Questions and answers of cns

Options for questions 207–209

A Carbamazepine
B Eslicarbazepine
C Gabapentin
D Lamotrigine
E Levetiracetam
F Oxcarbazepine
G Phenobarbital
H Phenytoin
I Pregabalin
J Primidone
K Sodium valproate
L Tiagabine
M Topiramate
N Vigabatrin
For each of the following clinical scenarios, choose the single most appropriate anti-
epileptic drug from the list of options above. Each option may be used once, more than
once or not at all.
207. A woman taking anti-epileptic medication attends for a routine fetal anomaly
scan at 20 weeks of gestation. The fetus is found to have spina bifida and a cleft lip.
Which medication is she most likely to be taking?
208. A pregnant woman attends antenatal clinic and is taking a single anti-epileptic
drug. She has been informed that the drug she is taking has two main advantages:
(1) it carries the lowest risk of congenital malformations; and (2) it does not
increase the risk of haemolytic disease of the newborn. Which drug is she most
likely to be taking?
209. A woman with epilepsy has a seizure in labour. Benzodiazepines are administered,
but the seizures continue. Which second-line therapy should now be
administered?

207. Answer K Sodium valproate

Explanation
Sodium valproate is associated with neural tube defects, a facial cleft and hypospadias.
208. Answer D Lamotrigine
Explanation
In women with epilepsy who are taking anti-epileptic drugs (AEDs), the risk of
major congenital malformation to the fetus is dependent on the type, number
and dose of AEDs. Among AEDs, lamotrigine and carbamazepine monotherapy
at lower doses have the lowest risk of major congenital malformation in the
offspring.
Enzyme-inducing AEDs (carbamazepine, phenytoin, phenobarbital,
primidone, oxcarbazepine, topiramate and eslicarbazepine) are considered to
competitively inhibit the precursors of clotting factors and affect fetal microsomal
enzymes that degrade vitamin K, thereby increasing the risk of haemorrhagic
disease of the newborn.
The drug that fulfils both of these characteristics is therefore lamotrigine.
209. Answer H Phenytoin
Explanation
If seizures are not controlled, consider administration of phenytoin or
fosphenytoin. The loading dose of phenytoin is 10–15 mg/kg by intravenous
infusion, with the usual dosage for an adult being about 1000 mg.
Reference
RCOG. Epilepsy in pregnancy. RCOG GTG No. 68. June 2016.

MMD31
Pregnant women with epilepsy have the highest risk of breakthrough seizures
during:
A. First trimester
B. Intrapartum
C. Postpartum
D. Second trimester
E. Third trimester

MMD31
MMD31 Answer: C
Explanation It is recognised that mothers with epilepsy are at higher risk of break-
through seizures at this time (Walker, Permezel et al. 2009). Reasons for this are
varied, including sleep deprivation, stress and altered treatment compliance, and it
seems likely that in some women biological changes (e.g. hormonal or neurochemi-
cal factors) may also be relevant.
Women with epilepsy and their families should be specifi cally advised of the
risks of epilepsy in the postpartum period and ways to mitigate these risks, includ-
ing not sleeping or bathing alone.
References 1. Walker SP, Permezel M, Berkovic SF. The management of epilepsy
in pregnancy. BJOG. 2009;116(6):758–76.

18. A 32-year-old woman contemplating her first pregnancy comes to see you in the pre-
pregnancy clinic. She has had epilepsy since the age of 10. The following are true about
anticonvulsants in pregnancy, except:
A. Clonazepam is not teratogenic
B. Phenobarbitone cross the placenta but carbamazepine does not
C. Phenytion is associated with congenital heart defects
D. The teratogenic effect of valproate is dose-dependent
E. The teratogenic risk of a combined anticonvulsant regime, which includes valproate,
carbamazepine, and phenytoin, is as high as 50%

Answer: B
Valproate, phenobarbitone, carbamazepine, and primidone all cross the placenta. Phenytion
and
valproate are associated with congenital heart defects. The risk of teratogenicity increases
with
the number of drugs. For patients taking two or more anticonvulsants the risks is 15%. For
those
taking valproate, carbamazepine, and phenytoin, the risk is as high as 50%. The teratogenic
effect of valproate is dose-dependent. The risk of teratogenicity increases sixfold in mothers
taking more than 1 g of valproate per day. Benzodiazepines including clonazepam are not
teratogenic.

