table of contents - hse.ie
TRANSCRIPT
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Table of ContentsVersion Control ......................................................................................................................4FORWARD ..............................................................................................................................5KEY RECOMMENDATIONS ..................................................................................................6 1.0 Purpose of Practice Guide .........................................................................................7 2.0. Scope of Practice Guide ............................................................................................7 3.0.Definitions ...................................................................................................................7 4.0.Responsibilities ...........................................................................................................7 5.0 Procedure ...................................................................................................................8 5.1 ManagingthecareofWWEatthepreconceptionstage,includingthose consideringpregnancy. ..............................................................................................8 5.2.ManagementbytheepilepsyserviceofWWEwhoispregnant ..............................11 5.3 ManagementbytheobstetricserviceofWWEwhoispregnant .............................13 5.4.ManagingthecareofWWEwhoareinlabour .........................................................15 5.5.ManagingthecareofWWEwithregardtopost-natalcare .....................................17 5.6.ManagingthecareofWWEofmenopausalage ......................................................19 6.0 EvaluationProcess(AuditTool) ................................................................................21 7.0 RelatedDocuments/Bibliography ............................................................................23References ...........................................................................................................................24 Appendix1 .......................................................................................................................25 AEDsandContraception–informationleafletforadviceoncontraception forwomenwithepilepsy...................................................................................................25 Appendix2 ......................................................................................................................32 NationalEpilepsyServices ...............................................................................................32 Appendix3 .......................................................................................................................33 ChecklistofinformationtobediscussedatfirstmeetingwithANPandWWEwho ispregnant ........................................................................................................................33 Appendix4 .......................................................................................................................35 Pregnancyregister–guidelineonhowtoregisteraWWEontheregister ......................35 Appendix5 .......................................................................................................................37 ChecklistofinformationtobediscussedwithWWEatfirstObstetricmeeting additionaltothenormalobstetricissuesdiscussed. .......................................................37 Appendix6 .......................................................................................................................38 BirthplanforWWE/ObstetricPlan ...................................................................................38 Appendix7 .......................................................................................................................39 ProtocolformanagingStatusEpilepticus ........................................................................39 Appendix8 .......................................................................................................................41 ChecklisttoguidePHNvisitstoWWEandtheirbaby’spostdelivery .............................41 Appendix9 .......................................................................................................................43 PostnatalRANPFirstClinicwithWomenwithEpilepsy,Informationtobe gatheredbyRANP ............................................................................................................43 Appendix10 .....................................................................................................................44 ReviewwithWWEregardingMenopauseandEpilepsy ...................................................44
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Version Control
ThisPracticeGuideistheworkofasubgroupoftheNationalClinicalProgrammeforEpilepsyinitiatedin2012.MembershipofthissubgroupwaswideincludingrepresentativesfromMedicsincludingConsultantNeurologistandGP,CNSEpilepsy,Patient,CNSNeurologyPAEDSandConsultantPhysicianID.ConsultantObstetricianinputwasalsoachievedwithsignificantinputfromDrMaryHolohan,RotundaHospitalandreviewedbyProfessorMcAuliffefromtheNationalMaternityHospital.
Version0.1 July2014 SubmissiontoObs&GynaeCAGVersion0.2 Sept2014 CirculationtoEpilepsyProgrammeCAGVersion0.3 Oct2014 EndofConsultationperiodforEpilepsyProgramme
CAGVersion0.4 Oct2014 Amendments made following initial review of SOP
by Clinical Programme for Obs & Gynae CAGincludinginclusionofkeyrecommendationssection& reformatting i.e. flow charts following relevantsections.ChangesmadebySineadMurphy,DrMaryHolohan&EdinaO’Driscoll.ThisamendmentswereagreedfollowingmeetingwithClinicalLeadofObs&GynaeProgrammeon20thOct2014
Version0.5 Nov2014 ResubmissiontoObs&GynaeCAGVersion0.6 Dec2014 Amendmentsbyworkinggroupfollowingpublication
of international recommendations re:prescribingofValproate.
Version0.7 Dec2014 Amendments made by Sinead Murphy followingreview by Clinical Programme for Obs & GynaeCAG including formatting changes/and clarity re:responsibility for getting trough levels checked onWWEtakingLamotrigineorLevetiracetam
Version0.8 Jan2015 SubmissiontoNCAGLAcuteHospitalsVersion0.9 Feb2016 Resubmission toClinicalAdvisoryGroupLeads for
ConsultationVersion0.10 Feb2016 Consultation with Medicines Management
ProgrammeVersion0.11 April2016 FinalVersionVersion0.12 Nov2016 FinalreviewinadvanceofpublicationVersion0.13 Mar2017 ReviewbasedonpublicationfromFSRHUKVersion0.14 Jan2018 ApprovalofdraftdocumentbyCSPDSMTVersion0.15 May2018 UpdatewithHPRArecommendationsre;pregnancy
preventionprogrammeVersion0.16 June2018 CSPDApprovalVersion1.0 July2018 FinalDraftPublished
This practice guide will be reviewed in October 2019
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FORWARD
WOMEN WITH EPILEPSY have particularissuesinrelationtocyclicalimpactonseizures,contraceptive choices, medication options andfoetal development, pregnancy complicationsand adverse menopausal impact; such thatWomen with Epilepsy should receive carefrom informed health professionals who canminimise the risks faced by these women andtheir children. This guide sets out the ClinicalCarePathwaythatbestaddressestheneedsofWomenwithEpilepsyinIrelandandidentifiestheresponsibilitiesofthehealthcareprovidersfromwhomthesepatientsreceivecare.Theobjectiveof this practice guide is to achieve optimalseizure control onmedication that hasminimalfoetal impact in pregnancy that is relativelycomplication free and supported throughoutadultlifeinadoptingpositivelifestylechoices.
DrMaryHolohanConsultantObstetricianFRCOG,FRCPI,FFFFLM(RCPLon).
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KEY RECOMMENDATIONS
lThediagnosisofepilepsyshouldbemadebyamedicalpractitionerwithexpertiseinepilepsy,usuallyaneurologist.
lWomenwithepilepsyandthosecaringforthemshouldbemadeawareofthedifferenttypesofepilepsyandtheirseizuretypesinordertoassesstheindividualriskstothemotherandbaby.
lWomenwithEpilepsy(WWEshouldbeencouragedtoattendforpreconceptioncounselingwithanepilepsyspecialistatleast1yearpriortoconception.
lCliniciansareencouragedtoinformWWEofthemostuptodateinformationconcerningtheindividualrisktothefetusexposedtoAEDmedication.
lWWEshouldbeinformedthattheriskofcongenitalabnormalitiescanbeassociatedwiththeparticularAnti-epilepticdrug(AED)typeanddose.
lThelowesteffectivedoseofthemostappropriateAEDshouldbeemployed.lDoctorsintheEUarenowadvisednottoprescribevalproateforepilepsyorbipolardisorder
inpregnantwomen,infemalesunlessothertreatmentsareineffectiveornottolerated.1 lValproatemaybeinitiatedingirlsandwomenofchildbearingpotentialonlyiftheconditions
ofthevalproatepregnancypreventionprogrammearefulfilled.Fulldetailsonthepregnancyprevention programme are available at http://www.hpra.ie/docs/defaultsource/Valproate/pharmacy-poster.pdf?sfvrsn=0
lWomen on Valproate therapy must be reviewed annually by a specialist and the riskacknowledgmentformcompletedannually.
lAllWWEshouldbeprescribedFolicAcid5mgonceananti-seizuremedicationiscommencedandshouldbecontinueduntilatleast3monthsintothepregnancy;howevertheepilepsyservicewillrecommendcontinuingtheFolicAcid5mgthroughoutthepregnancy23.
lWWEwithanunplannedpregnancyshouldattendanepilepsyspecialistoncepregnancyisconfirmed.
lWWEshouldneverstoptakingtheirAEDswithoutdiscussingitwiththeirdoctor/nursefirst,evenintheeventofconfirmationofapregnancy.
lWWEshouldhavebaselineprepregnancyAEDlevelsforcomparisoninpregnancyandtomonitorcomplianceforappropriateAED
lWWEonallAEDSshouldhaveatrough4levelstakentoassesscompliance.lAccording to the Royal College of Obstetricians and Gynaecologists in the UK routine
monitoringofserumAEDlevelsinpregnancyisnotrecommended.Clinicianswillneedtotakeintoaccountotherfeaturessuchassuspicionofnon-adherence,toxicityandintractable
_______________________________________1 HealthProductsRegulatoryAuthority2014,https://www.hpra.ie/docs/default-source/default-
document-library/prac---valproate-art-31---dhcp-sanofi-ie-final-27nov2014.pdf?sfvrsn=02 Crawford,P.Appleton,R.Betts,T.J.Duncan,J.,Guthrie,E.,&Morrow,J.(1999)Bestpractice
guidelinesforthemanagementofwomenwithepilepsy.Seizure8:201-2173 Epilepsies:diagnosisandmanagement.NICEguidelines[CG137]Publisheddate:January2012at https://www.nice.org.uk/guidance/cg137/chapter/1-guidance-accessedonlineApril20164 Inmedicineandpharmacology,atroughlevelortroughconcentrationisthelowestlevel
(concentration)atwhichamedicationispresentinthebody.
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seizuresintheirdecisionsontherapeuticdrugmonitoring(RCOG20165).ConcernsaboutroutineAEDlevelsinpregnancyshouldbediscussedwiththespecialistinvolvedintreatingtheWWE.
lThereshouldbeaminimumof1visitpertrimesterateithertheirprimaryneurologycenterorataspecialistnurseledclinic.ThefinalprenatalvisitshouldbescheduledfornolaterthanamonthbeforetheEDD.
lPregnantWWEwhohaveexperiencedseizureactivitywithinthelastyearshouldbecloselymonitored
lWWEwithepilepsycanBreastfeediftheywishtodoso.lIt is recommended that pregnant women taking antiepileptic drugs in general and
valproate in particular, are enrolled in the Irish Epilepsy and Pregnancy Register (www.epilepsypregnancyregister.ie).Thisshouldbedoneasearlyaspossible in thepregnancy,beforetheoutcomeisknown.
