Drug treatment of epilepsy: considerations in women of child-bearing age
Editor - We would like to draw attention to the fact that no
anticonvulsant has been shown to be without risk to the fetus in
pregnancy. Associations with neural tube defects and facial clefts are
well recognised but congenital abnormalities alone are a crude indicator
of teratogenicity. Of increasing concern is the risk of intellectual
impairment, frequently only apparent in later childhood. Several studies
which include long-term follow-up are currently underway.
We recognise that anticonvulsant therapy during pregnancy is
unavoidable for many women, for whom attempts should be made to achieve
control using the fewest agents and lowest dose. Nonetheless, we would
particularly like to highlight the women of childbearing age who, despite
being seizure free
for a number of years remain on anticonvulsant therapy rather than risk
the loss of their driving licence if a seizure occurs when therapy is
withdrawn. These women are unable to make informed decisions unless they
are fully aware of the teratogenic risks of their treatment.
More subtle effects of in utero exposure to anticonvulsants are
increasingly recognised in the medical literature, frequently by
developmental paediatricians and clinical geneticists(2,3). The experience
with newer anticonvulsant drugs is limited(4). Failure to appreciate the
risk of neurological impairment to the fetus by clinicians prescribing
anticonvulsants and providing pre-conceptual advice can mislead parents.
Indeed, we are aware of several instances where this omission has resulted
in litigation.
Elisabeth M Rosser Consultant in Clinical Genetics
Louise C Wilson Consultant in Clinical Genetics
Unit for Clinical Genetics
Institute of Child Health
30 Guilford Street
London WC1N 1EH
1 Feely M. Drug treatment of epilepsy. BMJ 1999:318;106-109 (9 Jan).
2 Clayton-Smith J, Donnai D. Fetal valproate syndrome. J Med Genet
1995:32;724-727.
3 Ornoy A, Cohen E. Outcome of children born to epileptic mothers
treated with carbamazepine during pregnancy. Arch Dis Child 1996:75(6);517
-520.
4 Morrell MJ. The new antiepileptic drugs and women: efficacy,
reproductive health, pregnancy and fetal outcome. Epilepsia 1996:37(suppl
6);S34-44.
Rapid Response:
Drug treatment of epilepsy: considerations in women of child-bearing age
Editor - We would like to draw attention to the fact that no
anticonvulsant has been shown to be without risk to the fetus in
pregnancy. Associations with neural tube defects and facial clefts are
well recognised but congenital abnormalities alone are a crude indicator
of teratogenicity. Of increasing concern is the risk of intellectual
impairment, frequently only apparent in later childhood. Several studies
which include long-term follow-up are currently underway.
We recognise that anticonvulsant therapy during pregnancy is
unavoidable for many women, for whom attempts should be made to achieve
control using the fewest agents and lowest dose. Nonetheless, we would
particularly like to highlight the women of childbearing age who, despite
being seizure free
for a number of years remain on anticonvulsant therapy rather than risk
the loss of their driving licence if a seizure occurs when therapy is
withdrawn. These women are unable to make informed decisions unless they
are fully aware of the teratogenic risks of their treatment.
More subtle effects of in utero exposure to anticonvulsants are
increasingly recognised in the medical literature, frequently by
developmental paediatricians and clinical geneticists(2,3). The experience
with newer anticonvulsant drugs is limited(4). Failure to appreciate the
risk of neurological impairment to the fetus by clinicians prescribing
anticonvulsants and providing pre-conceptual advice can mislead parents.
Indeed, we are aware of several instances where this omission has resulted
in litigation.
Elisabeth M Rosser Consultant in Clinical Genetics
Louise C Wilson Consultant in Clinical Genetics
Unit for Clinical Genetics
Institute of Child Health
30 Guilford Street
London WC1N 1EH
1 Feely M. Drug treatment of epilepsy. BMJ 1999:318;106-109 (9 Jan).
2 Clayton-Smith J, Donnai D. Fetal valproate syndrome. J Med Genet
1995:32;724-727.
3 Ornoy A, Cohen E. Outcome of children born to epileptic mothers
treated with carbamazepine during pregnancy. Arch Dis Child 1996:75(6);517
-520.
4 Morrell MJ. The new antiepileptic drugs and women: efficacy,
reproductive health, pregnancy and fetal outcome. Epilepsia 1996:37(suppl
6);S34-44.
Competing interests: No competing interests