Outcome of pregnancy ın women with epilepsy

Giriş

A comparison of 43 pregnancies in women with epilepsy and 30.945 pregnancies in nonepileptic women showed similar rates of breech presentation, premature birth and low birth weight infant.

Yöntem

 Induction of labor and cesarean section rates were also similar among epileptic and nonepileptic groups. 

Bulgular

The epileptic women were 3.28 times more likely to have pre-eclampsia, and 3.97 times more likely to have uterine bleeding during the third trimester, and congenital malformations were 5.09 times more likely to occur

Sonuç

There were no maternal or perinatal deaths. It is concluded that epileptic women may expect good maternal and fetal outcome with adequate care.

Anahtar Kelimeler

Epilepsi, gebelik komplikasyonları, perinatal komplikasyonlar.

Giriş

During pregnancy and labor, women with epilepsy reportedly have a slight increased risk of bleeding, preeclampsia, prematurity, low birth weight, fetal asphyxia, and perinatal death (l-8).They also appear to have an increased rate of cesarean sections (3). Series with no increase in obstetric complications or interventions in women with epilepsy have also been reported (9,10,11).
We present here the results of a retrospective study on the course and outcome of pregnancies in women with epilepsy.

Yöntem

Thirty-six epileptic women had 43 pregnancies (0.1% of fotal deliveries) of more than 20 weeks' duration and gave birth to 43 infants in the 12-year period from 1977 to 1988. The medical charts of all women who gave birth between these years at the Department of Obstetrics and Gynecology of Hacettepe University Medical School were reviewed retrospectively as well as the charts of the infants delivered in the same period.
Thirty-two but four of the patients were on at least one antiepileptic drug (AED) including phenobarbital, carbamazepine, valproic acid, clonazepam, phenytoin, primidone, or acetazolamide. Occurence of seizures increased in 12 (27.9%), decreased in 10 (23.3%) and remained stable in 21 (48.8%) of the pregnancies. No dose adjustment was made in 31 (72%) of the pregnancies, while dosage of AED was increased or a second drug was added to control seizures in 12 (28%) of the pregnancies.
In order to examine differences between epileptic women and the general parturient population with regard to complications of pregnancy, women with epilepsy were compared with 30,945 pregnancies of nonepileptic women who gave birth in the same period of time. Epilepsy was not considered on indication for induction of labor. During labor and delivery, the epeliptic women were treated according to the general obstetric principles.
Chi square test was used for statistical calculations. Relative risk was calculated for each pregnancy complication.

Bulgular

We studied eleven factors describing the process or outcome of pregnancy and found three to occur with significantly increased frequency for mothers with epilepsy (Table 1). Three of the pregnancy complications occurred among epileptic women as frequently as among the control group, these were low birth weight infant (p=0.95), premature birth (p=0.10), and breech presenation (p=0.91).
Women with epilepsy were 3-28 times more likely to develop preeclampsia than nonepileptic women (p=0.0005). Uterine bleeding in the last trimester was 3-97 times more common in epileptic women (p=0.05). Two medical interventions, induced labor and cesarean section, in epileptic women were as frequent as that in nonepileptic women (p=0.67 and p=0.97). Almost 18% of mothers with epilepsy underwent ce-sarean section. Only three of these were operated for epilepsy as the principal indication. Other indications were repeat cesarean in one, breech presentationin one and fetal distress in three patients. Postpartum haemorrhage was not frequent in epileptic women (p=0.65).
Congenital malformations were observed in 4 of 43 infants (93%) of epileptic mothers, while that was seen in 562 of 30,945 infants (1.82%) of control subjects (p=0.003). All four anomalies observed in infants of epileptic mothers were minor type anomalies, including polydactily, lumbar dermal sinus, hypospadias, and bilateral hydrocele.
There were no stillbirths, neonatal deaths or maternal deaths in this series. Thirty-five of the infants were breast-fed. Eight infants were bottle-fed for various reasons and one of those had with drawal symptoms.

