Pregnancy complications and outcomes in women with epilepsy

doi:10.4236/ojog.2012.23047

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Open Journal of Obstetrics and Gynecology, 2012, 2, 230-234 OJOG

http://dx.doi.org/10.4236/ojog.2012.23047 Published Online September 2012 (http://www.SciRP.org/journal/ojog/)

Pregnancy complications and outcomes in women

with epilepsy*

Mirzaei Fatemeh1#, Ebrahimi B. Nazanin2

1Physiology Research Center, Department of Obstetrics and Gynaecology, Afzalipour Hospital, Kerman University of Medical

Sciences, Kerman, Iran

2Department of Obstetrics and Gynaecology, Afzalipour Hospital, Kerman University of Medical Sciences, Kerman, Iran

Email: #[email protected]

Received 21 March 2012; revised 26 April 2012; accepted 10 May 2012

ABSTRACT

Epilepsy is the most common serious neurological

disorder. This is prospective study to investigate whe-

ther women with epilepsy have an increased risk of

fetal and maternal complications during pregnancy.

In this descriptive cross-sectional study, 50 pregnant

women who were presented for delivery at Afzalipour

Hospital, Kerman, Iran during 2003 to 2009 were

assessed. The groups were compared using the Stu-

dent’s t-test, and one-way-ANOVA for continuous

variables and the chi-square test (or Fisher’s exact

test if required) for categorical variables. P values of

0.05 or less were considered statistically significant.

All the statistical analyses were performed using

SPSS version 13 (SPSS Inc, Chicago, IL, USA) for

Windows. In 32 (64%) of cases no fetal complication

was found, in 5 cases (10.0%) intrauterine growth

retardation (IUGR), in 2 cases (4.0%) post-term labor,

in 2 cases (4.0%) fetal distress and in 9 cases (18.0%)

preterm labor were found. In 15 patients (30.0%) no

maternal complication was found; in 2 cases (4.0%)

pregnancy induced hypertension (PIH), in 12 cases

(24.0%) preterm labor , in 4 cases (8.0%) bleeding, in

14 cases (28.0%) premature rupture of the mem-

branes (PROM) and in 3 cases (6.0%) other compli-

cations were detected. Given these findings and pre-

vious studies, it seems that epileptic women required

more care during pregnancy and the rate of maternal,

fetal and obstetrical complications are relatively high

among them.

Keywords: Epilepsy; Maternal Complications; Fetal

Complications

1. INTRODUCTION

However about half of epileptic women are those in fer-

tile ages, the effects of epilepsy, seizures attacks and an-

tiepileptic drugs on pregnancy is not still accurately clear.

Most of the women with epilepsy spend natural preg-

nancy duration and will have safe labor [1]. It is obvious

that a woman with epilepsy faces a variety number of

problems during her pregnancy. Thus, she should be in

contact with her physician, because delivery a healthy

baby will compensate this care. Fortunately more than

90% of epileptic women have successful pregnancy and

deliver healthy children [2].

One of the potential dangers during pregnancy is com-

plications of antiepileptic drugs, since some of these

drugs have side effects on fetus. Fortunately, there are

drugs with lower side effects on pregnant women which

they should consult their physicians for further informa-

tion. Decrease in amount or arbitrary discontinuation of

drugs during pregnancy not only decreases the dangers,

will increase the risk of seizure as well [3,4]. Prenatal

consult should be begun before starting pregnancy. When

a patient intends to be pregnant and her seizure attacks

are not controlled, her attacks should be controlled with

appropriate drugs, as it is possible. The assessment of

genetic history of the family is also important [5,6].

When there is not a clear genetic problem consults with

genetic specialist before pregnancy will be of great value.

Generally, the consult process should not perform in a

hurry. The most appropriate time for pregnancy is when

patients have been consulted before pregnancy, reevalu-

ated, her drugs have been set and her attacks have been

controlled [7]. Since it is not possible to definitely com-

ment about outcome of pregnancy in epileptic women,

they should be closely followed during pregnancy [8,9].