Paper 1
EMQs
EMQ 1-5
For each of the following clinical scenario, choose the single diagnosis most appropriate
treatment. Each option may be used once, more than once or not at all.
A. Cerebral vascular thrombosis
B. Cluster headache
C. Conjunctivitis
D. Epilepsy
E. Impending eclampsia
F. ICH
G. Malaria
H. Meningitis
I. Migraine
J. Severe pre-eclampsia
K. Sinusitis
L. SAH
M. Viral gastritis
1. A 27-yr old primigravid woman at 24 weeks of pregnancy is complaining of throbbing pain
behind her left eye. This pain is so severe that she cannot sit still.
2. An 18-yr old primigravid woman at 36 weeks of pregnancy is complaining of sudden onset
of headaches, abdominal pain and a sensation of flashing lights in front of eyes.
3. A 24-yr old multiparous woman at 30 weeks of pregnancy had returned from her holidays
in
Brazil. She is vomiting, feeling feverish, and complaining of severe headaches.
4. A 35-yr old parous woman at 20 weeks of pregnancy complaints f severe headaches and
feeling tired, feverish and stiff around the neck.
5. A recently delivered multiparous woman with BMI of 45 complains on day 3 post-partum
of
sudden onset of severe headache, describing it as ‘the worst headache I ever had’.

Ans ; 1.B, 2.E; 3.G; 4.H; 5.A

1. Cluster headaches are uncommon and affect men more often than women. The word
‘cluster’
is used as the sufferers get a number of attacks over few weeks and thereafter they are
symptom-free for months or years. Cluster headaches normally present with severe
headache,
which is much worse than migraine. The pain usually occurs at the same time each day and
quite often wakens the individual a few hours after they have gone to sleep. Migraine is
usually categorized according to whether or not there is aura.
2. Impending eclampsia, as this patient has risk factors such as being primigravida, under
20,
and has sudden onset of headache and flashing lights. Her abdominal pain may be
suggestive
of perihepatic capsular congestion.
3. A history of travel is reported; therefore the most likely diagnosis is cerebral malaria,
which
is suggestive of severe headache and vomiting.
4. Meningitis is highly likely; the only giveaway would be that petechial rash has not been
mentioned, which could be suggestive of meningococcal infection.
5. Cerebral vascular thrombosis usually occurs post-partum and has been noted even in the
first
trimester in the confidential enquiries into maternal deaths. Patients usually describe it as
‘the
worst I ever had headache’. In the presence of leukocytosis, differential diagnosis will
include puerperal sepsis.
Centre for Maternal and Child Enquiries. Saving mothers’ lives: reviewing maternal deaths to
make motherhood safer: 2006-2008. The eight report on Confidential Enquiries into Maternal
deaths in UK. BJOG.2011; 118 (Suppl. 1): 1-203

EMQ 6-10
For each of the following clinical scenario, choose the single most likely diagnosis from the
listed provided. Each option may be used once, more than once or not at all.
A. Benign intracranial hypertension
B. Cerebral venous thrombosis
C. Cluster-type headache
D. Epilepsy
E. Menstrual-related migraine
F. Migraine with aura
G. Migraine without aura
H. PE
I. Pseudo-seizure
J. SAH
K. Tension headache
L. Thrombocytopenic purpura

6. A 24-yr old primigravid woman who is 24 weeks pregnant complains of a pulsating, right-
sided headache for 48hrs. This is associated with nausea and vomiting. She also complaints
of seeing ‘flickering lights’.
7. A 32-yr old multiparous woman who is 20 weeks pregnant complaints of a pressing
bilateral
headache for more than 10 days.
8. A 20-yr old primigravid woman who is 18 weeks pregnant complains of sharp, left-sided
headache, particularly around the eye. This is associated with a red eye and runny nose.
9. A 17-yr old woman has a history of heavy menstrual bleeding since menarche. She
complains of a left-sided headache, particularly 2-3 days before her periods.
10. A 38-yr old multiparous woman at 36 weeks of pregnant presents with history of
headaches,
vomiting, and photophobia. Her examination had signs of raised ICP.