1.0. Purpose of Practice Guide Thepurposeofthisguideistoensurethatallmedical/nursingstaffareclearontheirrolein
deliveringaservicetowomenwithepilepsy.2.0. Scope of Practice Guide Thisguideapplies toall femalepatientswithepilepsy,Neurologists,GPs,Obstetricians,
Nursingstaff,Midwives,PHNs,PharmacistsandstaffatFamilyPlanningClinics.3.0. DefinitionsAED Anti-epilepticdrugClinician AnyDoctorornursewhoreviewsthepatientDexascan DualEnergyXrayAbsorbtiometryEDD EstimatedDateofDeliveryEPR ElectronicPatientRecordGP GeneralPractitionerIV IntravenousMonotherapy SingleDrugPlanPHN PublicHealthNursePR PerRectumRANP RegisteredAdvancedNursePractitionerWWE WomenwithEpilepsy4.0. Responsibilities ForthepurposeofthisPracticeGuidethedeliverykeyaspectsofservicedeliveryrequires
separateresponsibilitiesfromdifferentmembersoftheMultidisciplinaryteamasoutlinedbelow.- ManagingthecareofWWEatthepreconceptionstage,includingthoseconsidering
pregnancy (Responsibility of theNeurologist,RANP theGP, thepatient andFamilyPlanningClinics)
_______________________________________5 RoyalCollegeofObstetriciansandgynaecologists.GreentopguidelineNo68,June2016
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- ManagementbytheepilepsyserviceofWWEwhoispregnant(ResponsibilityoftheCliniciantoincludeNeurologist,GPandRANP)
- ManagementbytheobstetricserviceofWWEwhoispregnant(ResponsibilityoftheNeurologist,RANPandGP)
- ManagingthecareofWWEwhoareinlabour(ResponsibilityofObstetrician,Midwives,Maternitystaff)
- ManagingthecareofWWEwithregardtopost-natalcare(ResponsibilityofObstetrician,Midwives,Maternitystaff)
- Managing the care of WWE of menopausal age (Responsibility of Obstetrician,Midwives,Maternitystaff,Neurologist,RANPandPHN)
TherecommendationsoutlinedinthisdocumentarepertinenttothetotalcareofWWEwithepilepsyinallhealthcaresettings.Inthecaseofwomenattendingmaternityhospitalswhoareseen inthespecialistobstetricalepilepsyclinics,whicharenurse-led;thisservice isconsideredanoutreachservicefromthespecialistepilepsycentres.
5.0 ProcedureThe following steps are to be carried out in the overall management of WWE5.1Managing the care of WWE at the preconception stage, including those considering
pregnancy. TheClinician/GPshouldidentifywomenofappropriateageandinvitethemforaconsultation
todiscusscontraceptionandfamilyplanningissueswiththem-seeappendix1. Keyissuestobediscussedattheconsultationinclude:
l Contraceptionl Familyplanningl Pregnancy,includingrisksofunplannedpregnanciestothewoman,andthefoetusand
whyWWEneedtobeplantheirpregnancies.l Doctors in theEUarenowadvisednot toprescribevalproate forepilepsyorbipolar
disorderinpregnantwomen,inwomenwhocanbecomepregnantoringirlsunlessothertreatmentsareineffectiveornottolerated.Thoseforwhomvalproateistheonlyoptionforepilepsyorbipolardisordershouldbeadvisedontheuseofeffectivecontraceptionand treatmentshouldbestartedandsupervisedbyadoctorexperienced in treatingtheseconditions6.TheconditionsofthenewPregnancyPreventionProgramme(HPRA,2018)shouldalsobemet.Thisincludes;lAssessingpatientsforthepotentialofbecomingpregnantandinvolvingthepatient
inevaluatingherindividualcircumstancesandsupportinginformeddecisionmakinglPregnancytestsbeforestartingandduringtreatmentasneededlCounsellingpatientabouttherisksofvalproatetreatment
_______________________________________6 AdabN,TudurSC,VintenJ,WilliamsonP,WinterbottomJ.Commonantiepilepticdrugsinpregnancy
inwomenwithepilepsy.CochraneDatabaseSystRev.2004;(3):CD004848.Review.
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lExplainingtheneedforeffectivecontraceptionthroughtreatmentlCarryoutreviewsoftreatmentbyaspecialistatleastannuallylIntroductionofanewriskacknowledgementformthatpatientsandprescriberswill
gothroughateachsuchreviewtoconfirmthatappropriateadvicehasbeengivenandunderstood
l WWEshouldbeprovidedwithaPatientInformationLeafletl Cliniciansmaywishtoconsidercompletingthechecklistforprescribersandpatients.l Women and girls who have been prescribed valproate should not stop taking their
medicineswithoutconsultingtheirdoctorasdoingsocouldresultinharmtothemselvesortoanunbornchild
l WWEshouldbegivenwritteninformationconcerningallaspectsofpregnancyl AllWWEofchildbearingpotentialshouldbeprescribedFolicAcid5mgsperdayat
least3monthspriortoconceptionunlesscontraindicatedandthisshouldbecontinuedthroughoutpregnancy.-seeappendix2.
5.1.2InthemanagementofWWE,whereclinicallyrelevantitisrecommendedtohavebaselineAEDmonitoringcompletedforthepurposeofcomparisonduringpregnancy.
5.1.3IfprescribingoralcontraceptiontoWWEitisimportantthattheCliniciannotesthatthecontraceptioneffectivenessmaybedecreasedduetoenzymeinducingAEDSsoareviewofmedicationmayberequiredseeappendix2.Ifamedicationreviewisrequired,thentheClinicianshouldrefertheWWEtotherelevantneurologyservice-seeappendix3.
5.1.4For WWE actively planning pregnancy Clinician should consider monotherapy wherepossibleandreferthewomantothelocalneurologyserviceformedicationreview-seeappendix3.
5.1.5 DiscussionregardingbonehealthonAED7s8.
_______________________________________7 Crawford,P.Appleton,R.Betts,T.J.Duncan,J.,Guthrie,E.,&Morrow,J.(1999)Bestpractice
guidelinesforthemanagementofwomenwithepilepsy.Seizure8:201-217.8 J.Liporace,A.D’AbreuEpilepsyandwomen’shealth:familyplanning,bonehealth,menopause,and
menstrual-relatedseizuresMayoClinProc,78(2003),pp.497–506
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5.1 Managing the care of WWE at the preconception stage, including those considering pregnancy
ReferenceMaterial/Key
Notes
Seeappendix1
Seewww.hpra.ie
Seeappendix2
Seeappendix2
Seeappendix3
TheClinicianwillidentifypatients,whoareatanagewherecertainissuesarebecomingimportant,suchascontraceptionandfamily
planning
TheClinicianinvitestheWWEtoaconsultationtodiscussthekeyissuesofContraceptionand
familyplanningasperappendix1
Inthecasewherevalproateisusedasatreatment,theconditionsoftheHPRA
recomendedPregnancyPreventionProgrammeshouldbemet
AnycontraceptionprescribedbytheClinicianshouldbeinlinewithinformationaboutAEDsandimpactonContraceptiveeffectivenessas
perappendix2
AllWWEofchildbearingpotentialshouldbeprescribedFolicAcid5mgsperdayatleast3monthspriortoconceptionunless
contraindicatedandthisshouldbecontinuedthroughoutpregnancy
ForWWEactivelyplanningpregnancytheclinicianshouldrefertothelocalepilepsy
serviceformedicationreviewandAEDbaselevelsreservedwherepossible
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5.2. Management by the epilepsy service of WWE who is pregnant 5.2.1Womanwithepilepsyisconfirmedaspregnant.5.2.2ThewomanshouldattendtherelevantRANPservice.Thiscanoccureitherasself-referral,
ObstetricianreferralorGPreferral.5.2.3RegisteredAdvancedNurse Practitioner (RANP) should review theWWE and provide
themwithrelevantinformationregardingpregnancythatthewomanneedstoconsider-seeappendix4.IftheRANPhasanyconcernsabouttheWWEtheyshouldrefertheWWEtotheneurologistforaconsultation.
5.2.4IftheWWEisonahighdoseAED(seeBritishNationalFormulary(BNF)Guidelines)orisonValproateoranyotherconcernstheRANPmayhave,thensheshouldbereferredforaconsultationwiththeneurologist.
5.2.5RANPshoulddiscussthepregnancyregisterwiththeWWEandgettheiragreementtoberegisteredontheregister-seeappendix5.
5.2.6RANP should ensure theWWE has linked in with the obstetrics service. The RANPshouldgetthecontactdetailsoftheobstetricservicefromtheWWEtocirculateanyOPDcorrespondencetoobstetricsservice.
5.2.7RANPshouldprovidetheWWEwithascheduleofappointmentswiththeepilepsyclinicor appointments with the specialist nurse led obstetric clinic at designated hospitalsensuringaminimumof1visitpertrimester.ThefinalvisitshouldbescheduledforatleastamonthpriortotheEDDofthewoman.TheRANPorthespecialistnurseledobstetricclinicatdesignatedhospitalsshouldalsoscheduleaclinicvisit forafter theexpecteddeliverydate.
5.2.8TheWWEshouldbeencouragedtocontacttheepilepsyserviceintheeventofchangestotheirepilepsy.
5.2.9TheEPRshouldbeupdatedaftereachclinicalinteraction(whereavailable).
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5.2 Management by the epilepsy service of WWE who is pregnant
ReferenceMaterial/Key
Notes
WWEConfirmedaspregnant
Woman/RANPregistersthepersononthepregnancyregister
Contactprimaryneurologyserviceintheeventof
changesintheirepilepsy
Post-natalappointmentcompletedbyprimaryneurologyserviceclinic
RANPensurestheWWEhaslinkedinwiththedesignatedobstetrics
serviceandgetscontactdetailsoftheobstetricservicefromtheWWE
1visitpertrimesteratprimaryneurology
centreorataspecialistnurse
ledclinic.ThefinalprenatalvisitshouldbescheduledfornolaterthanamonthbeforetheEDD.
