Managing Epilepsy in Women

Abstract

Purpose of review: Caring for a woman with epilepsy requires familiarity with the implications of antiepileptic drugs (AEDs) for pregnancy and contraception as well as an understanding of the effects of female hormones on epilepsy.

Recent findings: AED pregnancy registries and prospective studies of cognitive development continue to confirm that valproate poses a significantly increased risk of structural and cognitive teratogenesis. In contrast, data thus far suggest that lamotrigine and levetiracetam are associated with a relatively low risk for both anatomic and developmental adverse effects, although further studies are needed for these and other AEDs. The intrauterine device is a good contraceptive option for many women with epilepsy as it is highly effective and not subject to the drug-drug interactions seen between hormonal contraception and many AEDs. Hormonal-sensitive seizures are common among women with epilepsy; however, highly effective treatments for refractory catamenial seizures are limited.

Summary: Women with epilepsy should be counseled early and regularly about reproductive health as it relates to epilepsy. AED selection for women of childbearing age should take future pregnancies and contraceptive needs into consideration.

FIGURE 11-1

Rates of several specific major congenital malformations associated with exposure to monotherapy with antiepileptic drugs. The number of fetuses with specific malformations are shown on top of the bars. The figure is based on combined data from 21 pregnancy registries. Note that the Y axis ranges from 0% to 4%. While it is important to explain the increased relative risks of major congenital malformations with certain drugs, it is also important to explain the difference between relative and absolute risk to patients. Modified with permission from Tomson T, Battino D, Lancet Neurol. www.thelancet.com/journals/laneur/article/PIIS1474-4422(12)70103-5/abstract. ©2012 Elsevier Ltd.

FIGURE 11-2

Distribution of full-scale IQ scores across the control and valproate-exposed groups in Liverpool and Manchester Neurodevelopmental Group (LMNG) prospective study of antiepileptic drug–exposed children at 6 years. Colored dashed lines represent the mean IQ for each group. The adjusted mean IQ score of children exposed to high-dose (more than 800 mg/d) valproate was significantly lower than that of controls (P<.0001), with an adjusted mean reduction of 9.7 points. The adjusted mean IQ score of the children exposed to low-dose (800 mg/d or less) valproate was also lower than that of controls, although the difference was not statistically significant (P=.09). This trend illustrates the dose-dependent effect of valproate on cognitive development. Reprinted with permission from Baker G, et al, Neurology. www.neurology.org/content/84/4/382.short. © 2014 American Academy of Neurology.

FIGURE 11-3

Three patterns of catamenial epilepsy. Day 1 is the first day of menstrual flow and day −14 is the day of ovulation. A, Normal cycle with normal ovulation. C1 pattern is associated with exacerbation of seizures in the perimenstrual phase (day −3 to day +3 of next cycle), and C2 pattern is associated with exacerbation of seizures in the periovulatory phase (day +10 to day −13). B, Inadequate luteal phase cycle typically seen with anovulation. The C3 pattern is associated with exacerbations during the luteal phase (day +10 to day +3 of the next cycle). C = catamenial seizure pattern; F = follicular phase; L = luteal phase; M = perimenstrual phase; O = periovulatory phase. Reprinted with permission from Harden CL, Pennell PB, Lancet Neurol.www.thelancet.com/journals/laneur/artide/PIIS1474-4422(12)70239-9/abstract. ©2013 Elsevier Ltd.