Childbirth mortality in women with epilepsy

Women with epilepsy are at heightened risk for many adverse outcomes during childbirth, including a more than 10-fold increased risk for death, new research shows.

"These results are quite shocking. We are recommending that women with epilepsy are viewed as high risk when it come to delivery and should be triaged to an appropriate center with expert neurology care on hand," lead author, Sarah MacDonald, BSc, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, told Medscape Medical News.

The study was published online July 6 in JAMA Neurology.

But the study "raises far more questions than it answers," write Jacqueline A. French, MD, Langone School of Medicine, New York, and Kimford Meador, MD, Stanford University School of Medicine, Palo Alto, California, in an accompanying editorial. They point out that most women with epilepsy have uncomplicated pregnancies.

"My take-home message from these results would be: 'Don't panic, take care and learn more.' I would advise women with epilepsy not to worry too much but to have their baby in hospital rather than at home, and if possible choose a hospital where a neurologist would be available, that is, a tertiary center," Dr French told Medscape Medical News...

MacDonald said the reasons for the high death risk in this patient population could not be ascertained from this study.

"We reported what was happening between 2007 and 2011 in women with epilepsy in the US. This is absolutely what happened. We can't address cause or which particular women were more at risk from these data. We did find that women with epilepsy were more likely to have other comorbidities, such as renal disease, hypertension, diabetes, and depression, but we couldn't assess whether this explains the risk of death."

Dr French said that the death rate for the women with epilepsy worked out to about 1 in 1000.
"This is very high. I don't know what to do with this data. My colleagues are equally stymied. We know that many women with epilepsy can deliver without a problem, but this study makes us ask whether there is a subset who are at risk and if so, who are they?" she said...

Dr French noted that the only other major study of women with epilepsy during pregnancy was conducted in the United Kingdom; it also showed a higher mortality rate, but none of the deaths happened during the delivery period. 'The two studies both find an increased risk but at different stages of pregnancy."

The study's principal investigator, Thomas F. McElrath, MD, Brigham and Women's Hospital, Boston, Massachusetts, told Medscape Medical News that traditionally physicians thought that women with epilepsy were at no greater risk for poor outcomes in childbirth than the general population.

"These results were a surprise to me too and I have been practicing obstetrics for 20 years. We never thought the event rate would be as high as this. We have tried to look at the various comorbidities, such as hypertension, pre-eclampsia, et cetera, but when we take these out we still find an increased risk. Similarly we know women with epilepsy are more likely to have a C-section, but after accounting for this the death rate is still much higher," said Dr McElrath.

See:  http://www.medscape.com/viewarticle/847757?nlid=84043_2863&src=wnl_edit_dail&uac=60196BR&impID=760377&faf=1

Sarah C. MacDonald, BSc; Brian T. Bateman, MD, MSc; Thomas F. McElrath, MD, PhD; Sonia Hernández-Díaz, MD, DrPH.  Mortality and Morbidity During Delivery Hospitalization Among Pregnant Women With Epilepsy in the United States.  JAMA Neurol. Published online July 06, 2015

Jacqueline A. French, MD; Kimford Meador, MD.  Risks of Epilepsy During Pregnancy: How Much Do We Really Know?  JAMA Neurol. Published online July 06, 2015