This prospective, population based study in the former Northern health region was designed to establish the proportion of pregnant women with a history of epilepsy; doctors supervising their care; effectiveness of preconceptional counselling and control of epilepsy; and use of medication and pregnancy outcomes.
Subjects, methods, and results
The project had approval from regional ethics committees. Pregnant women with epilepsy were recruited to the study, predominantly by community midwives. Women who consented were interviewed by using a standard questionnaire. Hospital notes were reviewed after the women had given birth. General practice and hospital notes were checked in one area to confirm the women's response regarding preconceptional advice. Between 1 January 1997 and 31 December 1998, 400 notifications of pregnancies to women with epilepsy were received (the total number of livebirths, stillbirths, and medical terminations for this period was 65 478, giving a proportion of all pregnancies to women with epilepsy of 6.1/1000).
Three hundred women were interviewed, 60 did not consent to interview, contact was unsuccessful for 36, and 4 were notified retrospectively. Epilepsy management was undertaken by general practitioners in 182/300 (61%) women; 214/300 (71%) reported ongoing seizures; and 53/252 (21%) women taking antiepileptic drugs reported no seizures for >2 years. A history of epilepsy was reported by 48 women who no longer took antiepileptic drugs. Of the remaining 252, 210 (83.3%) were on monotherapy, most often carbamazepine (52%) and sodium valproate (35%). The diagnosis of epilepsy was questionable in 16/300 (5%) women. Incomplete compliance with medication was reported by 157/252 (62.3%) women.
Only 113/300 (38%) women recalled receiving preconceptional counselling. However, review of the notes of 25 women who denied having received advice showed that 8 (32%) had been counselled. Less than 50% (88/199) planned their pregnancies and 27/111 reported oral contraceptive failure. Only 32 (11%) took folate appropriately.
Of the 359/400 known pregnancy outcomes there were 330 live births (three sets of twins); two medical terminations, two stillbirths, 22 miscarriages, and five terminations.
The obstetric complication rate and mode of delivery were similar to that of the background population except for an excess of premature deliveries (8.2%).1 One woman drowned in the bath while pregnant and another died five months post partum after a seizure, a death rate of 1 in 200. (No abnormal outcomes from the remaining 41/400 pregnancies were notified to the regional maternity survey office.) Vitamin K was given as recommended to 87/244 (36%) babies. Malformations were more common in babies born to mothers with epilepsy (20/400 (5%; 95% confidence interval, 3.1% to 7.6%) than in the background population (2.4%; 2.32% to 2.46%; odds ratio 2.15 (1.30 to 3.37), P=0.0037) (table).2 Four affected infants were among 48 born to women not taking drugs (8%, P=0.055). The malformation rate in babies born to treated women was 16/352 (4.55%, P=0.024). 2
Comment
The study shows that guidelines in the literature for the management of women with epilepsy are not being followed.3,4 Most women with epilepsy in our region are supervised by their general practitioner, control of seizures is poor, compliance with medication is variable, and methods of preconceptional counselling are ineffective. Less than 50% of these pregnancies are planned, partly because of oral contraceptive failure. The malformation rate in their infants is double that of the background population, and not all malformations are attributable to antiepileptic drugs.2 Most published guidelines are targeted at neurologists,3,4 thereby failing to improve management of women under the care of their general practitioner. Considerable expansion of epilepsy services in primary and secondary care is needed if the guideline recommendations3,4 are to be achieved.5
Table.
Malformations seen in relation to use of drugs
| No of cases (n=20) | Malformation | Drug (dosage (mg/day)) |
|---|---|---|
| 2 | Spina bifida | Valproic acid (1200); carbamazepine with valproic acid (not known) |
| 1 | Phocomelia | Valproic acid (1500) |
| 1 | Caudal regression* | Carbamazepine (not known) |
| 1 | Cleft palate | Valproic acid (2000) |
| 1 | Rib anomalies | Valproic acid (1500), also lamotrigine (100) |
| 1 | Thick mitral valve | Carbamazepine (500) |
| 4 | Hypospadias | Valproic acid (1000); valproic acid (400); valproic acid (not known); no drugs |
| 1 | Hypoplastic left heart | Carbamazepine (400) |
| 1 | Coarctation | Carbamazepine (1200) |
| 1 | Pulmonary stenosis | Valproic acid (600) |
| 1 | Left duplex kidney | No drugs |
| 1 | Cleft lip | No drugs |
| 1 | Microcephaly | Valproic acid and phenobarbitone (not known) |
| 1 | Trisomy 21 | Valproic acid (1000) |
| 1 | Lissencephaly† | Carbamazepine (200) |
| 1 | Right toe syndactyly | No drugs |
Mother has insulin dependent diabetes mellitus in addition to epilepsy.
This child, a boy, has X-linked lissencephaly, and his mother has subcortical band heterotopia on MRI manifesting clinically as epilepsy.
Footnotes
Funding: SDF and PJ were funded for two years by Wellbeing and for one year by the Purchasers Clinical Auditors Group (of health authorities in the former Northern region).
Competing interests: MJ has given educational lectures for Janssen Cilag, GlaxoWellcome, and Sanofi Winthrop. SDF gave an educational lecture for Janssen Cilag. JB has given four lectures for GlaxoWellcome. GlaxoWellcome and Parke-Davies have funded MJ to attend four epilepsy conferences in four years. MJ has contributed to a clinical trial for Novonordisk. GlaxoWellcome, Sanofi Winthrop, and Parke-Davies have contributed £26 500 for equipment and a salary for a nurse to set up an epilepsy service coordinated by MJ. Sanofi Winthrop has contributed £2100 to pay for equipment for a related study coordinated by SAL. MJ has contributed to one advisory panel for Novartis. GlaxoWellcome was a donor, through its charitable arm, to the matching funds for the millennium landmark, Centre for Life, which includes the Institute of Human Genetics.
References
- 1.Regional Maternity Survey Office. The Northern Perinatal Mortality Survey Annual Report—1995. Newcastle upon Tyne: Regional Maternity Survey Office.
- 2.Regional Maternity Survey Office. Northern Regional Congenital Abnormality Survey (NorCAS) report 1991-1995. Newcastle upon Tyne: Regional Maternity Survey Office.
- 3.Wiebe S. Managing women with epilepsy. BMJ. 2000;320:3–4. doi: 10.1136/bmj.320.7226.3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Wallace H, Shorvon SD, Hopkins A, O'Donoghue M. Adults with poorly controlled epilepsy. London: Royal College of Physicians; 1997. [Google Scholar]
- 5.Ridsdale L, Robins D, Cryer C, Williams H. Feasibility and effects of nurse run clinics for patients with epilepsy in general practice: randomised controlled trial. BMJ. 1997;314:120–122. doi: 10.1136/bmj.314.7074.120. [DOI] [PMC free article] [PubMed] [Google Scholar]