Epilepsy:Epilepsy:

-Epilepsy is chronic neurological -Epilepsy is chronic neurological disorder.disorder.

- It can affect anyone at any age but - It can affect anyone at any age but the disorder commonly develops the disorder commonly develops before 20 years of age. before 20 years of age.

-30% of cases occurring in early -30% of cases occurring in early childhood. childhood.

-Epilepsy is chronic neurological -Epilepsy is chronic neurological disorder.disorder.

- It can affect anyone at any age but - It can affect anyone at any age but the disorder commonly develops the disorder commonly develops before 20 years of age. before 20 years of age.

-30% of cases occurring in early -30% of cases occurring in early childhood. childhood.

-Because the incidence of maternal -Because the incidence of maternal death with epilepsy is increasing ,sodeath with epilepsy is increasing ,so

-women with epilepsy are receiving -women with epilepsy are receiving appropriate information and appropriate information and counseling about contraception, counseling about contraception, conception and pregnancy so that conception and pregnancy so that they can make informed decisions they can make informed decisions about their care .about their care .

•• care is provided by a multidisciplinary care is provided by a multidisciplinary team comprising a named midwife, team comprising a named midwife, obstetrician and neurologist in order to obstetrician and neurologist in order to prevent significant morbidity/mortality in prevent significant morbidity/mortality in either the mother or fetuseither the mother or fetus

Etiology:Etiology: -An epileptic seizure results from abnormal -An epileptic seizure results from abnormal

electrical activity in the brainelectrical activity in the brain -disturbances of sensory, motor and -disturbances of sensory, motor and

autonomic function. autonomic function. -These disturbances recur spontaneously -These disturbances recur spontaneously

and are classified according to the parts of and are classified according to the parts of the brain affected.the brain affected.

- Seizures may be described as - Seizures may be described as 1-partial1-partial, usually arising from the , usually arising from the

temporal or frontal lobe of the brain,temporal or frontal lobe of the brain, 2-2- generalizedgeneralized, resulting from , resulting from

disturbances involving both halves of disturbances involving both halves of the brain.the brain.

** General seizures classified as General seizures classified as 1-absence seizures1-absence seizures (petit mal) (petit mal) 2-myoclonic seizures2-myoclonic seizures 3- tonic-clonic seizures3- tonic-clonic seizures (grand mal) (grand mal) 4-4- atonic seizuresatonic seizures 5- 5- statusstatus epilepticus epilepticus

The cause of epilepsy in most The cause of epilepsy in most instances is unknown. instances is unknown.

1- a genetic component, 1- a genetic component, 2- hypoglycemia2- hypoglycemia 3- encephalitis3- encephalitis 4- meningitis4- meningitis 5- cerebral hypoxia5- cerebral hypoxia 6- toxicity from alcohol or drugs6- toxicity from alcohol or drugs

-structural damage or abnormality of -structural damage or abnormality of the brain may result in epilepsy. the brain may result in epilepsy.

Precipitate factor;Precipitate factor; 1-emotional stress1-emotional stress 2- sleep deprivation2- sleep deprivation 3-physical exhaustion3-physical exhaustion 4-increased body temperature (fever, 4-increased body temperature (fever,

hot environments)hot environments)

5- environmental factors (strobe 5- environmental factors (strobe lighting, noise)lighting, noise)

6-non-compliance with drug therapy.6-non-compliance with drug therapy. 7-hormonal changes at the onset of 7-hormonal changes at the onset of

menstruation may trigger epileptic menstruation may trigger epileptic seizuresseizures

DiagnosisDiagnosis:: -Identification the type-Identification the type -identification cause of epilepsy -identification cause of epilepsy -taking a clear history including eyewitness -taking a clear history including eyewitness - blood tests to determine hematology, - blood tests to determine hematology,

biochemistry and toxicology assaysbiochemistry and toxicology assays -magnetic resonance imaging (MRI) -magnetic resonance imaging (MRI) - computerized tomography (CT) - computerized tomography (CT) -electroencephalogram (EEG) -electroencephalogram (EEG) -neuropsychological assessment to -neuropsychological assessment to

evaluate any learning disability and evaluate any learning disability and cognitive dysfunction cognitive dysfunction

TreatmentTreatment

--the use of one antiepileptic drug the use of one antiepileptic drug (AED)(AED)..

