Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy

Measure Specification

Epilepsy is associated with reduced fertility, increased pregnancy risks, and risks for malformations in the infant. Treatment of seizures with anti-seizure medications may alter hormone levels, render oral contraceptives less effective and may interfere with embryonic and fetal development. Certain anti-seizure medications may have specific malformation risks.

Folic acid supplementation, monotherapy for epilepsy, using lower doses of medication when possible, and proper obstetrical, prenatal and pre-pregnancy care all should be discussed with the patient so they understand the risks involved and how to mitigate these risks.

[AED=Antiepileptic Drugs; WWE= Women with Epilepsy; MCMs=major congenital malformations; VPA=valproate; PHT=phenytoin; LTG=lamotrigine; CBZ=carbamazepine; PHT=phenytoin; PB=phenobarbital] • There is probably no substantially increased risk (greater than two times expected) of late pregnancy bleeding for WWE taking AEDs (Level B). Neurology 2009; 73(2): 126-132.

• There is probably no moderately increased risk (greater than 1.5 times expected) of premature contractions or premature labor and delivery for WWE taking AEDs (Level B). Neurology 2009; 73(2): 126-132. • Seizure freedom for at least 9 months prior to pregnancy is probably associated with a high likelihood (84%–92%) of remaining seizure-free during pregnancy (Level B).

Neurology 2009; 73(2): 126-132. • Counseling of WWE who are contemplating pregnancy should reflect that there is probably no increased risk of reduced cognition in the offspring of WWE not taking AEDs (Level B). Neurology; 73(2): 133–141. • If possible, avoidance of the use of VPA as part of polytherapy during the first trimester of pregnancy should be considered to decrease the risk of MCMs (Level B).

Neurology; 73(2): 133–141. • To reduce the risk of MCMs, the use of VPA during the first trimester of pregnancy should be avoided, if possible, compared to the use of CBZ (Level A). Neurology; 73(2): 133–141. • To reduce the risk of MCMs, avoidance of the use of polytherapy with VPA during the first trimester of pregnancy, if possible, should be considered, compared to polytherapy without VPA (Level B).

Neurology; 73(2): 133–141. • Avoidance of the use of VPA, if possible, should be considered to reduce the risk of neural tube defects and facial clefts (Level B) and may be considered to reduce the risk of hypospadias (Level C). Neurology; 73(2): 133–141. • CBZ exposure probably does not produce cognitive impairment in offspring of WWE (Level B). Neurology; 73(2): 133–141.

• Avoiding VPA in WWE during pregnancy, if possible, should be considered to reduce the risk of poor cognitive outcomes (Level B). Neurology; 73(2): 133–141. • For WWE who are pregnant, avoidance of VPA, if possible, should be considered compared to CBZ to reduce the risk of poor cognitive outcomes (Level B). Neurology; 73(2): 133–141. • The fact that PB, PRM, PHT, CBZ, LVT, VPA, GBP, LTG, OXC, and TPM cross the placenta may be factored into the clinical decision regarding the necessity of AED treatment for a woman with epilepsy (Level B for PB, PRM, PHT, CBZ, LVT, and VPA, and Level C for GBP, LTG, OXC, and TPM).

Neurology 2009; 73(2): 142-149.

This measure contains one strata defined by a single submission criteria. This measure produces a single performance rate. For the purposes of MIPS implementation, this patient-process measure is submitted a minimum of once per patient during the performance period. The most advantageous quality data code will be used if the measure is submitted more than once.