RANPprovidestheWWEwithascheduleofappointmentswiththeRANPledclinicsorappointmentswiththe
specialistnurseledobstetricclinicatdesignatedhospitals+/-telephonecontact.TheRANPwillliaisebackallinformationtothePrimaryNeurologistwithallrelevant
information
RANPreviewsWWEandprovidesthemwithrelevantinformationregardingpregnancy
IftheWWEisonahighdoseAEDoronValproateoranyconcerns,theRANP
shouldreferthewomantotheNeurologist
SelfRefer
Obstetrician TorelevantRANP
GP ReferSeeappendix3
Seeappendix4
Seeappendix5
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5.3 Management by the obstetric service of WWE who is pregnant 5.3.1WWE should be identified by obstetric service as early as possible and referred to
Neurologyserviceifpatienthasnothadarecentneurologyconsultation.ScreenquestionsshouldbeaskedinobstetricclinicstoensurethatWWEareidentifiedasearlyaspossiblebytheobstetricservice.
5.3.2ThefirstappointmentwiththeObstetricianshouldbewithaconsultantobstetricianasearlyaspossibleinthefirsttrimester.
5.3.3A number of key issues should be discussed at this firstmeeting to ensure that thepregnancyanddeliveryisassafeaspossiblefortheWWEandherchild.Thechecklistseeappendix6shouldbeusedtoensurethatallcriticalissuesareaddressedinthisfirstappointment.
5.3.4ObstetricianisresponsibleforensuringallstaffinthematernityhospitalinvolvedinthecareoftheWWEaremadeawareofthekeyissuesincludingananomalyscanforbetween20-22 weeks as per current Irish practice. There is therefore no evidence for routineantepartumfoetalsurveillancewithcardiotocographyinWWEtakingAEDs(RCOG,2016).
5.3.5WWEwithepilepsyshouldbeencouragedtohaveawrittencareplandetailingmedicationstoavoidandmedicationsthatcanbegivenifthewomanhasaseizurewhileanin-patientatthematernityhospital.ThecareplanshouldincludeawrittenprescriptionforIVPRNLorazepam/BuccalMidazolamforuseiftheWWEhasaseizurewhilein-patient.-seeappendix7.
5.3.6WWEshouldhaveatroughlevel4monitoredasclinicallyindicatedorifnon-complianceissuspected(RCOG,2016).Theselevelscanbetakenbytheneurology/ObstetricteamorinPrimaryCarehoweverallresultsshouldbesenttoNeurologyteamforinspection.
5.3.7IfnotalreadyregisteredwiththeIrishEpilepsyandPregnancyregistertheWWEshouldbeencouragedtodoso.
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5.3 Management by the obstetric service of WWE who is pregnant
ReferenceMaterial/Key
NotesWWEidentifiedasearly
aspossible
Firstappointmentshouldoccurinthefirsttrimesterwitha
ConsultantObstetricianasearlyaspossible
Obstetricianisresponsiblefor
ensuringthatstaffinthematernityhospitalinvolvedinthecareoftheWWEareawareofthekeyissuesincludingananomalyscanforbetween20-22weeks
WWEshouldhaveatroughlevelmonitoredasclinicallyindicatedorifnon-complianceissuspected.Theselevelscanbetakenbytheneurology/ObstetricTeamorinPrimaryCarehoweverallresultsshouldbesent
Neurologyteamforinspection.NootherbloodlevelsshouldbetakenunlessspecificallyrequestedbyNeurologyTeamornoncomplianceissuspected
ScreenquestionshouldbeaskedtoidentifyWWEinObstetrics
Clinics
Keyissuestobecoveredinthisfirstappointmentoutlinedinthechecklistwhichcouldbeusedto
supporttheobstetricianinthefirstsessiontoensurethattheadditionalissuestonormalfirstmeetingdiscussionsarecovered
withWWF
Seeappendix6
Seeappendix7
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5.4. Managing the care of WWE who are in labour5.4.1WWEshouldbedeliveredinamaternityunitwithaccesstoonetoonemidwiferycare
duringthelabour.5.4.2WWEshouldhaveanIVcannulainsertedonadmissiontothelabourwardtoalloweasy
accessfortheadministrationofmedicationshoulditberequiredintheeventofaseizureoccurring during labour. Intravenous Lorazepam and/or Buccal Midazolam should beprescribedPRNonadmission.Abriefseizurehistoryshouldbetakendefiningseizuretypeandbeprominentlyplacedinthecasenotes.
5.4.3FactorsthatpredisposeWWEtoincreasedseizuresinlabour,suchashighlevelsofpain,sleepdeprivationandhyperventilationshouldbepreventedasmuchaspossible. Theuseofepiduralanaesthesiashouldbeavoided.
5.4.4TheuseofPethidineshouldbeavoidedifpossibleinaWWE.5.4.5TheWWE’s usual oral AEDmedication should be continued during labour and post-
natally.Inwomenunabletotolerateoralmedication,AEDscanbegivenbyotherroutestoincludeIVandPR.
5.4.6WWEshouldbecounselledandreassuredthattheriskofseizuresinlabourislow.5.4.7SeizuresinlabourshouldbeterminatedassoonaspossibleusingintravenousLorazepam
orBuccalMidazolam.Ifseizurespersist,manageasforstatusepilepticus-seeappendix8.Maternalairwayandoxygenationshouldbemaintainedatalltimes.Ifthereisdoubtwhetheraseizureinlabourisduetoeclampsiaorepilepsy,then,inadditiontointravenousLorazepam,thewomanshouldbetreatedasperlocalhospitalguidelinesformanagingeclampsia.Adiagnosisofepilepsyshouldbeoutruled.
5.4.8WhenadministeringmedicationtostopseizuresinlabourtheAnaesthesiologistshouldbeconsulted.
5.4.9An elective caesarean section should be considered and discussed with the treatingepilepsyspecialistiftherehavebeenfrequenttonic-clonicorprolongedcomplexpartialseizurestowardstheendofpregnancy
5.4.10All babies born to mothers with epilepsy on enzyme inducing medications shouldbe given IM vitaminK to prevent haemorrhagic disease of the new-born. (Phenytoin,phenobarbitone, Carbamazepine, Oxcarbazepine, Eslicarbazepine, Topiramate,Lacosamide).
16
5.4 Managing the care of WWE who are in labour ReferenceMaterial/Key
Notes
Appendix8
WWEmustbedeliveredinaconsultantledmaternityunitwithaccesstoonetoone
midwiferycareduringthelabour
WWEshouldberoutinelycannulatedaspartofadmission
tolabourwardandabriefdescriptionofseizurestaken.
Emergencymedicationshouldbeprescribed
AEDmedicationshouldbecontinuedduringlabourand
postnatally.InwomenunabletotakeAEDorallytheyshouldbegivenmedicationbyotherroutes
e.g.IVorPR
Seizuresinlabourmustbeinvestigatedastheymaybeduetoepilepsyandnoteclampsia
AnelectiveCaesareansectionshouldbeconsideredifthere
havebeenfrequenttonic-clonicorprolongedseizurestowardstheendofthepregnancy(SIGN)
SeizuresinlabourshouldbeterminatedassoonaspossibleusingintravenousLorazepamorBuccalMidazolam.Ifseizurespersist,manageasforstatus
epilepticus.(Appendix8)ContactrelevantANPisconcerned.Ifthereisaconcernabout
eclampsiatheninadditiontointravenousLorazepamthewomanshouldbetreatedas
perlocalhospitalguidelinesformanagingeclampsia.Adiagnosisofepilepsyshouldbeoutruled.WhenadministeringmedicationtostopseizuresinlabourtheAnaesthesiologistshouldbe
consulted.
Riskofseizureduringlabourshouldbereducedasmuchaspossiblebyencouragingrest,promotingpainreliefandavoidingpossibletriggersto
includehyperventilation.Adoptalowthresholdforepidural
anaesthesia.
Inputfromtheanaesthesiologistandpharmacistisrequired
Allbabiesborntomotherswithepilepsyonenzymeinducingmedications
shouldbegivenIMvitaminKtopreventhaemorrhagicdiseaseofthenew-born
Itisimportanttonotethatpethidinehasaconvulsive
effectandshouldbeavoidedispossible
17
5.5. Managing the care of WWE with regard to post-natal care5.5.1AcareplanshouldbedevelopedfortheWWEinthepost-natalwardbasedonthebirth
plandeveloped.5.5.2StaffcaringfortheWWEshouldeducatethemselvesonthetypeofepilepsyandthefirst
aidofseizuremanagement5.5.3StaffresponsibleforcaringfortheWWEmustensureasafeenvironmentforWWEand
thebabywhileinhospital.5.5.4NursingStaffinthepostnatalwardshouldensurethatWWEcontinuetakingtheirAEDs
ontimeandencouragetheWWEtoavoidanypossibletriggers,sleepdeprivationandpainstimuli.
5.5.5Compliancewithmedicationshouldbeemphasizedandreinforced.5.5.6AnyWWEwhowishestobreastfeedshouldbeencouragedtodosoandsupportgivento
herwithbreastfeedingtominimisesleepdeprivation.5.5.7Staffonthematernityunit(maternitystaffdoinghomevisitsiftheWWEhaschosenthe
earlydischargeoption)shouldmonitorthealertnessofthebabyifthemotheristakingAEDs.
5.5.8MaternitystaffshouldcheckwhowillbesupportingthenewmumonreturninghomeandaPHNreferralshouldbesent. ThePHNshouldbeawareofthespecialrequirementsthatneed tobeconsideredwhendealingwithaWWEandherbabypostnatally.- seeAppendix9.