--In some individuals a combination of In some individuals a combination of drugs (polytherapy) may be requireddrugs (polytherapy) may be required

--a few will require surgerya few will require surgery . .

--side-effects of(AED)side-effects of(AED)..

-drowsiness-drowsiness -sedation-sedation - nausea and skin rashes.- nausea and skin rashes. - better to use a single AED prescribed - better to use a single AED prescribed

at the lowest effective dose.at the lowest effective dose. - AED therapy must be started under - AED therapy must be started under

the guidance of a specialist physician the guidance of a specialist physician and will need to be reviewed at regular and will need to be reviewed at regular intervals and at a minimum once a intervals and at a minimum once a year year

Women who take AEDs have a 4% Women who take AEDs have a 4% chance of having a baby with a major chance of having a baby with a major congenital malformation ,drug will congenital malformation ,drug will need to be reviewed and adjusted in need to be reviewed and adjusted in pregnancy in order to reduce this risk pregnancy in order to reduce this risk

Health educationHealth education

knowledge of epilepsy in generalknowledge of epilepsy in general •• the significance of trigger factors the significance of trigger factors

which may precipitate a seizurewhich may precipitate a seizure •• a guide to AEDs, how they work, a guide to AEDs, how they work,

their side effects and the importance their side effects and the importance of complianceof compliance

•• an explanation of what happens an explanation of what happens during a seizure, recognizing status during a seizure, recognizing status epilepticus, what to do and when to epilepticus, what to do and when to get medical help get medical help

implications for employment, implications for employment, education, sports activities, driving education, sports activities, driving and maintaining independent livingand maintaining independent living

•• psychological and sociological psychological and sociological issuesissues

•• effects of treatment on fertility effects of treatment on fertility and pregnancy and the risk of and pregnancy and the risk of congenital abnormalitiescongenital abnormalities

•• sudden death in epilepsy sudden death in epilepsy

Effect of epilepsy on the fetus Effect of epilepsy on the fetus and neonateand neonate

Some women may experience an Some women may experience an increase in seizures and the risk of increase in seizures and the risk of complications in pregnancy is complications in pregnancy is increased when epilepsy is poorly increased when epilepsy is poorly controlled controlled

Epilepsy increase during Epilepsy increase during pregnancy due topregnancy due to: :

non-compliance with the drug regimennon-compliance with the drug regimen sleep deprivation during pregnancysleep deprivation during pregnancy the decline in plasma concentrations of the decline in plasma concentrations of

the AED as the pregnancy progresses. the AED as the pregnancy progresses. -Prolonged and/or serial seizures during -Prolonged and/or serial seizures during

pregnancy increase the risk of fetal pregnancy increase the risk of fetal morbidity and mortality caused by morbidity and mortality caused by hypoxia or placental abruption hypoxia or placental abruption

- the first aid measures that should be - the first aid measures that should be adopted following an epileptic seizure, adopted following an epileptic seizure, prevent aspiration, the dangers of hot prevent aspiration, the dangers of hot baths inducing fainting and consequent baths inducing fainting and consequent drowning and the risk of death drowning and the risk of death

-The majority of women on antiepileptic -The majority of women on antiepileptic drugs have physically normal babies, drugs have physically normal babies, however evidence suggests increased risk however evidence suggests increased risk of major congenital malformations in of major congenital malformations in babies of women with epilepsy babies of women with epilepsy

Pre-pregnancy carePre-pregnancy care

-Preconception advice is essential for women -Preconception advice is essential for women with epilepsy and a review of AED therapywith epilepsy and a review of AED therapy

-the gradual withdrawal of AED therapy may -the gradual withdrawal of AED therapy may be considered prior to pregnancy in order to be considered prior to pregnancy in order to reduce the risk of congenital malformation in reduce the risk of congenital malformation in the fetus. the fetus.

