14 of 15References
• Epilepsy in Pregnancy, Green-top Guideline No. 68, June, 2016. Royal
College of Obstetricians and Gynaecologists (RCOG);
https://www.rcog.org.uk/globalassets/documents/guidelines/green-top-
guidelines/gtg68_epilepsy.pdf
• Pregnancy and Contraception in Women with Epilepsy; ECHNHST; Dr V Hall,
Updated by Dr M Hazra; February 2018; Version 4.0
• NICE clinical guideline 137: Epilepsies: the diagnosis and management of the
epilepsies in adults and children in primary and secondary care;
2012;https://www.nice.org.uk/guidance/cg137
• The Faculty of the Sexual & Reproductive Healthcare of the RCOG;
www.rcog.org.uk; https://www.fsrh.org/home/ukmec
• Faculty of Sexual and Reproductive Healthcare. Drug Interactions with
Hormonal Contraception. 2012.
https://www.fsrh.org/pdfs/CEUGuidanceDrugInteractionsHormonal.pdf
• Wilby, J. et al (2005). Clinical effectiveness, tolerability and cost-effectiveness
of newer drugs for epilepsy in adults: a systematic review and economic
evaluation, Health Technology Assessment 2005; Vol. 9: No. 15
• Common antiepileptic drugs in pregnancy in women with epilepsy. Cochrane
Database of Systematic Reviews 2004, Issue 3
https://www.cochrane.org/CD004848/EPILEPSY_common-antiepileptic-
drugs-pregnancy-women-epilepsy
• Epilepsy in Pregnancy, Northern England Clinical Networks,
NECN/Maternity/Epilepsy/001; England.northernmaternity@nhs.net
GMEC Epilepsy in pregnancy guideline Final v1.0 October 2019 Issue Date October 2019 Version 1.0
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