5.5.9TheWWEshouldbeadvisedoncontraceptionandfolicacidpriortodischarge.StaffonthepastnatalwardshouldensurethattheWWEhasafollowupvisittotheEpilepsyClinicwithin3monthspost-delivery.-seeappendix3.
5.5.10IfAEDmedicationswere increasedduringpregnancy theWWEshouldbeadvisedtocontactherlocalneurologyserviceondischargeregardingtheneedtoreducethecurrentdoseofthemedicationtoavoidanypotentialsideeffectsduetotoxicity.
5.5.11AtthefollowupEpilepsyClinic,theRANPshouldgather informationabouttheWWEexperienceintheobstetricserviceasperchecklistandfileinthecharttobeauditedatalaterdate-seeappendix10.
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5.5. Managing the care of women with epilepsy in regard to post-natal care
ReferenceMaterial/Key
NotesApost-natalcareplanshouldbedevelopedfortheWWEbasedonherbirthplan.Stafftofamiliarisethemselveswithtypeofepilepsyandfirstaid
procedures
Examinewhowillbeathometosupportnewmumondischargehome.RefertoPHN+/-Familysupport
wherenecessary.IfPHNVisiting-Theyshoulduseachecklistfor
additionalissuestheyneedtobemindfulofinWWEpostnatally.
TheWWEshouldbeadvisedoncontraceptionandfolicacidpriortodischarge.StaffonthepostnatalwardshouldensurethattheWWEhasafollowupvisittotheEpilespyClinicwithin3monthspost-
delivery.Seeappendix3.
EpilespyservicegathersinformationabouttheWWEexperienceintheobstetricservice(asperchecklist)atthepost-natalmeetingofWWEwithRANPLedclinic(whereRANPavailable).ThisinformationshouldbestoredintheWWEchartforaudit
purposes.
StaffresponsiblecaringfortheWWEmustensureasafeenvironmentforWWEandbabyonthepost-
natalward
Encourageandsupportnewmotherwithchosenmethodoffeedingherbabytoincludebreastfeeding.
Minimisesleepdeprivation.
MonitoralertnessofthebabyifmotheristakingAEDs
Nursingstaffonthepost-natalwardshouldensuretheWWEtakesherAEDmedicationontime
Seeappendix9
Seeappendix3
Seeappendix10
19
5.6. Managing the care of WWE of menopausal age5.6.1The Neurologist/RANP/GPwill identify those patients attending their service who are
potentiallyapproachingmenopauseanddiscussthisattheirnextscheduledreview.5.6.2TheWWEshouldbegiveninformationaboutthepossiblechangestotheirepilepsyduring
menopause-seeappendix11 regarding the informationonpossiblechanges thatcanoccur).
5.6.3TheClinicianshouldbeawarethatWWEwhoareonorhavetakenAEDsaremorepronetoosteoporosisandacalciumsupplementshouldbeconsidered.
5.6.4If theWWEhasnothadaDexascanthentheGPshouldorganiseascanand initiateaplantomonitor theosteopeniaorosteoporosis ifDexascanshowsareducedbonedensity.
5.6.5WWE should be encouraged to visit their local primary care or epilepsy service (seeappendix3)sothattheycanbemonitoredforanychangesinepilepsy.
5.6.6AswithallwomenofmenopausalagetheWWEshouldbeprescribedHRTifclinicallyindicated.
20
5.6 Managing the care of women with epilepsy of menopausal age
ReferenceMaterial/Key
Notes
Neurologist/RANP/GPidentifiesWWEwhorequireaconsultationaroundtheissueofEpilepsyand
menopause
WWEshouldbegiveninformationaboutthepossiblechangesthatcanoccurwithepilepsyduring
menopause
HRTtreatmentshouldbeprescribedasnormalifclinicallyindicatedinallwomenofmenopausalage
WWEshouldbeencouragedtocontacttheirGP/specialistepilepsyserviceastheyentermenopause
tomonitoranychangesintheirepilepsy
Clinicianshouldbeawarewomenwhoare/havebeenonAEDsaremorepronetoosteoporosisandacalcium
supplementshouldbeconsidered
IftheWWEhasnothadaDexascanoneshouldbeorganisedandatreatmentplanputinplaceif
osteopeniaorosteoporosisconfirmed
Seeappendix11
Seeappendix3
21
6.0 Evaluation Process (Audit Tool) Theaudittoolsarebrokendowninlinewiththesixsectionsintheprocedure.
Audit tool in relation to section 5.1 YES NO Other
WWEprescribedfolicacidunlesscontraindicated Conditions of HPRA Pregnancy Prevention Programme
met(appendix1) NumberofWWEwhoareactivelyconsideringbecoming
pregnantreferredtoneurologistformedicationreview. All WWE are provided with information related to
contraceptionandfamilyplanningissuesbytheirGPs. Alleducationprovidedinlinewithappendix2
Audit tool in relation to section 5.2 YES NO Other
SourceofreferralstoRANPledclinics WWEisprovidedwithascheduleofmeetings,aminimum
ofonepertrimester,withthefinalmeetingscheduledfor4weekspriortowoman’sEDD
%ofWWEreferredtoneurologistfromRANPledclinic Allpregnanciesareregistered
Audit tool in relation to section 5.3 YES NO Other
Dateoffirstappointmentwithobstetricservice Dateofscan(intermsofnumberofweekspregnant) Documentedbirthplandeveloped
Audit tool in relation to section 5.4 YES NO Other
WWEwaslookedafterona1to1basisbymidwife WWEwasdeliveredinaconsultantledservice %ofmaternityunitsthathavesignedupfortheEpilepsy
programmeintheirunit.
22
Audit tool in relation to section 5.5 YES NO Other
Acareplan isdeveloped for theWWEwhich includesaplanfordealingwithseizuresshouldtheyoccur.
WWEwasprovidedwithadviceoncontraception %ofmother’swithepilepsybreastfeeding. Information gathered at post-natal meeting by RANP
on theobstetricexperienceof theWWE in linewith thechecklist.
Audit tool in relation to section 5.6 NO
HowmanyWWEhavehadDexascans HowmanyWWEoncalcium How many women have been referred to the epilepsy
servicebyGPformenopauserelatedissues
23
7.0 Related Documents/ Bibliographyl HPRAValproatePregnancyPreventionProgramme,May2018l RoyalCollegeofObstetricsandGynaecology.GreentopguidelinesNo68,June2016l CrawfordP,AppletonR,BettsTetal.Bestpracticeguidelinesforthemanagementofwomen
withepilepsy.Seizure1999;8:201–17.l LambertMV,BirdJM.Theassessmentandmanagementofadultpatientswithepilepsy–
theroleofgeneralpractitionersandthespecialistservices.Seizure2001;10:341–6.l Morrow JI, Craig JJ. Anti-epileptic drugs in pregnancy: current safety and other issues.
ExpertOpinPharmacother2003;4:445–56.l Morrow JI, Russell A, Gutherie E, et al. Malformation risks of anti-epileptic drugs in
pregnancy:Aprospectivestudy fromtheUKEpilepsyandPregnancyRegister.J.Neurol.Neurosurg.Psychiatrypublishedonline12Sep2005;doi:10.1336/jnnp.2005.074203
l National Institute for Clinical excellence (NICE). The epilepsies: The diagnosis andmanagementoftheepilepsiesinadultsandchildreninprimaryandsecondarycare.Clinicalguideline20.London:NICE,October2004.http://www.nice.org.uk/page.aspx?o=229248
l ScottishIntercollegiateGuidelinesNetwork(SIGN).Diagnosisandmanagementofepilepsyinadults.Anationalclinicalguideline.Edinburgh:SIGN,2003.www.sign.ac.uk/guidelines/fulltext/70/index.html
l ScottishIntercollegiateGuidelinesNetwork(SIGN).Diagnosisandmanagementofepilepsiesinchildrenandyoungpeople.Anationalclinicalguideline.Edinburgh:SIGN,2005.www.sign.ac.uk/pdf/sign81.pdf
l TheCoordinationgroupforMutualRecognitionandDecentralizedprocedures(CMDh)oftheEuropeanmedicinesagencyrulingNovember2014inrelationofValproate:http://www.ema.europa.eu/docs/en_GB/document_library/Referrals_document/Valproate_and_related_substances_31/Position_provided_by_CMDh/WC500177637.pdf
l YerbyMS,KaplanP,TranT.Risksandmanagementofpregnancyinwomenwithepilepsy.ClevelandClinicJournalofMedicine2004:71(Suppl2):S25-37.
l BromleyRL,BakerGA,MeadorKJ;Cognitiveabilitiesandbehaviourofchildrenexposedtoantiepilepticdrugsinutero.CurrOpinNeurol.2009Apr;22(2):162-6.
l BurakgaziE,HardenC,KellyJJ.Contraceptionforwomenwithepilepsy.RevNeurolDis.2009Spring;6(2):E62-7.Review
l WalkerSP,PermezelM,BerkovicSF;Themanagementofepilepsy inpregnancy.BJOG.2009May;116(6):758-67.
l BurakgaziE,PollardJ,HardenC.Theeffectofpregnancyonseizurecontrolandantiepilepticdrugsinwomenwithepilepsy.RevNeurolDis.2011;8(1-2):16-22
l Dutton C, Foldvary-Schaefer N. Contraception in women with epilepsy:pharmacokineticinteractions,contraceptiveoptions,andmanagement.IntRevNeurobiol.2008;83:113-34.Review.
l HardenCL,Pennell PB,KoppelBS,HovingaCA,GidalB,MeadorKJ,Hopp J, TingTY,HauserWA,ThurmanD,KaplanPW,RobinsonJN,FrenchJA,WiebeS,WilnerAN,VazquezB, Holmes L, Krumholz A, Finnell R, Shafer PO, Le Guen CL; American Academy ofNeurology;AmericanEpilepsySociety.Managementissuesforwomenwithepilepsy--focusonpregnancy(anevidence-basedreview):III.VitaminK,folicacid,bloodlevels,andbreast-feeding:ReportoftheQualityStandardsSubcommitteeandTherapeuticsandTechnologyAssessment Subcommittee of the American Academy of Neurology and the AmericanEpilepsySociety.Epilepsia.2009May;50(5):1247-55.Review.
l Merry L, Martin KL, Chen T. Major birth defects after exposure the newer-generationantiepilepticdrugs.JAMA.2011Aug24;306(8):826
24
References1. Health Products Regulatory Authority 2014, https://www.hpra.ie/docs/default-source/
default-document-library/prac---valproate-art-31---dhcp-sanofi-ie-final-27nov2014.pdf?sfvrsn=0
2. Crawford,P.Appleton,R.Betts, T. J.Duncan, J.,Guthrie,E.,&Morrow, J. (1999)Bestpracticeguidelinesforthemanagementofwomenwithepilepsy.Seizure8:201-217
3. Epilepsies:diagnosisandmanagement.NICEguidelines[CG137]Publisheddate:January2012 at https://www.nice.org.uk/guidance/cg137/chapter/1-guidance- accessed on lineApril2016
4. Inmedicineandpharmacology,atroughlevelortroughconcentrationisthelowestlevel(concentration)atwhichamedicationispresentinthebody.
