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Table of Contents    
COMMENTARY
Year : 2021  |  Volume : 69  |  Issue : 2  |  Page : 435-436

Shared Decision-Making in the Management of Women with Epilepsy


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 Submission16-Mar-2021
Date of Decision16-Mar-2021
Date of Acceptance16-Mar-2021
Date of Web Publication24-Apr-2021

Correspondence Address:
Manjari Tripathi
Department of Neurology, AIIMS, Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.314547

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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

How to cite this URL:
Tripathi M, Parihar J. Shared Decision-Making in the Management of Women with Epilepsy. Neurol India [serial online] 2021 [cited 2021 May 14];69:435-6. Available from: https://www.neurologyindia.com/text.asp?2021/69/2/435/314547




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.[1],[2],[3],[4],[5] 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.[5] 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.[6],[7] 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.[8] Conversely, most women with epilepsy maintain their seizure control during pregnancy.[9] 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).[10]

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.[9] 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.[11]

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.[9] 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.[9]

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.



 
  References Top

1.
Thomas SV. Grid-Based Preconception Counseling Can Facilitate Shared Decision Making for Women with Epilepsy. Neurol India 2020;68:1414-7.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Sachin S, Padma MV, Bhatia R, Prasad K, Gureshkumar C, Tripathi M. Psychosocial impact of epilepsy in women of childbearing age in India. Epileptic Disord 2008;10:282-9.  Back to cited text no. 2
    
3.
Dhanaraj M, Rangaraj R, Arulmozhi T, Vengatesan A. Nonepileptic attack disorder among married women. Neurol India 2005;53:174-7.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Thomas SV, Indrani L, Devi GC, Jacob S, Beegum J, Jacob PP, Kesavadas K, Radhakrishnan K, Sarma PS. Pregnancy in women with epilepsy: Preliminary results of Kerala registry of epilepsy and pregnancy. Neurol India 2001;49:60-6.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Sunitha T, Prasoona R, Munshi A, Sujatha M, Prabha TS, Jyothy A. A rare occurrence of concordant neural tube defects in monozygotic twins of an epileptic woman. Neurol India 2012;60:428-9.  Back to cited text no. 5
  [Full text]  
6.
Singh SP, Sankaraneni R, Antony AR. Evidence-based guidelines for the management of epilepsy. Neurol India 2017;65(Supplement):S6-S11.  Back to cited text no. 6
    
7.
Herzog AG, Mandle HB, Cahill KE, Fowler KM, Hauser WA. Predictors of unintended pregnancy in women with epilepsy. Neurology 2017;88:728-733. doi: 10.1212/WNL.0000000000003637.  Back to cited text no. 7
    
8.
Viale L, Allotey J, Cheong-See F, Arroyo-Manzano D, Mccorry D, Bagary M, et al. Epilepsy in pregnancy and reproductive outcomes: A systematic review and meta-analysis. Lancet 2015;386 (10006):1845-52. doi: 10.1016/S0140-6736(15)00045-8.  Back to cited text no. 8
    
9.
Tomson T, Battino D, Bromley R, Kochen S, Meador K, Pennell P, et al. Management of epilepsy in pregnancy: A report from the International League Against Epilepsy Task Force on Women and Pregnancy. Epileptic Disord 2019;21:497-517. doi: 10.1684/epd. 2019.1105.  Back to cited text no. 9
    
10.
Edey S, Moran N, Nashef L. SUDEP and epilepsy-related mortality in pregnancy. Epilepsia 2014;55:e72-4. doi: 10.1111/epi. 12621.  Back to cited text no. 10
    
11.
Pennell PB, Klein AM, Browning N, Baker GA, Clayton-Smith J, Kalayjian LA, et al. Differential effects of antiepileptic drugs on neonatal outcomes. Epilepsy Behav 2012;24:449-56. doi: 10.1016/j.yebeh.2012.05.010.  Back to cited text no. 11
    




 

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