Free to Bloom

Women with epilepsy now have new options to control their disorder and achieve pregnancy with confidence.

by Alicia Di Rado

Forethought is not unusual for a couple considering a baby. Many people weigh their financial stability. Others consider their lifestyle or career paths.

But Janet Deardorff and her husband, Scott, had a unique concern: her epilepsy.

Since age 7, Deardorff has experienced epileptic seizures, dazed episodes of confusion where time, awareness and control slipped away. Decades later, she continues taking anti-seizure medication. So, before opting for pregnancy, she and Scott grappled with questions: What if her medication threatens the pregnancy? What if the baby has birth defects?

Deardorff faced her epilepsy fears with facts. By turning to Laura Kalayjian, M.D., neurologist and epilepsy expert at the Keck School of Medicine of USC, she got the guidance, assurance and support she needed to enter pregnancy with confidence.

And she is not alone.

Preparing for pregnancy

Epilepsy is a disorder of the brain involving groups of the brain’s nerve cells, called neurons. Ordinarily, these neurons receive, process and send orderly signals; but in epilepsy, groups of neurons chaotically fire in a thunderstorm of activity.

As a result, an epileptic may experience seizures, which can range from a strange sense of déjà vu to full convulsions and muscle spasms.

Unlike isolated seizures due to problems such as high fever or insufficient blood sugar, epilepsy entails numerous seizures over time. “About 0.5 to 1 percent of the population has epilepsy, or recurrent seizures,” says David Ko, M.D., associate professor of neurology at the Keck School. That works out to about 3 million Americans. Factors such as brain injury and high fevers as a child play a big part, but some types of epilepsy run in families.

USC neurologists see male and female epilepsy patients, but women with epilepsy have unique needs, says Christi Heck, M.D., assistant professor of neurology at the Keck School.

Sometimes women develop epilepsy during puberty, due to changing hormone levels. Physicians can help discover whether a woman’s epilepsy is related to hormone levels during the menstrual cycle, since some women tend to have seizures during ovulation or just before their period starts. If so, physicians may prescribe pills containing progestin, a female hormone, which can help.

Researchers have found that women with epilepsy are more likely to have irregular periods, problems with infertility and, in some cases, earlier menopause.

When they see female patients, they ask if the patients have children or if they plan to have children. If not, physicians can recommend various methods of birth control, since some epilepsy medicines reduce the effectiveness of oral contraceptives.

When a woman with epilepsy plans to have a child, physicians stabilize her on a medication before conception. “Switching drugs while a woman is pregnant raises the risk of problems,” says Heck.

Preparation is key, physicians say, because pregnancy in those with epilepsy can be problematic. Beatriz and Oscar Ayala would likely agree.

Beatriz Ayala had her first seizure at age 1. “It feels like I am going into a daze,” she says. Then she may swing her arm and turn her head involuntarily, until her awareness returns.

The Ayalas thought they would never have a child; but to their surprise, a few years ago, Beatriz Ayala became pregnant.

The couple lost the baby, but they did not lose hope: They turned to their family physician to lay a foundation for a healthy pregnancy.

He referred them to Kalayjian, who made sure Beatriz Ayala took the right prenatal vitamins along with daily folic acid tablets to reduce her risk of birth defects, and was on medication that reduced the risk of seizures during pregnancy, which can deprive the fetus of oxygen. Kalayjian also told the Ayalas about precautions to reduce accidents that might result from holding the baby during a seizure.

“You have to be very careful, following up with your medical visits, keeping up with taking medications and staying informed,” Oscar Ayala says.

That meticulousness paid off. The couple now has a 1-year-old girl and hopes for another child soon.

Information and options

Kalayjian came to the Keck School of Medicine after training at Columbia University in a program recognized for focusing on women with epilepsy. “After that I just got hooked,” Kalayjian says. “There’s such a need to help these women.”

To start with, she and other neurologists want to provide more solid information to women about antiepilepsy drugs’ effects on their children’s health. Although more than 90 percent of babies born to epileptic women are fine, such babies face increased risks for heart defects, neural-tube problems, cleft palate and learning disabilities, among other problems.

That is why USC neurologists are involved in the National Institutes of Health’s Neurodevelopmental Effects of Antiepileptic Drugs study. Researchers in the study will follow women who took certain antiepilepsy medications during pregnancy and their babies, as well as the babies’ fathers. They will assess children’s developing intelligence and motor and verbal skills until age 3.

“We think that the newer medications may be safer for the babies, but we just don’t know,” says Kalayjian. “There’s not a lot of information in humans, but this may give us some answers.”

Understanding the effects of antiepilepsy medications has become increasingly important, as their number has tripled.

“Eight new medications have come out in the last 10 years,” says Ko. “It’s been an incredible period.”

As chief of neurology at LAC+USC Medical Center, Ko has been an investigator on numerous clinical trials of the new drugs. He explains that the variety of drugs available today gives physicians a better arsenal to choose from, because different types of seizures require different medications.