-Folic acid supplementation (5 mg/day) should -Folic acid supplementation (5 mg/day) should be commenced before pregnancy and be commenced before pregnancy and continued throughout pregnancy to prevent continued throughout pregnancy to prevent congenital malformation and the development congenital malformation and the development of anaemia .of anaemia .

Antenatal careAntenatal care

-Pregnancy has no effect on seizure -Pregnancy has no effect on seizure control and most women with epilepsy will control and most women with epilepsy will remain seizure free remain seizure free

- Close monitoring of the maternal and - Close monitoring of the maternal and fetal condition is required and antenatal fetal condition is required and antenatal care should be provided by a care should be provided by a multidisciplinary team which includes a multidisciplinary team which includes a named midwife, obstetrician and a named midwife, obstetrician and a neurologist or physician with a specialist neurologist or physician with a specialist interest in epilepsy in pregnancyinterest in epilepsy in pregnancy

-u\s at 18–22 weeks. -u\s at 18–22 weeks. -Epilepsy is not an indication for early -Epilepsy is not an indication for early

induction of labour or elective induction of labour or elective caesarean section.caesarean section.

Intrapartum careIntrapartum care

-labour and birth carry an increased risk -labour and birth carry an increased risk for tonic-clonic seizuresfor tonic-clonic seizures

-Careful observation and monitoring of the -Careful observation and monitoring of the maternal and fetal condition by the maternal and fetal condition by the midwife is required through labour and the midwife is required through labour and the early postnatal period.early postnatal period.

- AEDs should be administered as - AEDs should be administered as scheduled throughout labour and it is scheduled throughout labour and it is important to prevent the development of important to prevent the development of possible ‘trigger’ situations such as:possible ‘trigger’ situations such as:

1- sleep deprivation1- sleep deprivation 2- hypoglycemia2- hypoglycemia 3- stress3- stress 4- hyperventilation4- hyperventilation 5- anemia5- anemia -Women with epilepsy should be -Women with epilepsy should be

offered the same choices for pain offered the same choices for pain relief in labour as other women, relief in labour as other women, including epidural analgesia.including epidural analgesia.

Postnatal carePostnatal care::

-at an increased risk of seizures due -at an increased risk of seizures due to fluctuating hormone levels and to fluctuating hormone levels and sleep disturbance. sleep disturbance.

-Safety precautions in the home -Safety precautions in the home should be discussed with the woman should be discussed with the woman and her partner.and her partner.

- This will include giving advice about - This will include giving advice about how to minimize risks when feeding, how to minimize risks when feeding, bathing, changing and transporting bathing, changing and transporting the baby the baby

-AEDs cross the placenta freely and decrease -AEDs cross the placenta freely and decrease production of Vitamin K leading to the risk of production of Vitamin K leading to the risk of Vitamin K deficiency bleeding in the newbornVitamin K deficiency bleeding in the newborn

-This can be prevented by routine -This can be prevented by routine administration of oral vitamin K (20 mg/day) administration of oral vitamin K (20 mg/day) to the mother from 36 weeks' gestation and to the mother from 36 weeks' gestation and to the baby (1 mg i.m.) shortly after birth .to the baby (1 mg i.m.) shortly after birth .

- Breastfeeding is generally safe. How much - Breastfeeding is generally safe. How much AED passes into breast milk must be AED passes into breast milk must be considered considered

-Some AEDs have a sedative effect, -Some AEDs have a sedative effect, causing drowsy babies less efficient at causing drowsy babies less efficient at feeding and gaining weight more slowly. feeding and gaining weight more slowly.

-AED therapy should be reviewed soon -AED therapy should be reviewed soon after birth by the neurology team .after birth by the neurology team .

- Future pregnancy plans should be - Future pregnancy plans should be discussed and appropriate contraceptive discussed and appropriate contraceptive advice given. advice given.

-All methods of contraception are available -All methods of contraception are available to women with epilepsyto women with epilepsy

- oral contraceptives are less - oral contraceptives are less effective with some AEDs .effective with some AEDs .

-Women taking these AEDs will -Women taking these AEDs will require oral contraceptives with a require oral contraceptives with a higher dosage of estrogen higher dosage of estrogen