Nice | Epilepsy in women

Epilepsy in womenEpilepsy can have specific implications for women in terms of contraception, pre-conception, pregnancy and child-care. Obviously the latter of these applies to dads too; the new NICE guideline recognises all of this.

Contraception

I have added in some of the FSRH information here to clarify some points.

  • Enzyme Inducers - Carbamazepine and phenytoin. This will impact on COC, the POP and the implant. IUS, IUD and depot are OK. If no other contraception is acceptable, women can use the COC, but will need higher oestrogen doses than normal.
  • Sodium valproate isn’t an enzyme inducer and doesn’t have any effect on contraception.
  • Lamotrigine – it isn’t an enzyme inducer. Oestrogens can affect lamotrigine levels, so use with the COC normally isn’t advised (UKMEC3). The POP is fine. Bizarrely, if the patient is on lamotrigine and sodium valproate together, the COC is fine as valproate buffers the effects of oestrogen on lamotrigine.
  • Emergency Contraception – Ella One is affected by enzyme inducers, so don’t use it. With Levonelle, double the normal dose is needed.
  • Osteoporosis risk – You can use the depot, but beware the small increase risk of lower bone density with sodium valproate, carbamazepine and phenytoin.

Pre-conception advice

  • Teratogenicity. Advise the woman at each annual review that sodium valproate is teratogenic, especially if on doses over 800mg per day.
  • Folic Acid. Advise women on medication that they will need 5mg folic acid throughout pregnancy or if there is any chance of conception.

Pregnancy – risks to the mother

  • Women can be reassured that although their pregnancy is higher risk than average, that they are still at low overall risk.
  • It is unlikely that their seizure rate will increase and there is only a low risk of seizures during delivery.
  • Care should be obstetric / neurologist led.
  • Warn them of the risk of status / sudden unexpected death in epilepsy if they stop their medication.

Pregnancy – risks to the fetus

  • Suggest registering the pregnancy, so that outcomes can be followed-up.
  • Risk to the baby is low. The baby may be at higher risk during a tonic-clonic seizure, but not during other forms of epilepsy.
  • There is a higher risk of the baby having epilepsy than average, but overall risk is still low.

Breastfeeding

  • Is safe with most drugs – but check the BNF.
  • Expressing may allow the father to do some feeds and hence reduce tiredness in the mother.

Safe caring for a new baby

Appendix D has an excellent advice sheet that can be given to new parents. The information at www.epilepsy.org.uk is very similar.

  • Safe-places – if the parent is at risk of a seizure, they should identify a ‘safe place’ where the baby can be put down (eg cot / pram).
  • Feeding – sit on the floor surrounded by cushions to protect the baby if dropped.
  • Washing / changing – don’t bath the baby without someone else present in the bathroom. Sponge bath the baby / change the baby on the floor.
  • Stairs – minimise carrying the baby upstairs. If needs be, carry the baby in a car seat, where there will be some protection if dropped.
  • Prams and toddlers – levers that brake the pram if released or cords that stop it rolling off can be useful. Reigns for toddlers.
  • 999 – even very young kids can be taught to dial 999 (use red stickers on the 9 button). Even if they say nothing – the service will know the address calling.

Menopause

NICE lists headings to discuss with women, but doesn’t give any details about what aspects to discuss. I’ve fleshed this out with information from www.epilepsy.org.uk.

  • Fit frequency – may increase in peri-menopause
  • Osteoporosis – sodium valproate, carbamazepine and phenytoin lower bone density.
  • HRT – Oestrogens may lower effectiveness of lamotrigine. HRT may increase or decrease seizure activity. It is thought that oestrogen only HRT may have higher risk of increasing seizure frequency than combined HRT.
  • Evening primrose oil – I couldn’t find any decent resources on this, but there is some evidence that it and some other natural remedies may reduce seizure threshold.

Louise Hudman

I'm a freelance GP locum in Winchester & Southampton.

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