Maternal and fetal outcome in epilepsy complicating pregnancy

INTRODUCTION: Epilepsy describes a condition in which a person has recurrent seizures due to chronic underlying process. Epilepsy refers to a clinical phenomenon rather than a single disease entity, since there are many forms and causes of epilepsy. Traditionally, the diagnosis of epilepsy requires the occurrence of at least two unprovoked seizures which are 24 hours apart. Some clinicians diagnose epilepsy when one unprovoked seizure occurs in the setting of an interictal discharge. Seizures are the manifestation of abnormal hypersynchronous discharges of cortical neurons. The signs and symptoms of seizures depend on the cortical location of the epileptic discharges and the propagation pattern of the epileptic discharge in the brain. The causes of epilepsy may primary or secondary. Epilepsy is usually managed by neurologists or general practitioners. Treatment is symptomatic and similar whether the epilepsy is primary or secondary with usage of antiepileptic drug. Epilepsy is not a contraindication to pregnancy. Women with epilepsy can be reassured that having epilepsy should not prevent them from having children. However close medical care is essential and a multidisciplinary approach is recommended. Pregnancies in women with epilepsy are high risk and need careful management by both the medical and obstetric teams due to the increased incidence of complications and adverse outcomes of pregnancy. By the time a pregnant woman with epilepsy presents, the fetus is virtually fully formed and the opportunity for altering drug treatment has passed (Crawford P., 2002). AIM OF THE STUDY: To evaluate the effect of epilepsy on pregnancy regarding the maternal and fetal outcome. • To evaluate the effect of pregnancy on epilepsy regarding the frequency of seizure occurrence. MATERIALS AND METHODS: This prospective study on epilepsy complicating pregnancy was conducted in Government Rajaji hospital (GRH), Madurai from June 2010 to May 2011. Permission from Ethical Committee of the hospital was obtained for research purpose. All consecutive epileptic patients admitted in department of Obstetrics and Gynecology, Government Rajaji Hospital, Madurai, were recruited for this study with fulfillment of following criteria. Inclusion criteria: 1. All pregnant women with history of epilepsy, 2. Both primigravida and multigravida, 3. Both booked and unbooked cases, 4. All type of seizure disorder (GTCS, Partial), 5. Patients on regular or irregular intake of AEDs, 6. Patients on Monotherapy or polytherapy of AEDs, 7. Patients not on AEDs as per neurologist advice, 8. Patients who discontinued AEDs by themselves. Exclusion criteria: 1. Eclamptic patients, 2. Postpartum seizure (including Eclampsia, CVT), 3. Cases of metabolic encephalopathy / drug toxicity, 4. Psychogenic causes. SUMMARY: 75 epileptic women with pregnancy were assessed for maternal and fetal outcome including outcome of seizure frequency. • Mean maternal age was 24.1 years. • 53.3% were primigravida and 46.7% were multigravida. • 77% had epilepsy for more than 10 years. • 98.7% of patients had generalized tonic clonic seizures and 1.3% had partial seizures. • 72 % of patients were on monotherapy and 6.7% of patients were on polytherapy. • 90.7% of patients on antiepileptic drugs had regular intake of folic acid. • 85.3% had term deliveries and 14.7% had preterm deliveries. • 66.7% had normal delivery and 28% underwent caesarean sections for various obstetric indication. •Low birth weight babies (< 2.5 kg) were seen in23.3% of patients. No cases of microcephaly were observed in our study and all babies had normal head circumference. • Incidence of congenital anomalies was almost nil, except for one fetus with congenital diaphragmatic hernia. • None of the patients had any significant obstetric complications. • Seizure frequency was increased in 21.3%. • There was a significant correlation between disease free interval and increase in seizure frequency. Shorter the disease interval higher the incidence of seizure frequency. 76.2 % of cases with disease free interval of less than one year had increased seizure frequency. CONCLUSION: The maternal and fetal outcome was good in our study among the pregnant women with epilepsy, except for few complications like prematurity and low birth weight which has slightly increased. The good maternal and fetal outcome with reduced occurrence of obstetric complications and reduced incidence of congenital anomalies in our study may be due to early booking, regular antenatal care, regular intake of anti epileptic drugs (preferentially monotherapy) and regular intake of folic acid along with antiepileptic drugs, which was found in most of our cases. There is increased frequency of seizures in one fifth of our pregnant epileptic women with statistically significant correlation between the disease free interval and frequency of seizures. Shorter the disease interval higher the incidence of seizure frequency. Increased seizure frequency should be anticipated in patients with shorter disease free interval and may be advised to have regular antiepileptic drug intake and more frequent antenatal visits. There exists no statistically significant correlation between the disease free interval and occurrence of obstetric complications. Pregnant patients with epilepsy has to be considered as high risk pregnancy which need evaluation, specialist opinion and referral to tertiary care centres for better maternal and neonatal outcome. The maternal and fetal complications can be minimized by the close coordination between neurologist, obstetrician and the pediatrician. •