table of contents - hse.ie

3

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

4

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

5

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).

6

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.

7

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

8

- 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.

9

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

10

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

11

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).

12

5.2 Management by the epilepsy service of WWE who is pregnant


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

13

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.

14

5.3 Management by the obstetric service of WWE who is pregnant


NotesWWEidentifiedasearly

aspossible

Firstappointmentshouldoccurinthefirsttrimesterwitha

ConsultantObstetricianasearlyaspossible

Obstetricianisresponsiblefor

ensuringthatstaffinthematernityhospitalinvolvedinthecareoftheWWEareawareofthekeyissuesincludingananomalyscanforbetween20-22weeks

WWEshouldhaveatroughlevelmonitoredasclinicallyindicatedorifnon-complianceissuspected.Theselevelscanbetakenbytheneurology/ObstetricTeamorinPrimaryCarehoweverallresultsshouldbesent

Neurologyteamforinspection.NootherbloodlevelsshouldbetakenunlessspecificallyrequestedbyNeurologyTeamornoncomplianceissuspected

ScreenquestionshouldbeaskedtoidentifyWWEinObstetrics

Clinics

Keyissuestobecoveredinthisfirstappointmentoutlinedinthechecklistwhichcouldbeusedto

supporttheobstetricianinthefirstsessiontoensurethattheadditionalissuestonormalfirstmeetingdiscussionsarecovered

withWWF

Seeappendix6

Seeappendix7

15

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.

18

5.5. Managing the care of women with epilepsy in regard to post-natal care


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


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


SourceofreferralstoRANPledclinics WWEisprovidedwithascheduleofmeetings,aminimum

ofonepertrimester,withthefinalmeetingscheduledfor4weekspriortowoman’sEDD

%ofWWEreferredtoneurologistfromRANPledclinic Allpregnanciesareregistered


Dateoffirstappointmentwithobstetricservice Dateofscan(intermsofnumberofweekspregnant) Documentedbirthplandeveloped


WWEwaslookedafterona1to1basisbymidwife WWEwasdeliveredinaconsultantledservice %ofmaternityunitsthathavesignedupfortheEpilepsy

programmeintheirunit.

22


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