In previous studies on pregnant women with epilepsy

a variety number of complications have been reported

including preterm labor, small-for gestational age (SGA),

low birth weight (LBW) [10-13], spontaneous miscar-

riage, anemia, seizure during pregnancy [14], high rate of

cesarean section (CS), gestational diabetes, congenital

malformation, incidence of pregnancy induced hyperten-

*Disclosure of interest: None of the authors has conflict of interest.

#Corresponding author.

OPEN ACCESS

M. Fatemeh, E. B. Nazanin / Open Journal of Obstetrics and Gynecology 2 (2012) 230-234 231

sion (PIH), need to labor induction and also high rate of

fetal malformation [15]. In a study by Harden C., in the

United States it is revealed that consumption of anti-

epileptic drugs during pregnancy will decrease preg-

nancy complications in women with epilepsy [13]. In

contrast, Meador K., et al. in a study in the United States

confirmed higher fetal complications in epileptic women,

and especially those consumed several drugs simulta-

neously [10].

In other study by Borna S., et al. in Iran in 2006, LBW

and obstetrical complications including preterm labor,

premature rupture of the membranes (PROM) and pre-

eclampsia were two times more seen in epileptic women

compared to healthy group; however generally no chief

complication was detected [11]. In contrast, in a study by

Saleh K.M., et al. in Saudi Arabia in 2008, no significant

difference was confirmed for fetal complications be-

tween epileptic and non-epileptic women [12].

2. MATERIAL AND METHODS

This is a descriptive cross-section study on 50 pregnant

women with epilepsy who were presented at Afzalipour

Hospital, Kerman, Iran during 2003 to 2009. Afzalipoor

hospital Institutional Research Review Board approved

the study; furthermore, the study was carried out under

the Health Ministry Ethics protocols. Data were collected

from the computerized perinatal database that contains

information recorded by an obstetrician, immediately

after delivery.

The clinical characteristics of the mother such as ma-

ternal age, gravidity, duration of epilepsy and frequency

of seizure, use of anti epileptic drugs were recorded in a

detailed check list.

The Outcome of interest in this study was PIH (preg-

nancy induced pregnancy), preterm labor, PROM (pre-

mature rupture of membrane), bleeding during of preg-

nancy, mode of delivery, neonatal birth weight. Gesta-

tional age was based on the last menstrual period (LMP)

and confirmed by ultrasound examination, prior to 20

weeks gestation. PIH include: preeclampsia, gestational

hypertension. Gestational hypertension was defined as

blood pressure ≥ 140/90 mmHg on two measurements

taken at least 6 hours apart and after 20th week of gesta-

tion. Diagnostic criteria for preeclampsia were blood

pressure ≥ 140/90 mmHg with proteinuria.

PROM was identified according to standard clinical

criterion, including the patient’s history, a presence of a

vaginal pool, a positive Nitrazine test, ferning, and the

amounts of amniotic fluid estimated by ultrasonography.

Preterm labor was attributed to the start of labor at gesta-

tional age of 20 - 38 weeks. IUGR was defined as fetal

birth weight leaser than 10th percentile for gestational

age.

Results were reported as mean ± standard deviation

(SD) or median for quantitative variables and percent-

ages for categorical variables. The groups were com-

pared using the Student’s t-test, and one-way-ANOVA

for continuous variables and the chi-square test (or

Fisher’s exact test if required) for categorical variables. P

values of 0.05 or less were considered statistically sig-

nificant. All the statistical analyses were performed using

SPSS version 13 (SPSS Inc., Chicago, IL, USA) for

Windows.

3. RESULTS

A total number of 50 women (mean age: 25.81 ± 5.26

years) were entered the study. The mean duration of epi-

lepsy was 8.38 ± 8.06 years; the mean frequency of sei-

zure was 1.53 ± 0.74. The mean gravidity and parity was

2.35 ± 1.25 and 1.8 ± 092. Thirty seven (74%) of patients

underwent cesarean section and 13 (26%) had natural

vaginal delivery (NVD).

In studied population 23 women (46.0%) did not re-

ceive any drug for epilepsy, 18 (36%) received only car-

bamazepine, 9 (18%) consumed more than one drugs and

33 (66%) received folic acid.

In 32 cases (64%) no fetal complication was record.

