Obs teaching 3

Question 1

What are some secondary causes of seizures?

Answer 1

• Surgery to the cerebral hemispheres
• Intracranial mass lesion
• Antiphospholipid syndrome
• Eclampsia
• Cerebral vein thrombosis (CVT)
• Thrombotic thrombocytopenic purpura (TTP)
• Stroke/ intracranial haemorrhage

Question 2

What is the effect of pregnancy on epilepsy?

Answer 2

Mostly has no effect

64%: remained unchanged
17%: had an increase
16%: decrease in seizures in pregnancy

Question 3

Why is the immediate post partum period high risk for exacerbation of seizure frequency?

Answer 3

increased stress
sleep deprivation
missed medication
anxiety

Question 4

What is sudden unexplained death in epilepsy (SUDEP)?

Answer 4

Sudden, unexpected, nontraumatic and non-drowning death in patients with epilepsy, and excluding status epilepticus

Risk factors: uncontrolled epilepsy, women on multiple antiepileptic drugs, and early onset epilepsy

Question 5

What are the effects of epilepsy on the pregnancy?

Answer 5

Small but significant increased risk of:
- Odds of spontaneous miscarriage OR 1.54
- Antepartum haemorrhage OR 1.49
- Hypertensive disorders OR 1.37
- Induction of labour OR 1.67
- Caesarean section OR 1.40
- Foetal growth restriction OR 3.51
- Postpartum haemorrhage OR 1.33

Question 6

What is OR in statistics?

Answer 6

Odds ratio

Question 7

What are some congenital malformations associated with antiepileptic drugs?

Answer 7

Neural tube defects
- Valproate (1-3.8%)
- Carbamazepine (0.51%)

Orofacial clefts
- Phenytoin, carbamazepine, phenobarbitone

Congenital heart defects
- Phenytoin, phenobarbitone and valproate

Foetal anticonvulsant syndrome
Hypospadias

Question 8

What is hypospadias?

Answer 8

When the urethra develops on the underside of the penis

Question 9

Which interventions can minimise incidence of congenital malformations with antiepileptic drugs?

Answer 9

• Folic acid hight dose (5 mg/day) can be used pre-conception
• Use lowest effective dose
• Change to monotherapy if possible
• Avoid teratogenic agents (particularly sodium valproate) when planning for pregnancy

Question 10

Why is vitamin K given to babies born to epileptic mothers?

Answer 10

When the mother is taking enzyme-inducing epilepsy medication, 1mg of intramuscular vitamin K is given to prevent haemorrhagic disease of the new born

Eg. Carbamazepine, phenytoin, phenobarbital, primidone, oxcarbazepine, topiramate, esli-carbaepine

Question 11

What is the clinical effect of anaemia on pregnancy?

Answer 11

• Maternal Morbidity and mortality
• General effect on quality of life
• Increased risk postpartum haemorrhage, blood transfusion and cardiac failure
• Puerperal sepsis
• Foetus and infant
• Low birth weight and IUGR
• Preterm labour
• ? Cognition and language development in the neonate

Question 12

What are the contraindications of IV iron therapy during pregnancy?

Answer 12

• Decompensated liver disease
• Acute or chronic bacteraemia
• 1st trimester of pregnancy7
• Previous Hx of anaphylaxis or reaction to transfusion

Question 13

What is obstetric cholestasis?

Answer 13

• Itchy skin
• No skin rash
• Abnormal LFT’s

Resolves after birth

Question 14

What is the pathophysiology of obstetric cholestasis?

Answer 14

Exact cause is unknown
- Genetic: mutations affecting hepatic bile salt transport molecules, also been found in patients with progressive familial intrahepatic cholestasis
- Hormonal: Excess circulating oestrogen and/or progesterone (eg. COCP, progesterone for preterm labour)
- Environmental: more common in winter

Question 15

What are the consequences of obstetric cholestasis?

Answer 15

• Can cause serious foetal morbidity such as; preterm birth, iatrogenic pre-term induction or foetal death
• Increased bile salts in maternal blood can cross the placenta and bile salts can precipitate in baby’s brain and cause kernicterus

Question 16

What is Kernicterus?

Answer 16

Bilirubin-induces neurological damage

Question 17

How does obstetric cholestasis present?

Answer 17

Most common
- Itching, in particular but not limited to that of the palms of the hands and soles of the feet, without presence of a rash
- Itching that is more noticeable in the evening
- Darker urine

Less common
- Lighter stools
- Increased clotting time (due to possibly associated vitamin K deficiency)
- Fatigue
- Increased nausea
- Decrease in appetite
- Jaundice (less than 10% of women)
- Upper right quadrant pain

Question 18

What are some differentials for obstetric cholestasis?

Answer 18

Exclude other causes of itching during pregnancy
- Polymorphic eruption of pregnancy (PEP)
- Pemphigoid gestationis
- Atopic eruption of pregnancy
- Pruritic folliculitis of pregnancy

Exclude other causes of impaired liver function
- Hepatitis A, B, and C, Epstein Barr and cytomegalovirus, autoimmune
- Primary biliary cirrhosis
- Pre-eclampsia
- Acute fatty liver of pregnancy

Question 19

What is Polymorphic eruption of pregnancy (PEP)?

Answer 19

An itchy, bumpy rash that starts in the stretch marks of the abdomen in the last 3 months of pregnancy then clears

Question 20

What is Pemphigoid gestationis?

Answer 20

An intensely itchy urticaria-like rash during mid to late pregnancy

Diagnosed with skin biopsy and treated with steroids