Women With Epilepsy: 'Shocking' Childbirth Outcomes

July 10, 2015

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.

More Questions than Answers?

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.

For the retrospective cohort study, the researchers assessed outcomes in more than 20 million pregnant women from delivery hospitalization records from the 2007-2011 Nationwide Inpatient Sample, a representative sample of 20% of all US hospitals. The sample included 69,385 women diagnosed with epilepsy identified from International Classification of Diseases, Ninth Revision (ICD-9), codes.

Results showed that women with epilepsy had a risk for death during the delivery hospitalization of 80 per 100,000 pregnancies, significantly higher than the 6 deaths per 100,000 pregnancies found among women without epilepsy (adjusted odds ratio [OR], 11.46).

Women with epilepsy were also at a heightened risk for other adverse outcomes, including preeclampsia (OR, 1.59), preterm labor (OR, 1.54), and stillbirth (OR, 1.27) and had increased healthcare utilization, including an increased risk for cesarean delivery (OR, 1.40) and prolonged length of hospital stay (>6 days) among both women with cesarean deliveries (OR, 2.13) and women with vaginal deliveries (OR, 2.60).

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.

Inaccurate Data?

She noted that while the data are certainly worrying, there are many uncertainties as to how to interpret them.

"Whoever these women are that they have identified need to be carefully monitored. But we are not sure who these women are. Because they used ICD-9 diagnostic codes to identify women with epilepsy, this can be misleading. Codes are notoriously inaccurate.

"They may not all have had epilepsy. A seizure does not always mean epilepsy. There was also no indication of cause of death. What did these women die of? What should we be concerned about? I'm concerned that this data may cause panic, but is that justified given all the uncertainty over what is going on?" she added.

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.

'We have asked whether we have overrepresented a certain type of hospital or patient and we couldn't dismiss this. But even if the risk is a half or even a quarter of what we found that would still be an excess and needs to be taken seriously," he added.

The study was supported by the National Institute for Mental Health and the Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health. The study authors have disclosed no relevant financial relationships. The editorialists' disclosures are available at http://archneur.jamanetwork.com/journal.aspx

JAMA Neurol. Published online July 6, 2015. Full text Editorial

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