July 16 - Epilepsy

"For when the breath does not find entrance to him, he foams and sputters like a dying person. And the bowels are evacuated in consequence of the violent suffocation; and the suffocation is produced when the liver and stomach ascend to the diaphragm, and the mouth of the stomach is shut up; this takes place when the breath does not enter by the mouth, as it is wont. The patient kicks with his feet when the air is shut up in the lungs and cannot find an outlet, owing to the phlegm; and rushing by the blood upward and downward, it occasions convulsions and pain, and therefore he kicks with his feet."
-Hippocrates, "On the Sacred Disease" ca 400BCE

Late entry here. Pt was a pregnant female who presented with recent seizure activity and had recurrent seizures in the hospital.  She had been off anticonvulsant therapy for some time.  Seizures become more common in about 25% of pregnant women with epilepsy, and a variety of reasons may play a role:

1- increase clearance and larger VD for antiepileptic drugs (AEDs)
2 - noncompliance or cessation of AEDs due to concern for fetal risk
3 - possible lower sz threshold related to stress, sleep loss, and hormonal changes

Key poitns in managing epilepsy in women of childbearing age:

Ideally have effective seizure control before conception

Supplement folate

Use monotherapy at lowest effective dose

Avoid valproate if possible - this drug has the strongest link to teratogenicity.

The newer agents lamotrigine and carbamazepine may have an increase risk of cleft lip and palate.

This article from the Neurology journal reviews the current literature and concludes that no antiepileptic drug has been shown to be conclusively "safe" but registry data indicates that most agents can be used with a low incidence of fetal complications.