5. RoyalCollegeofObstetriciansandgynaecologists.GreentopguidelineNo68,June20166. AdabN,TudurSC,VintenJ,WilliamsonP,WinterbottomJ.Commonantiepilepticdrugs
inpregnancyinwomenwithepilepsy.CochraneDatabaseSystRev.2004;(3):CD004848.Review
7. Crawford,P.Appleton,R.Betts, T. J.Duncan, J.,Guthrie,E.,&Morrow, J. (1999)Bestpracticeguidelinesforthemanagementofwomenwithepilepsy.Seizure8:201-217.
8. J. Liporace, A. D’Abreu Epilepsy and women’s health: family planning, bone health,menopause,andmenstrual-relatedseizuresMayoClinProc,78(2003),pp.497–506
9. Faculty of Sexual andReproductiveHealthcareClinical EffectivenessUnit. Antiepilepticdrugsandcontraception,Jan2010.http://www.fsrh.org/pdfs/CEUStatementADC0110.pdf
10.Faculty of Sexual & Reproductive Healthcare Clinical Guidance. Drug Interactions withHormonalContraception,ClinicalEffectivenessUnit,Jan2012.http://www.fsrh.org/pdfs/CEUGuidanceDrugInteractionsHormonal.pdf
11.Faculty of Sexual & Reproductive Healthcare, Clinical Effectiveness UnitStatement, August 2013. Update on newer antiepileptic and antiretroviraldrugs and interactions with hormonal contraceptives. http://www.fsrh.org/pdfs/CEUstatementUpdateNewerAntiepilepticAntiretroviralDrugs.pdf
12.Faculty of Sexual & Reproductive Healthcare January 2017. Clinical Guidance: druginteractionswithhormonalcontraception.
13.EuropeanMedicinesAgency,Oct2014.PharmacovigilanceRiskAssessmentCommittee(PRAC).
14.Faculty of Sexual & Reproductive Healthcare. Clinical Guidance. EmergencyContraception. Clinical Effectiveness unit, Jan 2012) http://www.fsrh.org/pdfs/CEUguidanceEmergencyContraception11.pdf
15.TomsonT,BattinoD.Pregnancyandepilepsy:whatshouldwetellourpatients?JNeurol.2009Jun;256(6):856-62.Epub2009Mar1.Review
16.RiccardoDavanzo,SaraDalBo,JennyBua,MarcoCopertino,ElisaZanelliandLorenzaMatarazzo;Antiepilepticdrugsandbreastfeeding.ItalianJournalofPaediatrics2013;39:50http://www.ijponline.net/content/39/1/50
25
Appendix 1AEDs and Contraception – information leaflet for advice on contraception for women with epilepsy
Contraception advice for women with epilepsyInteractionsbetweenantiepilepticdrugsandcontraceptivehormonesareimportantduetotherisksassociatedwithcontraceptivefailureorreducedseizurecontrol9.1. Effect of enzyme inducing AEDs on hormonal contraception Someantiepilepticmedicineshaveadrug-drug interactionwithhormonalcontraceptive
pillswhichcan increase thespeed inwhichsomecontraceptivepillsand injectionsareprocessedbytheliver.(Thesemedicinesareknownasliverenzymeinducersastheyspeedupmetabolisminlivercells)(Walkeretal2009;AdabN2004).
Thefollowingantiepilepticmedicinesareliverenzymeinducers:
Stronginducers Lesspotentinducers
Carbamazepine Rufinamide Eslicarbazepine Topiramate Oxcarbazepine Phenobarbital Phenytoin Primidone
Reference; Faculty of Sexual and Reproductive Healthcare Clinical Effectiveness Unit.Antiepilepticdrugsandcontraception,Jan2010
Evidencewouldsuggestthattheimpactontheeffectivenessofthecontraceptivepillislinkedtothedoseofhormone(s)andtherouteofadministration(egtabletorinjection).The effectiveness of the progesterone-only injectable, depot medroxyprogesterone acetate(DMPA)isnotreducedbyAEDs.Astheconsequencesofcontraceptivefailure ispotentiallyveryserious, theNationalClinicalProgramme for Epilepsy advises the consistent use of barrier methods of contraception inwomen using any enzyme inducingAEDwith combined hormonal contraceptive (CHC), theprogesterone-onlypill (POP)orprogesteroneonly implant.Forwomenon long termenzymeinducing AEDs, alternative reliable contraceptive methods are recommended (eg DMPA orintrauterinemethods).Enzymeactivityreturnstonormalwithin28daysofstoppingmostenzymeinducingdrugs,thus28daysissufficientforrecoveryofthecontraceptiveefficacy.Forsomedrugswithassociatedrisksforfoetalabnormalities,barrierprotectionforlongerthan28daysmayberecommended.
_______________________________________9 FacultyofSexualandReproductiveHealthcareClinicalEffectivenessUnit.Antiepilepticdrugsand
contraception,Jan2010.http://www.fsrh.org/pdfs/CEUStatementADC0110.pdf
26
ThetablebelowoutlinesspecificadviceforwomenusingenzymeinducingAEDs;
Reference;FacultyofSexual&ReproductiveHealthcare&ClinicalGuidance,Jan201210
TheguidanceaboveshouldalsobenotedbywomentakingtherelativelynewAEDs,FycompaandZebinix,bothofwhichareenzymeinducingAEDs.
_______________________________________10FacultyofSexual&ReproductiveHealthcareClinicalGuidance.DrugInteractionswith
HormonalContraception,ClinicalEffectivenessUnit,Jan2012.http://www.fsrh.org/pdfs/CEUGuidanceDrugInteractionsHormonal.pdf
27
Reference;FacultyofSexual&ReproductiveHealthcare,ClinicalEffectivenessUnitStatement,August201311.
Reference;FacultyofSexual&ReproductiveHealthcareJanuary2017
_______________________________________11FacultyofSexual&ReproductiveHealthcare,ClinicalEffectivenessUnitStatement,August2013.
Updateonnewerantiepilepticandantiretroviraldrugsandinteractionswithhormonalcontraceptives.http://www.fsrh.org/pdfs/CEUstatementUpdateNewerAntiepilepticAntiretroviralDrugs.pdf
28
2. Effect of non-enzyme inducing AEDs on hormonal contraceptionSomeoftheotherantiepilepticmedicines,includingsodiumvalproate(Epilim)andlamotrigine(Lamictal),arenotconsideredtobeliverenzymeinducers,howevertheydocomewithspecificrisksasoutlinedbelow;nLamotrigine(Lamictal).WhileLamictaldoesnothaveadirecteffectonhormonalcontraception,thehormonalcontraceptivepillhasadirecteffectonthelevelsoflamictalinthebodybyincreasingtherateatwhichthemedicationisclearedwithinthesystem.(FSRH2010).Thiscanleadtodecreasedseizurecontrolintheactivehormonephaseandthenincreasedlamotrigineexposurewithariskoftoxicityinthehormone–freeweek(FSRH201712).Theuseofcombinedhormonalcontraceptionwhentakinglamictalforseizuremanagementisnotrecommended.ItisconsideredUKMEXcategory3(risksgenerallyoutweighthebenefits).Ifitisbeingprescribed,thedoseshouldbeincreasedby25%whenanOCPisinitiated.
Reference;FSRH2017
lSodiumValproate(Epilim)TakingSodiumValproateduringpregnancycancauseharmtotheunbornbabyincludingbirthdefectsandproblemswithdevelopmentandlearning.Inwomenwhotakevalproatewhilepregnant,around10babiesinevery100willhaveabirthdefect.Birthdefectsseeninchildrenofmotherswhotakevalproateduringpregnancyinclude:lSpinabifida(whenthebonesofthespinedonotdevelopproperly)lFacialandskullmalformations(includingcleftlipandpalate,wheretheupperliporfacialbonesaresplit)lMalformationsofthelimbs,heart,kidney,urinarytractandsexualorgans.Inviewoftherisksassociatedwithuseduringpregnancy,valproateandrelatedsubstancesshouldnotbeusedinfemalechildren,womenofchildbearingpotentialandpregnantwomenunlessalternativetreatmentsareineffectiveornottolerated(EMA,201413)_______________________________________12FacultyofSexual&ReproductiveHealthcareJanuary2017.ClinicalGuidance:druginteractions
withhormonalcontraception.13EuropeanMedicinesAgency,Oct2014.PharmacovigilanceRiskAssessmentCommittee(PRAC).