Tatışma

An excess in almost all of the common pregnancy complications has been observed in many studies of pregnancy in women with epilepsy, including preec-lampsia, bleeding in pregnancy, placental abruption, premature labor, and breech presentation (1-8). The relative risk for these complications is approximately 1.5-3 times the risk in women without epilepsy, indi-cating a slight increase for women with epilepsy. Ho-wever, no clear association has been seen between these obstetric complications and seizures or use of AEDs during pregnancy. On the other hand, there are obstetric series showing only minimal or no increase in obstetric problems among women with epilepsy (9,10,11). Our series shows an increased risk of pre-eclampsia and third trimester bleeding as obstetric complications. No increase in therates of breech deli-very, premature labor, or low birth weight infant was observed.
Rates of induction of labor four times greater than those for nonepileptic women have been reported for women with epilepsy (2). Nevertheless, the rate of induction of labor was similar in both epileptic and nonepileptic groups in our series where epilepsy was not considered an indication for induction of la-bor just as in some other series (4).
Maternal epilepsy warrants a cesarean section in only a selected minority of women. Patients with substantial neurologic or mental deficit, with very po-or seizure control in late pregnancy or with prior knowledge of the occurance of severe seizures du-ring heavy physical or mental stress should be the candidates for cesarean section (4,9). Thirty-seven percent of the patients in our series had cesarean sec-tion because their epilepsy and others had obstetric indications for the intervention, while total rate of ce-sarean sections in the group of women with epilepsy was similar to the rate in nonepileptic women.
Almost all published reports agree that there is a 1.2 to 3-fold increase in perinatal mortality (1,9). Ho-wever, no perinatal mortality was observed in our se-ries.
The incidence of congenital malformations, major and minor, among infants of mothers with epilepsy treated with AEDs during pregnancy is higher than that among infants of normal control (12-15). The ra-te of malformations was 5-fold in our series. Howe-ver, all of these malformations were minor anomalies which are defined as morphologic features of no seri-ous medical or cosmetic consequence to the patient (15)

Sonuç

The pregnancies of women withepilepsy defini-tely carry additional obstetric risks, most importantly congenital malformations. Those women need neuro-logic and obstetric follow-up during pregnancy as well as prepregnancy councelling at medical centers with the experience and resources to handle very specific problems of epileptic women. Provided that adequate care is available, almost all women with
epilepsy can be assured of a good maternal and fetal
outcome.

Kaynaklar

1. Nelson KB,Ellenberg JH,Maternal Seizure disorder,outcome of pregnancy,and neurologic abnormalities in the children.Neurology 32:1247-1254,
2. Yerby M, Koepsell T, Daling J. Pregnancy complications and out comes in a cohort of women with epilepsy. Epilepsia 26: 631-635, 1985.
3. Robertson IG. Breech presentation associated with anticonvulsant drugs. Obstct Gynecol 4: 174-177,1984.
4. Hiilesmaa VK. Pregnancy and birth in women with epilepsy. Neu rology 42 (Suppl 5): 8-11, 1992.
5. Yerby MS. The effects of epilepsy on pregnancy. Clinical Research 31 (2): 239A, 1983.
6. Yerby MS: Pregnancy and epilepsy. Epilepsia 32 (Suppl 6.): 51-59, 1991.
7. Svigos JM. Epilepsy and pregnancy. Aust NZ J Obstet Gynaecol 24: 182-5, 1984.
8. Wilhelm J, Morris D, Hotham N. Epilepsy and pregnancy: a revi ew of 93 pregnancies. Aust NZ J Obstet Gynaecol 30: 290-5, 1990.
9. Hiilesmaa VK, Bardy A, Teramo K. Obstetric outcome in women with epilepsy. Am J Obstet Gynecol 152: 499-504,1985. 10. Watson JD, Spellacy WN. Neonatal effects of maternal treatment with the anticonvulsant drug diphenyl hydantoin. Obstet Gynecol 37: 881-5,1971.
11. Bianchi A, Fiasco L, Manfredi M, Vigevano F. Epilepsy and preg nancy: a retrospective study of 418 pregnancies. Electroencephalog raphy and Clinical Neurophysiology 58 (3): 72,1984.
12. Kaneko S, Otani K, Kondo T, et al. Malformations in infants of mothers with epilepsy receiving antiepileptic drugs. Neurology 42 (Suppl 5): 68-74, 1992.
13. Dravet C, Julian C, Legras C, et al. Epilepsy, antiepileptic drugs, and malformations in children of women with epilepsy. A French prospective cohort study. Neurology 42 (suppl 5): 75-82,1991.
14. Koch S, Lösche G, Jager-Roman E, et al. Major and minor birth malformations and antiepilepric drugs. Neurology 42 (Suppl 5): 83- 88, 1992.
15. Gaily E, Granström M-L. Minor anomalies in children of mothers with epilepsy. Neurology 42 (Suppl 5): 128-131,1992.

	Dosya / Açıklama
	Tablo 1. Coplications of Pregnancies of Women With Epilepsy and Control Group