Theme: Antenatal care in pregnancy

Subtheme: Epilepsy in pregnancy

Task: Pre-pregnancy counselling and management
Total marks: 10
Time: 12 mins
Scenario:
You are the registrar in pre conception counseling clinic. A
23-year-old lady reports to you. She got married 4 months
back and is a known epileptic for last 5 years. She is planning
her first pregnancy and wants to get information regarding
pregnancy with epilepsy?
Candidate's instructions

This is a structured viva. The examiner will ask you a series of questions about
issues relating to the management of this patient.

A 23-year-old lady reports to you in pre-conception clinic. She got married 4

months back and is a known epileptic for last 5 years. She is planning her first
pregnancy and wants to get information regarding pregnancy with epilepsy?

It will assess the following domains:

Communication with colleagues

Applied clinical knowledge
Patient safety
Marking
Communication with colleagues
 Clearly explains clinical concepts
 Structures the risks and complications associated with Epilepsy and
pregnancy
 Explains the antenatal and intrapartum care considerations in a
methodical manner
Applied clinical knowledge
 Clear understanding of the risks and complications associated with
Epilepsy and pregnancy
 Is aware of how to manage an Epileptic obstetric patient during
pregnancy
Patient safety
 Implements a safe antenatal management plan for the patient

Examiner's instructions:
This is a structured viva assessing the candidate's knowledge regarding the
obstetric care of Epileptic women. You should ask the candidate the questions
provided in sequence. If required, you can prompt the candidate; however,
this should be reflected in your overall assessment.

Structured viva questions:

1.What important information do you need from this patient? 2 marks

 Details of epilepsy diagnosis and investigations
 Details of medication being used, Monotherapy/ Polytherapy
 When was the last fit and how was it controlled?
 Review of neurophysician’s treatment record
 Other co-morbids
 Quality of life including profession, stresses, habits, mental health etc
 Any contraception being used
2.What advise will you give in Pre-pregnancy counselling? 3 marks
 A competent clinician to make decisions about choice and dose of AED
 The risk of congenital malformation is low but depends upon dose, type
and number of AED used
 There is effect on long term neurodevelopment of newborn in case of
exposure to sodium valproate in utero but not with carbamazepine and
lamotrigine
  Advice tab folic acid 5mg/day pre-conception and the lowest effective
dose of AED
 Arrange a follow up visit with husband
 Reassurance that epilepsy if controlled would not have detrimental
effects on her married and pregnant life
 Written as well as verbal information should be provided
 Minimize stress, insomnia and dehydration
3.What advise will you give in Antenatal period? 2 marks
 MDT; regular visits with both Obstetrician and Neurophysician
 Do not stop AED on your own
 2/3rd of patients will not deteriorate in pregnancy
 AED associated with NTD. Anomaly Scan and regular growth scans
 Oral Vitamin K 20mg from 36 weeks onwards to avoid HDNB
 Double dose of Antenatal steroids i.e. 48 mg in place of 24mg for fetal
lung maturity
4.What precautions will you take during labour? 2 marks
 Deliver in consultant-led unit
 Risk of seizure in labour is low 1-2 %
 Adequate analgesia (TENS & Entox) ,good hydration
 AED intake should continue in labor, if can’t tolerate oral then give IV
 No contraindication for normal or induced labour
 Fits during labour managed with i.v. Diazepam10-20mg; 10 mg bolus
then 2 mg further boluses as per requirement. Inj Phenytoin if Diazepam
fails to control fits, Oxygen inhalation
 C section in case of repeated fits
5.What postpartum advice will give? 1 mark
 Encourage Breast feeding, provide support
 Counsel about contraception; COC pills with double dose 50 ug of
Estrogen or use of 4 packs of COCP consecutively with short pill free
interval
 Depo provera ; reduce interval between 2 inj. from 12 to 10 weeks
 POP avoided, Norplant not recommended