29
EffectivemethodsofcontraceptionareconsideredessentialiftakingthismedicationandshouldbediscussedwithConsultantNeurologistorEpilepsyNursePractitioner.(seeappendix13foradditionalinformationincludingpatientinformationleaflet)
3. Effect of AEDs and hormonal contraception on boneTheMedicinesandHealthcareproductsandRegulatoryAgency(MHRA)suggeststhatlongtermtreatmentwithCarbamazepine,phenytoin,primidoneandsodiumvalproateisassociatedwithandecreasedbonemineraldensity(BMD).Thiscanincreasetheriskofdevelopingosteopenia,osteoporosisandfracturesinpatientsconsideredtobeat-risk.‘At-risk’patientsincludethosethat;lAreimmobilisedforlongperiodslHaveinadequateexposuretothesunlHaveinadequatedailycalciumintake.Thosewithinthe‘at-risk’groupshouldbetakingvitamindsupplementation.Whiletheprogesteroneonlyinjectable(DMPA)islistedasanappropriatecontraceptiveforwomenwithepilepsyonanAED,itshouldbenotedthatDMPAitselfhasbeenlinkedwithlossofbonemineraldensity(BMD).TheuseofbothAEDsandDMPAtogetherisnotcurrentlyassociatedwithanadditionalhigherrisk(FSRH2010).StrategieswhichcanhelpprotectagainstBMDshouldbeusedbywomenoneitherAEDsorDMPA(orboth).Suchstrategiesinclude;lDiet(calciumintake)lVitaminDsupplementslExercise
4. Emergency ContraceptionIfyouaretakingliverenzyme-inducingdrugs(orwhohavestoppedtakingthismedicationwithinthelast28days)acopper-bearingintrauterinedevice(Cu-IUD)istheonlymethodofemergencycontraceptivenotaffectedbythesedrugs(FSRH2012)14.IfyouchoosenottouseaCu-ICD,adoseof3mgLNG(2levonelletablets)canbetakenassoonaspossible.Thisisoutsidetheproductlicenseandassuch,isnotavailableoverthecounter.Itshouldbetakenassoonaspossibleandwithinthefirst72hoursofunprotectedsexualintercourse(FSRH2010).ThisisnothoweverrecommendedforwomenusingenzymeinducingAEDs.Theemergencycontraceptive,ulipristalacetate(EllaOne)isnotrecommended(FSRH2010).
5. PregnancyMostpregnantwomenwithepilepsyhaveanormalpregnancyandchildbirth.Thefrequencyofseizuresmayincreaseinpregnancyinaround3in10womenwithepilepsy.Forwomenwithepilepsy,theriskofcomplicationsduringpregnancyandlabourisslightlyhigherthanfor
_______________________________________14FacultyofSexual&ReproductiveHealthcare.ClinicalGuidance.EmergencyContraception.Clinical
Effectivenessunit,Jan2012)http://www.fsrh.org/pdfs/CEUguidanceEmergencyContraception11.pdf15TomsonT,BattinoD.Pregnancyandepilepsy:whatshouldwetellourpatients?JNeurol.2009
Jun;256(6):856-62.Epub2009Mar1.Review.
30
womenwithoutepilepsy(Tomsonetal2009).Theincreaseinriskisduetotheriskofharmcomingtoababyifyouhaveaseriousseizurewhilstpregnant,andalsotheriskofharmtoanunbornbabyfromsomeantiepilepticmedicines(asdiscussedabove).Note:Theriskofcomplicationstobothmotherandbabyisgreaterwithuncontrolledseizurescomparedtotherisksoftakingmedication.Itisnotproventhatuncontrolledseizurescausecongenitalabnormalitiesbutthereappearstobeariskofincreasedfoetallossandmaternalmortality(Tomsonetal2009,Pennelletall200915).
6. Before becoming pregnantBeforebecomingpregnant,itisbesttoseekadvicefromyourdoctororepilepsynurse.Youshouldbeseenbyanepilepsyexperttodiscussyourtreatmentduringyourpregnancyindetail.Thepotentialrisksandbenefitsofadjustingyourtreatment,ifnecessary,canbediscussed.Ifyourpregnancyisplannedcarefullythenanyriskofcomplicationsmaybeminimised.Adviceondiet,smoking,alcohol,avoidinginfection,etc)willbethesameforanywomanplanningpregnancy,however,otherspecificthingsthatmaybepertinentforwomenwithepilepsyinclude:Insomecasesitmaybewisetochangetoadifferentmedication,whichislesslikelytocauseharmtoadevelopingbaby(dependingonthemedicationyouarealreadytaking).Itmaybeanoptiontostoporreducethedoseofyourtreatmentbeforeyoubecomepregnantifyourseizureshavebeenwellcontrolled.However,decidingtocomeoffantiepilepticmedicationcanbeadifficultdecision.Factorssuchasthetypeofepilepsythatyouhavecanbeimportant.Forexample,ifyouhavethetypeofepilepsythatcausesseveretonic-clonicseizures,thereisariskthatyoucouldhaveasevereseizurewhenyouarepregnantifyoustopyourmedication.Advicetotakefolicacidatstrengthof5mgaday.Thisshouldideallybetakenbeforeyoubecomepregnantandcontinueduntilyouare12weekspregnant.Althoughfolicacidisrecommendedforallwomenwhoarepregnant,thedoseforwomentakingantiepilepticmedicinesishigherthanusual.Takingfolicacidhasbeenshowntoreducetheriskofhavingababybornwithaspinalcordproblemsuchasspinabifida.ThereissomeevidencetosuggestthatFolicacidshouldbeavoidedinthosewithahistoryofbowelcancerduetothepotentialfortumourreactivation.AdvicetonotifyyourpregnancytotheIrishEpilepsyandPregnancyRegister(Phone:1800320820)thisistoallowinformationtobegatheredtoimprovethefuturemanagementofpregnantwomenwithepilepsy. 7. Breast-feedingBreast-feedingformostwomentakingantiepilepticmedicinesisgenerallysafe(Davanzoetal201316),however,eachmotherneedstobesupportedinthechoiceoffeedingmethodthatbestssuitsherandherfamily.
_______________________________________16RiccardoDavanzo,SaraDalBo,JennyBua,MarcoCopertino,ElisaZanelliandLorenzaMatarazzo;
Antiepilepticdrugsandbreastfeeding.ItalianJournalofPaediatrics2013;39:50http://www.ijponline.net/content/39/1/50
31
PrescribersshouldconsultindividualdrugadviceintheSPCandtheBNF(availableat)whenprescribingAEDsforwomenandgirlswhoarebreastfeeding.ThedecisionregardingAEDtherapyandbreastfeedingshouldbemadebetweenthewomanorgirlandtheprescriber,andbebasedontherisksandbenefitsofbreastfeedingagainstthepotentialrisksofthedrugaffectingthechild.Inadditionsomesuggestthatbycontinuingtobreastfeedthisisagoodwaytoweanthebabyoffthemedicationthattheyhavealreadybeenexposedtoinutero,asexposuretomedicationthroughbreastmilkislowerthanthatoccurringduringpregnancy.Anydecisiontolimitoradviseawomanwithepilepsyagainstbreastfeedingmustbejustifiedbyconfirmationthattherisktothebabyclearlyoutwaysalltheknownbenefitsbreastfeeding.Yourdoctor,midwifeornursespecialistcanadviseyouinmoredetail.
8. What are the risks that your child will also have epilepsy?Ingeneral,theprobabilityislowthatachildborntoaparentwithepilepsywillalsohaveepilepsy.However,itcanpartlydependonyourfamilyhistory,assometypesofepilepsyruninfamilies.Therefore,geneticcounsellingmaybeanoptiontoconsiderifyouoryourpartnerhasepilepsyandalsoafamilyhistoryofepilepsy.
32
Appendix 2National Epilepsy Services
Neurology Centres
IrelandEast DublinNortheastMaterHospital BeaumontStVincent’sUniversityHospital -OutreachtoDrogheda-OutreachtoCavan
Mid-west DublinMidlandsUniversityHospitalLimerick StJamesHospital TallaghtHospital
West/Northwest South/southwestUniversityHospitalGalway CorkUniversityHospitalSligoGeneralHospital MercyHospital-OutreachtoLetterkenny WexfordGeneral -OutreachtoKilkenny SessionstoKerry
33
Appendix 3Checklist of information to be discussed at first meeting with
ANP and WWE who is pregnant
InformationthatneedstobegainedfromandimpartedtothepregnantWWEbytheANPattheir1stvisittotheepilepsyclinic
lAllpregnantWWEshouldbeencouragedtonotifytheirpregnancy,orallowtheANP/Canp/CNSEtonotifythepregnancytotheIrishEpilepsyandPregnancyRegister(seeappendix6)
lObtainEDDlAdviseobstetricappointmentassoonaspossiblelDiscuss/prescribefolicacid5mglReviewEpilepsyhistoryandseizuresemiologyanddiagnosislEstablishifpatientsepilepsyisstable/monitoringofseizurefrequencylDiscussriskofseizuresinpregnancyandwhattodoifWWEhasseizureinpregnancylReviewanddocumentwhatAEDspatientisonlDiscusswithepilepsyspecialistifnecessarylIf theWWE is prescribed Lamotrigine an AED level should be taken on confirmation of
pregnancyandineverytrimesterorifseizuresincrease.ACarbamazepinelevelshouldonlybereservedwhenclinicallyindicated.
lWWEshouldbeencouragedtocarryownsupplyofAEDSandtotakeasnormalthroughoutantenatal appointments/labour/after birth. (This is to ensure consistency of supply, aschangesindrugbrandcanpotentiallyaffectseizurecontrol).
lDiscuss any triggers for seizureswhichmay be important in course of pregnancy – e.g.nausea & vomiting, changes in WWE metabolism due to pregnancy, sleep deprivation(maternaldiscomfortoractivefoetalmovements),non-compliancewithAEDs.
lDiscussriskstodevelopingbabyassociatedwithtakingAEDsinpregnancylDiscussrisksassociatedwithseizuresinpregnancylCompleteObstetricPerformainPatientsobstetricchartlWWEshouldbedeliveredinaconsultantledmaternityunitandonetoonemidwiferycare
duringlabourlReassurethatmajorityofmothershaveuncomplicatedpregnanciesandnormaldeliverieslReassurethatmajorityofmothersgivebirthtohealthybabiesandthatAEDsshouldbetaken
asprescribedlDiscusshealthylifestyle,cessationofsmoking&alcohollAdvisebirthplan(appendix7)
34
lDiscusslabour-lPotentialseizuretriggers(e.g.stress,exhaustion, lackofsleep, inadequatepainrelief,
hyperventilation,forgettingtotakeAEDsontime,dehydration).lRiskofseizureinlabourapprox.1-4%lMajorityofWWEhavenormalvaginaldeliveries(iffoetal&maternalhealthuncompromised).