The most common fetal complication was preterm labor

in 9 cases (18%), followed by IUGR in 5 cases (10.0%).

The most common maternal complication was PROM

(28.0%), followed by PLP (24.0%), 15 cases (30.0%)

showed no maternal complications (Table 1).

In 62.2% of women underwent C/S and 69.2% of

women with NVD no fetal complication was found, no

statistical difference was found in fetal complication

Table 1. Absolute and relative frequency of fetal and maternal

complications among epileptic women.

Complications Number Percentage

IUGR 5 10

Post term 2 4

Fetal distress 2 4

Preterm 9 18

Fetal

complications

None 32 64

PIH 2 4

PLP 12 12

Bleeding 4 4

PROM 14 14

Others 3 3

None 30 15

Maternal

complications

Total 50 100

M. Fatemeh, E. B. Nazanin / Open Journal of Obstetrics and Gynecology 2 (2012) 230-234

232

OPEN ACCESS

based on types of labor (P = 0.305). There was a signifi-

cant relation between antiepileptic drugs and fetal com-

plications (P = 0.001), and women who were under treat-

ment with carbamazepine showed lower fetal complica-

tions compared to others. No significant relation was

found between fetal complications and using folic acid (P

= 0.154) (Table 2).

A significant relation was confirmed between maternal

complications and kind of labor (P = 0.003), and the rate

of maternal complications was greater in women with

NVD and also patients with prenatal complications mostly

had NVD. There was no statistically significant associa-

tion between types of antiepileptic drugs and maternal

complications (P = 0.89) while a significant relation was

found between consumption of folic acid and maternal

complications (P = 0.004); the complication rate was

lower in women who consumed folic acid during pre-

gnancy (Table 3).

4. DISCUSION

Epilepsy and seizure are one of the most important dis-

eases during pregnancy. It is obvious that a woman with

epilepsy may suffer many problems during pregnancy.

Thus, she should be constantly in contact with her physi-

cian, because delivery of a healthy baby compensates

this care [2,3]. Fortunately, more than 90% of epileptic

women would have a successful pregnancy and deliver

healthy children; however it is not possible to definitely

make comment about this issue, these patients should be

followed frequently during pregnancy [4,5].

This study is designed to assess the outcome of preg-

nancy (maternal, fetal and obstetrical complications)

among women with epilepsy who presented to Afzali-

pour Hospital during 2003 and 2009.

In this study, in 32 (64%) of cases no fetal complica-

tion was found, in 5 cases (10.0%) IUGR was detected

which had no difference with low birth weight during

pregnancy, in 2 cases (4.0%) post-term labor, in 2 cases

(4.0%) fetal distress and in 9 cases (18.0%) preterm labor

were found. It seems that preterm labor is more common

during pregnancy. In continence with to our findings, in a

study by Chen Y.H., et al. in Taiwan in 2009, preterm

labor was found to be an important complication due to

epilepsy followed by SGA and LBW [8]. Meanwhile, in

other study by Borna S., et al. in Iran in 2006, LBW and

obstetrical complications including preterm labor, PROM

and preeclampsia were two times more seen in epileptic

women compared to healthy group; however generally

no chief complication was detected [11], which is similar

to our results. In contrast, in a study by Saleh A.M., et al.

Table 2. Association between fetal complication and kind of delivery, anti-epileptic drugs and folic acid in women with epilepsy.

Variables None IUGR Post-termFetal distress Preterm P value

Cesarean section 23 (62.2) 5 (13.5) 2 (5.4) 2 (5.4) 5 (13.5)

Kind of labor

NVD 9 (69.2) 0 (0.0) 0 (0.0) 0 (0.0) 4 (30.8)

0.305

None 14 (60.9) 3 (13.0) 0 (0.0) 0 (0.0) 6 (26.1)

Carbamazepine 16 (88.9) 0 (0.0) 2 (22.2) 0 (0.0) 2 (22.2)

Antiepileptic drugs

More than one drug 2 (22.2) 2 (22.2) 0 (0.0) 2 (22.2) 3 (33.3)

0.001

Yes 20 (60.6) 5 (15.2) 2 (6.1) 2 (6.1) 4 (12.1)

Folic acid

No 12 (70.6) 0 (0.0) 0 (0.0) 0 (0.0) 5 (29.4)

0.154

Table 3. Association between maternal complications and types of delivery, anti-epileptic drugs and folic acid in women with epi-

lepsy.

