One lesson to master 5 hot issues in women's epilepsy management

Only for medical professionals to read for reference.
What are the characteristics of the management of female patients with epilepsy? Clinically, the various conditions of female epilepsy patients of childbearing age have always been hotspots discussed in the academic circle
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Women of childbearing age refer to women who are fertile and in the reproductive period, generally 15 to 50 years old
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In China, women of childbearing age account for 40% of the 4 million women with epilepsy.
Due to many considerations in treatment, improper treatment can lead to psychological, physical, and infant health problems in pregnant women, so they have attracted much attention
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Xiaojie invited Mr.
Mu Jie, the deputy chief physician of West China Hospital of Sichuan University, to teach us "Management of People with Special Epilepsy"
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This article will emphasize the importance of women with epilepsy of childbearing age when taking Antiseizure Medications (ASM)
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 1.
Female epilepsy patients of childbearing age and anti-epileptic drugs First of all, what clinical problems will female patients with epilepsy face? Menstrual epilepsy: the worsening of seizures at different stages of the menstrual cycle; the influence of ASM on the menstrual cycle
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Hormones: The effect of cytochrome enzymes on ASM metabolism and hormone metabolism
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Contraception: the interaction of birth control pills and ASM
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Reproductive dysfunction: The incidence of PCOS in ASM treatment has increased
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Sexual dysfunction: the effect of ASM on sexual function
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Pregnancy: The impact of ASM on offspring, such as teratogenesis and cognition
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Breastfeeding: Breastfeeding recommendations when taking ASM
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Menopause and bone mineral density: the effect of ASM on bone mineral density; drug interactions; worsening of menopausal seizures
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Mental health: female psychiatric comorbidities are relatively high; psychotropic drugs interact with ASM
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One of the issues that everyone is most concerned about is the impact of female epilepsy patients of childbearing age on their offspring
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The International Anti-Epilepsy Alliance (ILAE) survey on female epilepsy pointed out that there are still some blind spots for female patients in the pregnancy guidelines.
For example, the 20% pregnancy guidelines do not include information on specific fetal risks related to certain anti-epileptic drugs
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The 25% pregnancy guide does not include information related to fetal cognitive development
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 The 19% pregnancy guidelines did not include information related to safe breastfeeding
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 Therefore, before further discussing the relationship between female epilepsy patients and fetuses, we need to discuss the effects of medications related to female epilepsy patients of childbearing age
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How should women with epilepsy of childbearing age be treated with medication? Xiaojie summarized the following table for your reference
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Table: Whole-course drug management strategies for female epilepsy patients of childbearing age.
The consistent requirements of domestic and foreign guidelines require no seizures before pregnancy, that is, a detailed pregnancy plan must be made
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In addition to the absence of seizures, it is also necessary to pay attention to the supplement of folic acid
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Studies have also shown that epileptic seizures are related to the decrease in blood concentration of anti-epileptic drugs
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When the blood concentration of anti-epileptic drugs drops by 35% compared to before pregnancy, the risk of seizures increases
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Therefore, even if there are no symptoms, women with epilepsy of childbearing age still need to take anti-epileptic drugs for disease control during pregnancy, and the blood concentration of ASM needs to be tested
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Anti-epileptic drugs should be appropriately increased during the first trimester of pregnancy
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2.
Will antiepileptic drugs and fetal ASMs cause fetal abnormalities? There are relevant drug risk analyses at home and abroad.
The following two charts are comparative studies on the safety of antiepileptic drugs during pregnancy
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 Table: Systematic review and meta-analysis table of congenital malformations and prenatal examination results: Mixed data from 32 monotherapy studies.
Therefore, for the drugs with higher teratogenic risk in the above figure, the gender of the patient should be considered when starting to use it.
And whether there are preparations for childbearing age and the risk of teratogenicity to the fetus! It is worth mentioning that valproic acid is the first-line drug for idiopathic/hereditary generalized epilepsy in women of non-bearing age; for women of childbearing age, the possibility of teratogenicity should be considered before starting treatment, and only the following conditions can be used Consider using valproic acid: In generalized epilepsy, patients with poor efficacy of other medications can only choose valproic acid patients, and if the risks are fully known, the lowest effective dose of valproic acid (500~750mg) , Or to ensure effective contraception
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3.
Women with epilepsy and breastfeeding According to relevant data, among the reasons why women with epilepsy refuse to use breastfeeding, fear of infant ASM exposure is the most common reason
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A total of 294 patients with epilepsy and 89 women without epilepsy were enrolled in the MONEAD study.
Visits were conducted at 3, 6, 9 and 12 months postpartum to ask whether the infant was breastfeeding
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Use this to compare breastfeeding rates
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The results are as follows: It can be seen that the breastfeeding rate of women with epilepsy in the 0~3 months postpartum is lower than that of ordinary women; and the breastfeeding rate further decreases with time
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The breastfeeding rate of epilepsy women after childbirth showed a downward trend, and the breastfeeding rate at 6 months after childbirth was less than 1/5! From the perspective of enabling the healthy development of infants and balancing the body and mind of women with epilepsy of childbearing age, integrating the benefits and risks of breastfeeding with epilepsy and increasing the rate of breastfeeding is the focus of current epilepsy management
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In addition, domestic and foreign guidelines are also unanimously recommended to encourage female patients treated with AMSs to breastfeed
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Regarding breastfeeding medication, the consensus of Chinese experts on the use of antiepileptic drugs for pregnant women mentioned that compared with the concentration of drugs that pass through the placental barrier, valproic acid, phenobarbital, phenytoin, carbamazepine, and lamotrigine Drugs such as oxazine and topiramate have low drug concentrations in maternal milk and have relatively little impact on the fetus, but levetiracetam has a high concentration in breast milk, and the related risks need to be confirmed by further clinical studies
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In addition, the expert consensus on the long-term management of adult patients with epilepsy also mentioned that the concentration of ASMs in breast milk is not only affected by the blood drug concentration of the mother, but also by the breast milk passing rate of ASMs.
At the same time, drugs with a lower breast milk passing rate should be selected to reduce the risk.
affect the baby, such as lamotrigine, etc.
, clobazam, O'Casey equality
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Worldwide, the management of female patients with epilepsy still has a large gap and faces many difficulties
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When choosing anti-epileptic drugs, attention should be paid to choosing drugs that have little effect on fetal development and teratogenicity.
Early use of medium doses of folic acid is beneficial to the offspring of AMSs, and breastfeeding in female patients with epilepsy has basically no safety effect on the offspring
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Due to space reasons, Xiaojie can only talk about it today and ask you a few questions: How should folic acid be supplemented during pregnancy in women with epilepsy? Does the ASM program be adjusted if the frequency of pregnancy attacks remains unchanged? Scan the QR code below, experts face to face and learn for free! Scan the code to download the Doctor Station App Famous Doctor Classroom for you to watch for free, read the original text, watch it now↓↓↓↓