Caesareansectionsshouldbeconsideredifincreaseinseizurestowardsendofpregnancy.lPainrelief–Avoidpethidine(whenmetabolisedcanconverttonorpethidinewhichmay
bepro-convulsive),allotherpainreliefacceptable(TENSmachine,gas&air,epiduralanaesthesiaetc)
lAEDscontinuedduringlabourandpostnatally.lDiscusstherisksandbenefitsofbreastfeeding.lDiscusssafetyissueswhenbabyarrives.
35
Appendix 4Pregnancy register – guideline on how to register a WWE on the register
HowtoregisteraWWEtotheIrishEpilepsyandPregnancyRegisterl PregnantWWEmayregistertheirownpregnancytotheRegisterbycontacting
thefree-phonelineinconfidence:1800320820toregister. Orl Pregnant WWE may also register their pregnancy via website www.
epilepsypregnancyregister.ie Orl HealthProfessionalsmayalsoregisteraWWEpregnancybycontactingthefree-
phoneadviceline1800320820orbydownloadingtheregistrationformsfromthewebsitewww.epilepsypregnancyregister.ie
l If voicemail obtained WWE are asked to leave their contact details on the Registervoicemailsystem-name,contactnumberandreasonforcall.Areturncallwillbemadetothewomantoenablefullregistration.
Orl IfvoicemailobtainedtheHealthProfessionalisaskedtoleavetheWWEcontactdetails
ontheRegistervoicemailsystem-name,contactnumberandreasonforcall.Acallwillbemadetothewomantoenablefullregistration.
The Role of the Register in completing patient’s registrationlThe role of theRegisterwith the aimsandobjectiveswill be explained to thewomanat
the timeof registration.The reason forwrittenconsentaswell asverbalconsentwillbeexplained.AquestionnaireisthencompletedoverthephonewiththewomanandtheninputintoaDatabaseandheldinClinicalResearchCentre,BeaumontHospital,Dublin9.
lWhen registering by phone, explanation that 3 consent forms will be mailed out to thewoman’spostaladdressandexplanation toher thatall 3 tobesignedanddatedand2returnedbacktotheRegisterinanattachedstampedaddressedenvelope.Onreceiptofthe2signedanddatedconsentforms,thisconfirmsfullyinformedconsentforpersonaldatatobeheldondatabaseandheldinClinicalResearchCentre,BeaumontHospital.
lIf registering via thewebsitewww.epilepsypregnancyregister.ie a questionnaire is printedoffandcompleted.Threeconsent formsareprintedoffandsignedanddatedand2arereturnedbacktotheRegistertogetherwiththecompletedquestionnaire.Full informationabout theaims&objectives and runningof theRegister are availableonline.On receiptofcompletedquestionnaireandconsent formsthepregnantWWEis thenregisteredandonreceiptofthecompletedquestionnaireandthe2signedanddatedconsentforms,thisconfirmsfullyinformedconsentforpersonaldatatobeheldonsecuredatabaseandheldinClinicalResearchCentre,BeaumontHospital.
lGPwillbecontactedbyletteratthetimeofregistrationand3monthspostexpecteddateofdelivery(EDD)foroutcomeofpregnancy.
lTheWWEcancontacttheRegisteronfree-phone1800320820foranyfurtherquestionsrelatedtotheRegisterorwomen’sissuesquestions.
lAdditionalwritteninformationontheRegisteranditsfunctionsanduseofdatawillalsobe
36
postedouttothewoman’spostaladdresswhenregistered.lOver thephone,WWEmayaskadditionalquestionsontheRegisterand/orquestionson
epilepsyandpregnancy.lWritteninformationonepilepsyandpregnancy/folicacid/contraceptionetcisofferedtothe
womanandwillbepostedout.lLetterconfirmingregistrationwillbepostedtothewomanlAdditionalinformationwillbepostedouttoGPonissuesrelatingtoepilepsyandPregnancy.lTheIrishEpilepsyandPregnancyRegisteroperationaldaysandhours(whichmayvary)will
beonvoicemailatalltimes.lConfidentialityofcallswillbemaintainedatalltimeslAllphone-callsforregistrationofpregnancywillbedocumentedandrecordedintoaphone
logbooklAnyqueriesorquestionsthatneedtobediscussedwithPIwillbedoneinconfidenceand
callreturnedtotheperson.lIfacurrentlyregisteredwomancontactstheregistrationwithquestions/issues/difficulties
withherepilepsyduringpregnancy,aletterwillbesenttotheirNeurologist(ifattendinganeurologist)orrelevanthealthcareproviderduringpregnancyinformingtherelevanthealthcareproviderofcontactwithRegister.Consentfromtheregisteredpregnantwomanwillbeobtainedpriortosendingtheletter.
lUseofData:TheanonymiseddatafrombothIrish&UKRegisterswillbeamalgamatedevery6months.Thisdatamaybepresentedatvariousconferencesbothnationalandinternationaleitherplatformorposterpresentations. Irishdata from the IrishEpilepsyandPregnancyRegisteralonemayalsobepresentedindividuallyaseitherplatformorposterpresentations.AnonymiseddatafromtheIrishEpilepsyandPregnancyRegistermayalsobeviewedbypharmaceuticalcompaniesabouttheirownlicenseddrug.Thisdisclosureofthisdatainananonymisedwayisreferredtoinpatientinformationleafletandconsentform.
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Appendix 5Checklist of information to be discussed with WWE at first Obstetric
meeting additional to the normal obstetric issues discussed.
Checklistofwhatshouldhappenat1stvisitwithWWE&theObstetricianInparallelwithroutineobstetricchecksthefollowingisachecklistforpregnantWWE:
lAllpregnantWWEshouldbeencouragedtonotifytheirpregnancy,orallowtheircliniciantonotifythepregnancytotheIrishEpilepsyandPregnancyRegister(seeappendix6)
lEstablishifpatientsepilepsyisactiveandrecordseizuretypeandfrequencyqDocumentwhatAEDspatientistakinglDiscussanytriggersforseizureswhichmaybeimportantincourseofpregnancylEnzyme-inducerAEDsacceleratemetabolismofsteroids(ifrequiredtoreducetheriskof
respiratorydistressinpreterminfants)l Anyincreaseinseizurefrequencyinpregnancyshouldbemonitoredcloselyandreferred
urgentlybacktoherepilepsyspecialistlDoseofAEDsshouldnotbeincreasedroutinelybutonlyonclinicalgroundslLamotrigineandLevetiracetamlevelspertrimesterminimum,Carbamazepinelevelreserved
ifclinicallyindicated,andnootherAEDlevelsrequired.lInterpretationofAEDbloodlevelsisbestdonebyepilepsyspecialistlArrangeanomalyscanforbetween20-22weeks.lWWEshouldbeencouragedtocarryownsupplyofAEDSandtotakeasnormalthroughout
antenatalappointments.(Thisistoensureconsistencyofsupply,aschangesindrugbrandcanpotentiallyaffectseizurecontrol).
lAdvisebirthplan(appendix9)lDiscusslabour&adviseriskofseizureinlabourislow(approximately1–2%)lDocumenttreatmentplanifWWEhasseizurewhileinhospitallDiscussdesiredmethodoffeedingthenewbornandifthepatientwishestobreastfeedlRegularobstetricfollow-upappointmentsandcommunicationbetweenepilepsyspecialist
andobstetrician.lAdvisethatmajorityofmotherswithepilepsywillcontinuetohavegoodseizurecontrolin
pregnancy.
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Appendix 6Birth plan for WWE/Obstetric Plan
BirthPlanSampleforWWEAbirthplanisadocumentdrawnupbythewoman(withorwithoutherpartner)whichenables
hertoexpressherwishesforlabourandtheimmediatepostpartumperiodandtoactivelyparticipate in the decision making when delivering her baby. It affords the woman anopportunitytodiscusswiththemidwifeonhowshewouldliketobesupportedduringthistime.
Abirthplanforwomenwithepilepsyshouldinclude:lNameandaddresslEpilepsyTypelBriefdescriptionofseizureslInformationonroutineseizuremedicationandwhenitshouldbeadministeredandbywhomlOnetoonemidwiferycareasperNationalEpilepsyCareProgrammeStandardOperating
ProcedureGuidelineslInformationfromNeurologist/ANP/cANP/CNSEonhowtomanageeachseizuretypein
labour;getemergencymedicationprescribedforthedurationofthishospitaladmissionlRequestsaboutPainrelief(AvoidPethidineconvertstoproconvulsingagent)lRequests about Vaginal Examinations, rupturing of membranes, using medication to
acceleratelabour,babymonitoring,deliverytypewherepossiblelLabouringanddeliverypositionpreferredlPreferredchosenmethodoffeedingthenew-born
AfterthebirthlPersonalandbabysafety(toincludenottobeleftalonewithbabyinthebedbesidemum,
nobathingthebabyalone;assesssupportavailableondischargehome)lOnetoonemidwiferycareasperNationalEpilepsyCareProgrammeStandardOperating
ProcedureGuidelineslAssistanceandsupportwithpreferredchosenmethodoffeedingthenew-bornl Informationonseizuretypesandhowtomanageeachseizurepostnatally;getemergency
medicationprescribedforthedurationofthishospitaladmissionlInformationonroutineseizuremedicationandwhenitshouldbeadministeredandbywhomlPreventroutinetriggerssuchassleepdeprivation,missedmedicationandpain
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Appendix 7Protocol for managing Status Epilepticus
GuidelinesforAdministrationofBuccalMidazolam.