Variables None PIH PLP Bleeding Prom Others P value

Cesarean section 13 (35.1)0 (0.0) 12 (32.4)2 (5.4) 7 (18.9) 3 (8.1)

Kind of labor

NVD 2 (15.4) 2 (15.4)0 (0.0) 2 (15.4) 7 (53.8) 0 (0.0)

0.003

None 5 (21.7) 2 (8.7) 6 (26.1) 0 (0.0) 8 (34.8) 2 (8.7)

Carbamazepine 8 (44.4) 0 (0.0) 2 (11.1) 4 (22.2) 3 (16.7) 1 (5.6)

Antiepileptic drugs

More than one drug 2 (22.2) 0 (0.0) 4 (44.4) 0 (0.0) 3 (33.3) 0 (0.0)

0.089

Yes 11 (33.3) 0 (0.0) 11 (33.3) 4 (12.1) 7 (21.2) 0 (0.0)

Folic acid

No 4 (23.5) 2 (11.8)1 (5.9) 0 (0.0) 7 (41.2) 3 (17.6)

0.004

M. Fatemeh, E. B. Nazanin / Open Journal of Obstetrics and Gynecology 2 (2012) 230-234 233

in Saudi Arabia in 2008 no significant difference was

confirmed for fetal complications between epileptic and

non-epileptic women [12].

Regarding maternal complications, in 15 patients

(30.0%) no complication was found, in 2 cases (4.0%)

PIH, in 12 cases (24.0%) PLP, in 4 cases (8.0%) bleeding,

in 14 cases (28.0%) PROM and in 3 cases (6.0%) other

complications were detected. In a study by Thomas SV,

et al in India in 2008, it was illustrated that spontaneous

miscarriage, anemia and seizure are the most important

complications in pregnant women [13]. In other study by

Kats O., et al. in Israel in 2006, high rate of gestational

diabetes and congenital malformation was reported in

epileptic pregnant women [14]. In our study we also

found a considerable rate (74.0%) of cesarean section. In

a study by Richmond J.R., et al. in Canada in 2004, it

was revealed that the rate of PIH which required induc-

tion and fetal malformation is high in epileptic women;

we also found some cases of PIH in our study. In contrast

to our findings, in a study by Saleh A.M., et al. in Saudi

Arabia in 2008 no significant difference was detected for

maternal complications in epileptic and non-epileptic

women, they had totally 4 cases of seizure and 2 cases of

fetal disorders [12].

There was a significant association between maternal

complications and types of labor (P = 0.003); patients

with prenatal complications had more NVD, but a same

association was not found for fetal complications and

types of labor (P = 0.305).

Fetal complications and types of antiepileptic drugs

showed a significant relation (P = 0.001) and the fetal

complication rate was lower in those who consumed

carbamazepine. In a study by Meador K., et al. in the

United States in 2008, it was illustrated that fetal com-

plication are more in epileptic women especially those

consume several anti-epileptic drugs [10], which is simi-

lar to our findings.

No statistical association was confirmed between an-

tiepileptic drugs and maternal complications (P = 0.898),

in a study by Harden C., et al. in the United States in

2010, it was found that consumption of anti-epileptic

drugs during pregnancy can reduce complications [9],

our results also revealed lower complications in women

under treatment with carbamazepine.

There was no significant association between fetal

complications and consumption of folic acid (P = 0.154)

while a significant relation was found between maternal

complications and consumption of folic acid (P = 0.004),

and the complications was lower in those consumed folic

acid during pregnancy.

5. CONCLUSION

Given these findings and previous studies, it seems that

epileptic women required more care during pregnancy

and the rate of maternal, fetal and obstetrical complica-

tions are relatively high among them which implies the

necessity of targeted plans to reduce such complications.

Inability to follow some cases, low sample size and

inexistence of a control group are some limitations of

this study which are recommended to be considered in

further studies beside investigation about effects of other

factors on such complications.

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