“Many patients were allergic to the old medications, but we’re seeing less of that with the new ones,” says Ko, who also sees patients at the USC Healthcare Consultation Center. Although some patients still have difficult-to-control seizures, he says, “I’ve found some patients have miraculous responses when they try some of the newer medications.”

Surgery is also an option, he notes. When physicians can identify the origin of the brain’s misfiring,sometimes visible as a lesion in brain scans,neurosurgeons such as Charles Liu, M.D., Ph.D., assistant professor of neurological surgery at the Keck School, may be able to end the seizures by surgically removing the lesion. Neurologists conduct tests beforehand to make sure the procedure poses a low risk of harming the patient’s speech, memory and thought.

Deardorff opted for a different type of surgery to ease her epilepsy.

Months before becoming pregnant, she underwent a procedure at USC University Hospital to implant a Vagus Nerve Stimulator, or VNS, below her collarbone.

The device, which sends regular, small electrical signals along a nerve that leads to the brain stem, can reduce the severity and frequency of seizures, and it becomes more effective over time.

“We have a reputation for VNS surgery at USC, because we have a long history with it,” says Heck. USC neurologists and neurosurgeons were among the first to evaluate VNS in the late 1990s.

Deardorff hopes the VNS and medication will minimize her seizures. She has not suffered one in the 12 weeks since her son was born, but still, she skips no precaution. She does not bathe him by herself, and she sits on the floor and leans against the couch to breastfeed him, in case she goes into a seizure.

“I definitely want to have another baby,” she says. “My seizures haven’t kept me from doing sports, and they didn’t make me any different as a person. You can live as normally as possible, and if you have epilepsy and you want to get pregnant, then it’s something you can do. If you look into it well beforehand,there are things you can do to make it safer.”

For more information about epilepsy and pregnancy, or to learn more about The Doctors of USC, call 1-800-USC-CARE (1-800-872-2273).

 

Calming the Brain's Storm

Physicians at the Keck School are testing a unique, minimally invasive treatment for people dealing with one of the most common forms of epilepsy.

Called the Radiosurgical Treatment of Temporal Lobe Epilepsy trial, the National Institutes of Health-sponsored study is evaluating a technique called stereotactic radiosurgery to remove the small area of brain tissue to blame for epilepsy’s dangerous seizures. Put simply, this type of surgery uses focused radiation beams from outside the cranium to destroy tissue—without the need to open the skull.

Traditionally, patients with frequent seizures due to temporal lobe epilepsy who want surgery must undergo a temporal lobectomy: a five-to-six-hour procedure to cut the scalp, open the skull and physically remove the brain lesion—usually about the size of a thumb—at fault for the seizures. The temporal lobe is a part of the brain important to aspects of hearing, smell, language, memory and emotion.

The surgery usually requires a week-long hospital stay, carries the usual risks of open surgery and results in significant swelling, discomfort and facial bruising, says Christi Heck, M.D., assistant professor of clinical neurology at the Keck School and principal investigator for the trial at USC. But radiosurgery is different.

“In the radiosurgical technique, the lesion is destroyed by using radiation beams without needing an incision,” Heck explains. “Several months after treatment, the seizures are expected to taper off, and the maximum effect of the procedure is seen about 12 to 18 months out from surgery.”

A piece of equipment named the Gamma Knife provides the trial’s radiosurgical firepower. Located at USC University Hospital, the Gamma Knife does not contain any type of blade. Instead, it uses 201 beams of gamma rays emanating from cobalt 60 sources located in a helmet-like structure placed around the patient’s head. The beams of radiation are focused precisely on the target, using location information from magnetic resonance imaging (MRI) scans of the patient’s brain. The radiation exposure is comparable to a few X-ray pictures, Heck adds.

But it is not just about the Gamma Knife. Michael L.J. Apuzzo, M.D., professor of radiation oncology, biology and physics and the Edwin M. Todd-Trent H. Wells Jr. Professor of Neurological Surgery at the Keck School, says that advances in computer software, imaging techniques, control of radiation sources and burgeoning knowledge about the brain all combined to bring stereotactic radiosurgery to the treatment of epilepsy.

Heck explains that interested participants must undergo the same battery of tests as traditional temporal lobectomy surgery candidates before physicians can determine if surgery is appropriate. These include MRIs, videotaped seizure observations during a monitored, weeklong stay in the hospital and neuropsychiatric tests to see how epilepsy has affected the patient’s memory and language. Physicians also must thoroughly test patients to ensure the procedure wields a minimal risk of harming their language ability.

Patients over age 18 with intractable temporal lobe epilepsy—those who have at least three complex seizures per month—may be eligible for the study, unless they have high blood pressure or diabetes.

Zbigniew Petrovich, M.D., the Albert Soiland Professor in Radiation Oncology at the Keck School, is participating in the project along with Heck, Kalayjian, Ko and Apuzzo.

The National Institute of Neurological Disorders and Stroke and Elekta Radiosurgery Inc., maker of the Gamma Knife, are sponsoring the trial, which includes nine institutions around the nation and is led by UC San Francisco neurosurgeon Nicholas Barbaro, M.D.