UW Doubt!........................ - forever07

[ArchivalUser]

 A 22-year-old Caucasian primigravida presents to your office at 12 weeks' gestation for routine prenatal counseling. She has a history of idiopathic seizures since childhood and receives valproate monotherapy. She is very concerned that the use of the anti-epileptic drug could harm her baby. Her last seizure occurred one year ago, and she was hospitalized for aspiration pneumonia after that episode. She denies the use of tobacco, alcohol, or any recreational drugs. There is no family history of congenital abnormalities.

Which of the following is the best management strategy for this patient?

Options

1. Switch to carbamazepine and add folic acid.
2. Switch to phenobarbital and offer amniocentesis.
3. Continue valproate and add folic acid.
4. Continue valproate and offer alpha-fetoprotein screening.
5. Continue valproate.

I did wrong, what is your answer? Thanks

[ArchivalUser]

When a patient is having seizure and taking antiseizure medication and get pregnant. Try to simplify the medication and use monotherapy. I will choose 3...... for this

[ArchivalUser]

4. Folic acid has no role if taking after first trimester. Need to continue on same medication since she is well controlled. No switch to other med since this one is giving an appropriate clinical response. Monitor AFP levels

[ArchivalUser]

http://www.usmleforum.com/showthread.php?tid=582714

If this patient already 12 wks, pregnancy, so organogenesis is over, eventhough we stop or change drug, there is no help.

So, this case came in before pregnancy, or just after ucg positive, we should change to carbamazapine.
Do you agree guys?

[ArchivalUser]

Yup folic acid has no role after 12 weeks as most of the organogenesis occurs within 10 weeks....
At this point of time just use same drug & do AFP monitoring

So ans will be 4


Update: if you get option of livateracitam (keppra) ...keppra is the safest antiepleptic of all as it is class C ...others are class D

So keppra will be the choice if provided..but again if antiepleptic has to be changed it should be changed 4-6 weeks on presentation.

Hope this helps

Bumba

[ArchivalUser]

forever carbamazepine & valproate most probably are class D ..plz check their class most likely both class D ..why will u like to switch to carbamazepine???

[ArchivalUser]

This is UW explanation, but kaplan sad DOC for epilepsy in pregnancy is Carbimazole.

Although anti-epileptic drug use during pregnancy is associated with an increased risk of congenital abnormalities, over 90% of women with epilepsy have normal pregnancy. There is currently no agreement about which anti-epileptic drug is most or least teratogenic; therefore, the drug that works best for the patient should be used. Early detection of neural tube defects by serum alpha-fetoprotein screening, amniocentesis or ultrasonography is important. If major abnormalities are present, the pregnancy can be terminated or an optimal management strategy can be planned.

(Choices A and B) Switching to another drug is not recommended for this patient because: (1) it can precipitate a seizure, (2) it can increase the risk for the fetus due to overlapping effects with valproate, and (3) it has a minimal possible benefit because pregnancy has already been established for 12 weeks.

(Choice C) There is no direct evidence that supplementing folic acid may decrease the risk of neural tube defects in patients taking anti-epileptic drugs; however, animal studies have established that at least phenytoin and valproic acid can lower the concentration of certain forms of folate and can cause neural tube defects.

For this reason, high dose (4mg/day) folic acid is recommended prior to conception (one to 3 months) and during the first trimester of pregnancy. Once the organogenesis period is over, the role of folic acid prevention is very limited.

[ArchivalUser]

Thanks Dr Bumba, i did not see u post, Keppra.. i will note it, appreciate your updated info.

[ArchivalUser]

sorry , i mean Carbamazapine.

[ArchivalUser]

http://www.healthcareimprovementscotland...e3651f78e7&version=-1


Yes, this is grade c recommendation, we can continue valproate, as divided dose to two times or slow release.

Thanks all.