Valproate usage in pregnancy: An audit from the Kerala Registry of Epilepsy and Pregnancy.

OBJECTIVE: This is an audit of the use of valproate (VPA) during pregnancy in women with epilepsy (WWE). METHODS: We identified all pregnancies exposed to VPA in the Kerala Registry of Epilepsy and Pregnancy between January 2010 and December 2019. Subjects' past usage of antiepileptic drugs (AEDs), seizure count before and during pregnancy, fetal outcome, and major congenital malformations (MCMs) were abstracted from the registry records. The presumed reason for usage of VPA was deducted from the clinical records. RESULTS: There were 221 pregnancies (17.75%) exposed to VPA (monotherapy, n = 149) during the audit period. The MCM rate for the completed pregnancies exposed to VPA was higher (n = 20, 10.36%) than that of VPA-unexposed pregnancies (n = 39, 4.96%). The relative risk for MCM with VPA exposure was 2.1 (95% confidence interval = 1.24-3.48, number needed to treat with VPA to result in MCM = 19). Reasons for using VPA during pregnancy (some women had more than one reason) were (1) VPA was the first AED prescribed and was effective (68, 29.06%), (2) other AEDs were ineffective (128, 54.70%), and (3) other AEDs were discontinued due to adverse effects (17, 7.28%). Other reasons (21, 8.97%) were (1) VPA was selected after the epilepsy classification was revised (3, 1.28%), (2) other AEDs were expensive (2, .85%), and (3) patient switched to VPA from other AEDs for unspecified reason (16, 6.83%). VPA was discontinued during pregnancy for 6 (2.71%) persons. Less than 10% of women were tried on lamotrigine or levetiracetam before switching to VPA. SIGNIFICANCE: Nine MCMs per thousand pregnancies can be avoided if VPA is not used in WWE. Safe and effective AEDs as alternatives to VPA are the need of the hour. Professional bodies and regulatory authorities need to implement updated guidelines on AED usage in girls and women.

Grid-Based Preconception Counseling Can Facilitate Shared Decision Making for Women with Epilepsy.

Women with epilepsy (WWE) and their care providers are equally concerned about the risk of seizures and adverse effects of using antiepileptic drugs (AED) during pregnancy to the mother and the baby. The risk of death or other complications during the pregnancy period is high when WWE continue to have seizures. Antenatal exposure to valproate and several other AEDs as monotherapy and polytherapy is associated with a higher risk of Major Congenital Malformations (MCM). The risk of MCM is dose dependent for valproate and several other AEDs. Children who were exposed to AEDs in the antenatal period demonstrate impaired intelligence and language functions when examined in early childhood, and this effect endures into the second decade of life also. There is considerable difficulty in communicating the complexities of the benefits and risks of using AEDs during the preconception period and pregnancy to the women and their relatives. In this technical note, we are presenting the grid-based preconception counseling of the risk and benefits of different treatment options to facilitate shared decision making. The clinician elicits the preferences and concerns of WWE in the first column of the grid. The potential outcomes of different treatment options concerning these preferences and concerns are presented in the remaining columns of the grid so that a shared decision can be reached. This option grid provides an opportunity to the WWE to review the options holistically and make appropriate decisions.