Whatisthedefinitionofaprolongedseizure?Aprolongedseizureisdefinedasageneralisedtonicclonic(Grand-mal)seizurelasting5minutesorlonger,orwhenthereissuccessiveseizuresoccurringwhichpreventstheindividualregainingconsciousnessfully.ThisshouldbeconsideredanoperationaldefinitionofStatusEpilepticus(Lowensteinetal,1999,MeldrumB,1999)
Whyinterventionisrequired.Prolongedseizuresdemandpromptmedical treatment.Anyseizure last>=5minuteshasa30%chanceoflastingmorethan30minuteswhichisconsideredthebiologicalthresholdforseizurerelatedbraindamage(LowensteinDH,1999)InformationaboutMidazolam.Midazolam ispartof theBenzodiazepinesgroup. Itsmechanismofaction is topromote theactivityofGABAoneoftheinhibitoryneurotransmittersintheCentralNervousSystem.Thusishaspotentanxiolyticandseizurecontrollingactivity.ItworksaseffectivelyandreliablyasrectalDiazepam(McMullanJ,2010).MidazolamBrandsThemidazolamshouldbestoredinacoolcupboard,safelyoutofthereachofchildren.Eachbottleofmidazolamhasitsownshelflifeof2years.BuccalMidazalom(Epistatus)comesinaglassbottlecontaining5mlsofsolution(10mg/ml)withasupplyof4oralsyringesorin10mg/1mlprefilledsyringes.BuccalMidazolam(Buccalam)comes inage-specific,prefilled,needle-freeoralsyringes in4strengths2.5mgsin0.5ml,5mgsin1ml,7.5mgsin1.5mlsand10mgsin2mlsSyringesarecolour-codedaccordingtotheprescribeddoseforaparticularagerange.Procedureforadministration:Intheeventofaprolongedconvulsion:1.Generalmanagementoftheconvulsion lMakethepatientsafeandnotethetimetheconvulsionstarted. lPlacethepatientonaflatsurface lPlacesomethingsoftundertheheadtoprotectthemfrominjury. lEnsuretheairwayisnotobstructed.Turnthepatienttotherecoveryposition2.Administrationofmidazolam.
lIftheconvulsionlasts5minutes,orifthepatienthasoneseizureafteranother(acluster)lastingmorethan5minutes,theneitheranambulanceshouldbecalledormidazolamshouldbeadministered.
lThestandarddoseforanadultis10mgandforchildren6-12months(2.5mg)1-4years(5mg)5-9years ............................................................. (7.5mg)10years+(10mg).
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3.Directionsforuse.lCheckthatmidazolamiswithinexpirydate.
ForEpistatuslOpenthesyringeandopenthebottleofmidazolamandputongloves.(optional)lPlacethesyringeintothebottleofmidazolamuntiltheendofthesyringeisinthefluid.lDrawup________mlofthesolution,ensuringthatthedoseiscorrectoncethesyringeis
removed. ForBuccalam Take one plastic tube, break the tamper proof seal and remove the syringe containing
buccolam ForbothbrandsofBuccalMidazalom
lInsertthesyringegently intothebuccalcavityofthemouth.(insidethebottomofthecheek,outsideoftheteeth)
lSquirt the contents of the syringe into themouth very slowly (a drop at a time, over30-60seconds)thenremovethesyringe.
lSupportthecheek/lipswhilstgivingthemidazolamandafterwardstoreducetheamountofleakage.Usegauzeswabstowipemouthafter.
lIf the seizure lasts any more than five minutes after giving the midazolam then anambulanceneedstobecalled.
References1.LowensteinDH,BleckT,MacdonaldRL.It’stimetorevisethedefinitionofstatusepilepticus.
Epilepsia.1999Jan;40(1):120-2.2.LowensteinDH.Statusepilepticus:anoverviewoftheclinicalproblemEpilepsia.1999;40
Suppl1:S3-8;discussionS21-2.3.McMullanJ,SassonC,PancioliA,SilbergleitR.Midazolamversusdiazepamforthetreatment
ofstatusepilepticusinchildrenandyoungadults:ameta-analysis.AcadEmergMed.2010Jun;17(6):575-82..
4.Meldrum B. The revised operational definition of generalised tonic-clonic (TC) statusepilepticusinadults.Epilepsia.1999Jan;40(1):123-4.
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Appendix 8Checklist to guide PHN visits to WWE and their baby’s post delivery
GuidelineforPHN’SforlookingafteraWWEwhohashadababyrecently
InparallelwithroutinePHNchecksthefollowingisachecklistforWWEandbabypostnatally:
lDiscussdesiredmethodof feeding thenewborn and if thepatientwishes tobreastfeed.WWEshouldnotbediscouragedfrombreastfeedingbecauseofepilepsy
lDiscusstherisksandbenefitsofbreastfeedingiftakingAEDslRisksofbreastfeedingwhileonAEDs-hypersensitivityinbabiesexposedtoAEDsthrough
mothersbreastmilkmaydeveloplBenefitofbreastfeedingbabieswhowereexposedtoAEDsinutero-mayhelpbabiesto
weanofftheirmothersAEDs.lPossibilityofsedationshouldbeconsideredifmotherstakingolderAEDse.g.Phenobarbital
andbottlefeedingshouldbeconsideredlMonitorbabyalertnessandbabyweightifmothertakingAEDslToreducetheriskofaccidentsandminimiseanxiety-Promoteandreinforcebaby/toddler
safetyinthehomelIfpossible,sharethecareofbabyatnight(toreduceexhaustion/sleepdeprivation)while
mothergetsalternatefullnight’ssleeplFeedingand/orholdingbaby–sittingonthefloor,onarugorcushion(lowtoground)
mayreducethepotentialimpactofdroppingtheirchildduringaseizure.lBathingbaby –never alone, small amountofwater inbath, in eventof seizurebaby
wouldn’tgounderwater.lA“top&tail”washisasaferalternativethanbathingbabywhilealonelCarryingbaby–Ifstairsinhousehaveallbabyitemsdownstairssoanotcarryingbaby
upanddownstairs;usecarrycot/carseatupanddownstairstoprovideprotectionfromafallintheeventofaseizure.
lWhereaparent’sseizuresaffect justonesideoftheirbody,theyshouldpositiontheirchildonthenon-affectedside,toreducetheriskoffallingontothechild.
lParentswhofalloverduringaseizure(tonicclonicseizure)shouldbeadvisedagainsttheuseofababysling.
lSafetygates/playpens in thehomeandchild reinsorwrist strapswill preventchildwanderingawayiftheparenthasaseizure.
lPramwithabrakethatisautomaticallyactivatedwhenthehandleisreleased Ifusinghighchair–makesurecan’tknockover (ineventofseizure);orusebouncer
chair/carseatonfloor
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lInformationregardingcontraceptionwithAEDsshouldbediscussedwiththeWWElEnzyme-inducingAEDsreducetheeffectivenessofthecombinedoralcontraceptivepill
(COCP),progesteroneonlypill,progesteroneimplantandcontraceptivepatch.lDepotProvera, intrauterinedevice (IUD) andMirena intrauterine system (IUS)provide
effectivecontraceptionforwomenwithepilepsy,astheyarenotaffectedbyAEDs.lWomenontheAEDlamotrigineneedtodiscusscontraceptionwiththeirepilepsyspecialist
before prescribing COCP to allow adjustment of lamotrigine dose to be considered.PrescribingCOCPcansignificantly reduceblood lamotrigine levelsandmay result inbreakthroughseizures.LamotriginemayalsoreducetheeffectivenessofCOCP
lFuture pregnancies should be discussed/ planning next pregnancy and seeking pre-conceptualcounsellingpriortonextpregnancy
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Appendix 9Post-natal RANP First Clinic with Women with Epilepsy, Information to be
gathered by RANP
Information to be gathered at post-natal visit of WWE
BirthType:Vaginal,Instrumental,C-SectionWereyouofferedpethidineforpainreliefduringlabour?: Y/NDidyouexperienceseizuresduringlabour?: Y/NDidyouexperienceseizurespostnatally?: Y/NWeretherecotsidesinplacewhileyouwereinhospital?: Y/N/NotknownWereyourAED’sadministeredontime?: Y/NDidyouhavemidazolamwithyou?: Y/NDidyouhaveassistancewiththebaby?: Y/NDidyouhaveassistancewithfeeding?: Y/NDidaPHNvisityouathomeafterdischarge? Y/N
InformationregardingcontraceptionwithAEDsshouldbediscussedwiththeWWEatfirstpost-natalmeeting:lEnzyme-inducing AEDs reduce the effectiveness of the combined oral contraceptive pill
(COCP),progesteroneonlypill,progesteroneimplantandcontraceptivepatch.lDepot Provera, intrauterine device (IUD) and Mirena intrauterine system (IUS) provide
effectivecontraceptionforwomenwithepilepsy,astheyarenotaffectedbyAEDs.lWomenontheAEDlamotrigineneedtodiscusscontraceptionwiththeirepilepsyspecialist
before prescribing COCP to allow adjustment of lamotrigine dose to be considered.Prescribing COCP can significantly reduce blood lamotrigine levels and may result inbreakthroughseizures.LamotriginemayalsoreducetheeffectivenessofCOCP
lFuture pregnancies should be discussed/ planning next pregnancy and seeking pre-conceptualcounsellingpriortonextpregnancy.
lEnsurecompliancewithFolicAcid5mg.lEnsuretheWWEhasafollowupOPDappointmentatepilepsyclinicwithin3monthspost-
delivery.
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Appendix 10Review with WWE regarding Menopause and Epilepsy
ChecklistforinteractionwithWWEandMenopause
ThefollowingissuesshouldbediscussedwithaWWEregardingherepilepsyandmenopause:lConfirmation/diagnosisofmenopauselPossibilityofchangeinseizurefrequencylNeedforHRTlDEXAscanl+/-CalciumsupplementationlMoodIssues