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|Year : 2021 | Volume
| Issue : 2 | Page : 435-436
Shared Decision-Making in the Management of Women with Epilepsy
Manjari Tripathi1, Jasmine Parihar2
1 Professor, Neurology, All India Institute of Medical Sciences, New Delhi, India
2 Assistant Professor, Neurology, Lady Hardinge Medical College, New Delhi, India
|Date of Submission||16-Mar-2021|
|Date of Decision||16-Mar-2021|
|Date of Acceptance||16-Mar-2021|
|Date of Web Publication||24-Apr-2021|
Department of Neurology, AIIMS, Delhi
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Tripathi M, Parihar J. Shared Decision-Making in the Management of Women with Epilepsy. Neurol India 2021;69:435-6
Epilepsy is a chronic disease that imposes a physical, emotional, and economic burden on the patients and their families. Women with epilepsy (WWE) face additional gender-based psychosocial challenges, especially during their reproductive years.,,,, These challenges include changing seizure frequency with the menstrual cycle, the interaction of the antiepileptic drugs (AEDs) with the contraceptive medications, the effect of epilepsy on pregnancy, and risk of major congenital malformation (MCM) as well as neurocognitive and behavioural development disorders in the child born to mother taking AEDs.
The clinical equipoise in these situations warrants pre-conceptional counselling in all WWE and the need for shared decision making (SDM) to choose the AEDs during their reproductive period to improve the pregnancy outcomes. The article by Thomas V S. et al. proposing the grid-based presentation of treatment options is a welcome addition to the decision tools to facilitate SDM for WWE. The option grid is easy and can help patients' effortless understanding of the risks and benefits associated with various treatment options to treat epilepsy.
Approximately 15 million WWE are of childbearing age worldwide. Nearly 67% of pregnancies in WWE are unplanned., Though more than 90% of pregnancies in WWE have a good prognosis, WWE is at increased risk of pregnancy-related complications like spontaneous miscarriage, antepartum hemorrhage, preterm birth, and fetal growth restriction in addition to MCM. Conversely, most women with epilepsy maintain their seizure control during pregnancy. Nevertheless, the seizure frequency may increase if the patient had poorly controlled seizures in the pre-partum period. Epilepsy with uncontrolled seizures is also associated with 10-fold increased risk of maternal mortality, mostly due to sudden unexpected death in epilepsy (SUDEP).
The risk of MCM has been extensively reported in the literature. Valproate is associated with the highest risk of MCMs, phenobarbital and topiramate with an intermediate risk, and lamotrigine and levetiracetam with the lowest risk. The risk is generally dose-dependent and more if the culprit drugs are used in polytherapy. In addition to being most notorious for causing MCM, valproate has been most implicated in causing neurodevelopmental disorders. For these reasons, NICE and UK Royal College of Obstetricians and Gynecologists guidelines recommend avoiding this drug in any woman of childbearing potential. AEDs also increase the fetus's risk of being small for gestational age, with the risk being most likely with topiramate, carbamazepine, valproate, and polytherapy. It has been found that exposure to AEDs polytherapy or monotherapy with primidone, phenobarbiturate, carbamazepine, and valproate is also associated with smaller head circumference though less commonly to the extent of microcephaly and may normalize by two years of age.
To have a safe pregnancy outcome, the preconception care and planning should begin well ahead of pregnancy, and a patient of childbearing potential needs to be sensitized about this during all consultations. Since the patient may need a change in AEDs or its dose, adequate time is needed to see the new regime's efficacy to make the patient seizure-free before conceiving. While adjusting the dose, it is essential to check the serum drug levels as <35% of the baseline levels are associated with increased seizure precipitation. Adequate folic acid supplementation is initiated in the preconception stage with the recommended dose of at least 0.4 mg/day; a higher dose of 4 mg/day should be prescribed in those with a history of neural tube defect.
The patient must be involved in decision making at all steps from preconception to post-delivery. Although the evidence for shared decision-making in WWE is limited, the apparent benefits include improved decision quality, more informed choices, and better compliance.
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