Эпилепсия и беременность

[Armoracia]

Дорогие коллеги акушеры-гинекологи. Какой способ родоразрешения при эпилепсии вы предпочитаете - естественным путем или кесаревым сечением? Как вы считаете, нужно ли оперировать всех пациенток с эпилепсией? Дело в том, что в нашем городе эпилептологи многим пациенткам с эпилепсией рекомендуют родоразрешение кесаревым сечением, даже при отсутствии приступов в течение длительного времени. Имея опыт родоразрешения таких пациенток естественным путем без каких либо осложнений и, считая, что в случае контролируемого течения болезни предпочтительно влагалищное родоразрешение, хочется узнать, каковы все-таки показания к кесареву сечению при эпилепсии. Буду благодарен за ответ, ссылки на источники и др.

[Dr.Vad]

Epilepsia. 2009 May;50(5):1229-36.
Management issues for women with epilepsy-Focus on pregnancy (an evidence-based review): I. Obstetrical complications and change in seizure frequency: Report of the Quality Standards Subcommittee and Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology and the American Epilepsy Society.
Harden CL, Hopp J, Ting TY, Pennell PB, French JA, Allen Hauser W, Wiebe S, Gronseth GS, Thurman D, Meador KJ, Koppel BS, Kaplan PW, Robinson JN, Gidal B, Hovinga CA, Wilner AN, Vazquez B, Holmes L, Krumholz A, Finnell R, Le Guen C; American Academy of Neurology; American Epilepsy Society.
University of Miami, Miami, Florida, USA.

A committee assembled by the American Academy of Neurology (AAN) reassessed the evidence related to the care of women with epilepsy (WWE) during pregnancy, including the risk of pregnancy complications or other medical problems during pregnancy, change in seizure frequency, the risk of status epilepticus, and the rate of remaining seizure-free during pregnancy. The committee evaluated the available evidence according to a structured literature review and classification of relevant articles. For WWE who are taking antiepileptic drugs (AEDs), there is probably no substantially increased risk (>2 times expected) of cesarean delivery or late pregnancy bleeding, and probably no moderately increased risk (>1.5 times expected) of premature contractions or premature labor and delivery. There is possibly a substantially increased risk of premature contractions and premature labor and delivery during pregnancy for WWE who smoke. WWE should be counseled that 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. WWE who smoke should be counseled that they possibly have a substantially increased risk of premature contractions and premature labor and delivery.

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BJOG. 2011 Jul;118(8):956-65.
Obstetric outcome in women with epilepsy: a hospital-based, retrospective study.
Borthen I, Eide MG, Daltveit AK, Gilhus NE. Department of Clinical Medicine, University of Bergen, Norway.

OBJECTIVE: To report the complications during pregnancy and delivery in women with epilepsy, compared with a control group without epilepsy, with special focus on potential risk factors, such as epilepsy severity and dosage of antiepileptic drugs.

DESIGN: Hospital-based retrospective study.

SETTING: Data from pregnancy notification forms and hospital case records.

POPULATION: Women with a past or present history of epilepsy (n = 205) delivered in Bergen, Norway, in the period 1999-2006, and a matched control group of women (n = 205) without epilepsy.

METHODS: Data were compared and odds ratios (ORs) with 95% confidence intervals (CIs) were calculated by multiple logistic regression models.

MAIN OUTCOME MEASURES: Pre-eclampsia (mild and severe), gestational hypertension, vaginal bleeding (early and late), caesarean section, vaginal operative delivery, postpartum haemorrhage and major malformations.

RESULTS: Women with epilepsy using antiepileptic drugs had an increased risk of severe pre-eclampsia (OR, 5.0; 95% CI, 1.3-19.9), bleeding in early pregnancy (OR, 6.4; 95% CI, 2.7-15.2), induction (OR, 2.3; 95% CI, 1.2-4.3) and caesarean section (OR, 2.5; 95% CI, 1.4-4.7) adjusted for maternal age, parity, education, smoking, medical conditions and body mass index ≥30 kg/m(2) . There was also an increased risk of malformations in the offspring (OR, 7.1; 95% CI, 1.4-36.6). Women without antiepileptic drug use had increased risks of forceps delivery and preterm birth. Active epilepsy (seizures during the last 5 years) versus nonactive epilepsy did not discriminate for any of these complications; 84.5% of women with epilepsy and antiepileptic drug use were using folate.

CONCLUSION: Women with epilepsy using antiepileptic drugs had an increased risk of pregnancy and delivery complications, whereas women not using antiepileptic drugs had few complications. Seizures, high doses of antiepileptic drugs, obesity and lack of folate could not explain these increased risks.