INFORMATION FOR CANDIDATE:

Your next patient in general practice is a 24 year old

Mrs. Nicole Marsh who has been married for 2 years
and they want to start a family. She has suffered from
grand mal epilepsy since age 12 and has been on
medication (valproate = Epilim) since. She has not
had a seizure for at least 2 years. She consults you
regarding managing her pregnancy and what epilepsy
means for the pregnancy and the baby.
YOUR TASK IS TO:
Take a focused history
Manage the patients request
Answer questions from the examiner

HOPC: Nicole developed grand mal seizures at the age of 12 and required treatment
since. She has been quite stable on valproate (epilim) and she has not had a seizure for
more than 2 years. The epilepsy has not stopped her leading a very active life, she has
always been involved in sport, got her drivers license at age 18 although she had to give
up driving for 2 years from age 20 because she had some fits at that time. Her medication
was increased at the time and she got her license back 2 months ago because she had been
seizure free for 2 years after recommendation from her neurologist whom she sees
regularly.
Otherwise she has always been very healthy, no operations, no other medications, she uses
condoms as contraceptive at this stage.
PHx. + FHx.: unremarkable
SHx: married secretary, no alcohol, no smoking, NKA, no recreational drugs.
MANAGEMENT: There is an increased risk of seizures during pregnancy by about 30%.
However, >90% of women with epilepsy have a normal pregnancy with a healthy baby
but there is an increased risk of morbidity and possible mortality to mother (preeclampsia, preterm delivery) and child (especially prematurity, low birth weight, perinatal
mortality, congenital malformations like orofacial clefts, CVS and neural tube defects
abnormalities in brain or spinal cord development! 3% of babies have a risk of developing
epilepsy later in life.)
About 25% to 45% of women have an increased number of seizures secondary to a fall of
antiepileptic drug levels but then also an increased risk of seizures during labour and
puerperium.
Therefore it would be risky to stop the valproate and an antiepileptic should be given
during pregnancy or changed over to a less risky drug (in conjunction with the
neurologist!), considering that all antiepileptics have potentially teratogenic (harmful to
the baby!) effects:
Phenytoin (Dilantin) D: cleft lip and palate, congenital heart disease
Sodium valproate (Epilim) D: spina bifida / neural tube defects
Carbamazepine (Tegretol) D: spina bifida / neural tube defects but probably the
antiepileptic drug of choice!
All antiepileptic drugs cross over into breast milk but such low concentration that it
should not stop breast feeding! Close monitoring of the blood levels before and during the
pregnancy is mandatory because they might require adjustment.
It is advisable to recommend to the patient to take high dose folic acid (5 mg rather than
the usual 0.5 mg) 3 months before conception and for the first 3 months of the pregnancy,
mainly to prevent neural tube defects (i.e. until the neural tube closures).
All test routinely done at the first antenatal visit should be done before: Blood group/Rh,
FBE, U&E, TORCH screening, LFT, TFT, HIV, Hep B+C, MSU.
An ULTRASOUND should be organised looking for a nuchal fold translucency / thickness at the end
of 1st trimester and maternal serum screening. Another U/S is normally performed at 18-20 weeks to
check fetal development.
Possible referral to high risk pregnancy clinic for multi-disciplinary management with O+G,
neurologist and GP involvement!
For subsequent contraception a higher dose oestrogen pill is recommended because the antiepilieptics
usually increase liver enzyme activity.

The pregnancy would be followed in a high risk pregnancy clinic by multidisciplinary team with a
neurologist, obstetrician and GP.