Drug-resistant epilepsy in women: Making the case for surgery before pregnancy

For women with drug‐resistant focal epilepsy planning to conceive, undergoing surgery prior to pregnancy is the best option, with outcomes being more favourable than choosing to defer the procedure until after giving birth or opting for pharmacotherapeutic management, a study suggests.

“The precise timing of surgery before or after pregnancy had been a dilemma for women with epilepsy and their caregivers,” according to a team of researchers from Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST) in Trivandrum, India.

“Successful surgery for epilepsy may lead to total seizure freedom and withdrawal of antiepileptic drugs (AEDs), and this subgroup probably has the least risk to the mother and the child,” they added.

In the study, the team looked at three groups of female drug-resistant focal epilepsy patients with completed pregnancies. The first comprised 67 women who underwent surgery prior to conception (surgery-first group), while the second consisted of seven women who deferred the procedure until after the pregnancy (pregnancy-first group). The last was a comparator group that included 134 women who were medically managed.

Seizure frequency in the pre-pregnancy month was similar in the surgery-first and comparator groups (mean, 0.30 vs 0.52; p=0.184), but the frequency increased more in the latter during pregnancy (14.9 percent vs 39.6 percent; p=0.001). [Epilepsia 2020;doi:10.1111/epi.16613]

Also, there were fewer instances of AED dose escalation during pregnancy among women who had undergone surgery (14.9 percent vs 28.4 percent; p=0.025).

In terms of pregnancy outcomes, preterm deliveries occurred more frequently in the surgery-first than the comparator group (24.6 percent vs 12.2 percent; p=0.029). There were no significant differences seen in the rates of foetal loss (10.4 percent vs 6.7 percent; p=0.255), caesarean delivery (48.3 percent vs 41.3 percent; p=0.0543), major congenital malformations (8.5 percent vs 11.1 percent; p=0.395), and child having development quotient of <85 at 1 year of age (42.5 percent vs 42.3 percent; p=0.569).

Meanwhile, compared with women in the pregnancy-first group, those in the surgery-first group had better outcomes in terms of AED dose escalation (14.9 percent vs 85.7 percent; p=0.001), seizure control during pregnancy (proportion of women with seizure increase, 14.9 percent vs 100 percent; p=0.001), and the incidence of child having development quotient of <85 at age 1 year (41.0 percent vs 100 percent; p=0.005).

“Our data have demonstrated that compared to women who had pregnancy first [and those who were medically managed], the women who had surgery first had better outcomes in terms of seizure control and AED use during pregnancy,” the researchers said.

These results are encouraging, the team added. This is because seizures during gestation can be detrimental to both mother and foetus, as they increase the risk of several adverse outcomes, including physical trauma and metabolic stress, foetal cardiac deceleration, hypoxia, preterm delivery, and low birth weight. Additionally, antenatal exposure to AEDs may affect the developmental and cognitive outcomes of the infants.  [Arch Neurol 2009;66:979-984; Neurology 2016;86:297-306]

The researchers, however, acknowledged that the risk of major congenital malformation was not significantly different between the comparator and surgery group in the current study, perhaps due to the limited power of the study from a smaller number of cases.

Aside from the small sample size, the study lacked data on newer AEDs such as lamotrigine, levetiracetam, and zonisamide. The researchers underscored a need for larger studies to confirm the findings and to further investigate the risk of developmental outcome, which might be an important signal of possible benefit of pre-pregnancy seizure surgery.