Authors :
Presenting Author: Pallavi Juneja, MD – Columbia University Irving Medical Center
Charlotte Constantine, Research Volunteer – Worcester Academy; Suzette LaRoche, MD – UNC-Chapel Hill; Catrin Mann, MD – Goethe University Frankfurt; Felix Rosenow, MD – Goethe University Frankfurt; Dionne Swor, DO – University of Toledo
Rationale:
Status epilepticus in pregnancy (SEP) is rare and life-threatening for both mother and fetus. There are well-established guidelines for the management of women with epilepsy during pregnancy. There is little evidence guiding the management of SEP leading to uncertainty among treating physicians. This survey aims to investigate the real-world practices of physicians treating SEP to explore management approaches for improvements in care.
Methods:
An anonymous, electronic survey was distributed between September and December 2021. Respondents shared their past experience managing SEP, including involvement of specialty consultants and if gestational age affects decisions. Respondents were also presented a clinical scenario of new-onset SEP and asked to choose first- and second-line anti-seizure medications (ASMs) as well as therapies for refractory and super-refractory SEP.
Results:
A total of 100 physicians initiated the survey and 95 completed it in full: 87 (87%, 87/100) identified neurology as their primary specialty, 31 had subspecialty training in neurocritical care and 48 in epilepsy and/or clinical neurophysiology. Over half of survey respondents (67%, 67/100) reported ever managing SEP with 48.9% (49/98) having done so in the past year. Most (73%, 73/100) reported that their management approach to SEP is different than that of non-pregnant patients. More than half (58.5%, 58/99) wanted to involve epilepsy consultants when treating SEP and the vast majority opted to involve Obstetrics/Maternal Fetal Medicine consultants (90.8%, 89/98). The majority factored gestational age into their treatment decisions (79%, 79/100). Respondents showed a clear preference for levetiracetam (89.7%, 87/97) in the treatment of benzodiazepine-refractory status epilepticus followed by lacosamide (61%, 60/98) if an additional agent was needed. Valproate and phenobarbital were unlikely to be used. There was less agreement for the management of refractory and super-refractory SEP.
Conclusions:
Respondents' preference for an interdisciplinary team in the management of SEP likely reflects the uniqueness of providing care within the duality of the maternal-fetal relationship. The choice of levetiracetam as first-line ASM is consistent with most respondents’ typical practice likely because it has the lowest risk for teratogenesis compared to other anti-seizure medications (ASMs) recommended for status epilepticus, valproate and phenytoin. Lacosamide as the second-line ASM of choice in SEP was atypical for about half of respondents, which likely reflects respondents' tendency to avoid teratogenic ASMs. However, it is important to recognize that the absence of data about teratogenicity for newer medications is not proof of safety. Furthermore, most respondents reported consideration of gestational age in their treatment decisions. It may be reasonable to consider use of valproate, phenytoin, and phenobarbital outside of the first trimester although this needs additional study. Since (super)/refractory SEP is more rare and more serious for the fetus, medication decisions were varied but generally aligned with current guidelines for non-pregnant women which prioritize seizure termination.
Funding: N/A