ANS; 6.F, 7.K, 8.C, 9.E, 10.B

6. Migraine may present with or without aura. It may be unilateral or bilateral but is pulsatile
in
nature. It may be aggravated by routine activities of daily living. Typical aura symptoms
include visual symptoms such as flickering lights, spots or lines, and /or particular loss of
vision; sensory symptoms such as numbness and / or pin and needles; and/or speech
disturbance.
7. A tension headache is usually bilateral, pressing (non-pulsatile), and lasts for 30 mins
(continuous). It may be episodic (occurring fewer than 15 times per month) or chronic
(occurring more than 15 times per month, for at least 3 months).
8. A cluster headache is usually unilateral (around the eye, above the eye, and along the
side of
head/face). It is associated with red eye and/or runny nose/nasal congestion.
9. Menstrual-related migraine usually presents 2-3 days before the menstrual cycle. It may
have
other features of migraine as described previously. A headache diary is recommended for at
least two menstrual cycles to reach the diagnosis.
10. The incidence of CVT is 1 in 10,000 and is associated with high mortality rate. The
majority
of cases are seen in pregnant or puerperal women. It should be differentiated from severe
PE
(as no BP reading have been given). Signs of raised ICP are suggestive of this diagnosis.
NICE Clinical Guideline 150. Diagnosis and management of headaches; 2012

5. A 37-year-old primigravida woman presents at ten weeks gestation to antenatal clinic.

She has been referred because she has a known diagnosis of myasthenia gravis. What is
the mainstay of treatment?
A. Baclofen
B. Beta-interferon
C. Gabapentin
D. Isoniazid
E. Pyridostigmine
Answer: E
Myasthenia gravis is a rare autoimmune condition caused by antibodies against the nicotinic
acetylcholine receptors. It is more commonly seen in women, and 40% have an
exacerbation in
pregnancy. Pyridostigmine is a long-acting anticholinesterase drug used to treat myasthenia
gravis. Other medications which may also be considered include corticosteroids,
azathioprine
and plasmaphoresis.

4. A 23-year-old primiparous woman is seen in clinic at ten weeks gestation. She is known
to have epilepsy, for which she takes lamotrigine. Her last fit was one year ago. When
considering her medication, what is the most appropriate management plan?
A. Administer 5 mg folic acid until the end of the pregnancy
B. Administer 5 mg folic acid until the second trimester
C. Administer vitamin K until the end of the pregnancy
D. Change her medication to carbamazepine
E. Stop administering lamotrigine
Answer: A
Anti-epileptic medication should be continued unless the woman has been sezure-free for a
minimum of two years. Major congenital malformations are more likely with sodium valproate
and carbamazepine than lamotrigine. Folic acid 5 mg should be commenced at least three
months
before conception and continued throughout pregnancy. Vitamin K 10-20 mg oral should be
prescribed from 36 weeks gestation.

93) How does the estimated risk of major congenital malformations in

babies born to women with epilepsy but are not on any medication
compare to that in the non-affected pregnant aged-matched
population?
Double
Five times higher
Four times higher
Similar
Three times higher

Correct answer:
Similar
Most anti-epileptic drugs (AEDS) cross the placenta and are potentially
teratogenic. The incidence of major malformations in the fetuses of
women with epilepsy who are not exposed to AEDs is similar to that in the
general population (1–3%).

94) When during pregnancy does exposure to anti-epileptic drugs (AEDs)

run the risk of causing harm to the fetus?
First and second trimester
First trimester
Second trimester
Third trimester
Throughout pregnancy

Correct answer:
Throughout pregnancy