Global variation in pregnancy complications in women with epilepsy: A meta-analysis

OBJECTIVE: Women with epilepsy are at risk of pregnancy complications. Whether these vary globally is unknown. We undertook a systematic review to assess the overall rates of obstetric outcomes in women with epilepsy, and variations in estimates across geographical region, economic status of country, and over time.

STUDY DESIGN: We searched Medline, Embase, Cochrane, AMED and CINAHL, (January 1, 1990 and November 29, 2016), without any language restrictions for studies reporting core maternal and fetal outcomes in women with epilepsy. We pooled the results using Freeman-Tukey Transformation random effectsanalysis, and reported our findings as rates of complications per 100 pregnancies with 95% confidence intervals (CI). We assessed for differences in risk across World Health Organisation (WHO) regions, income status, and year of publication.

RESULTS: From the 7420 articles screened, we included 60 studies (62 articles). In women with epilepsy (116,105 pregnancies), the commonest complications were caesarean section (29.2 per 100 pregnancies; 95% CI 25.4-33.1, I2=98.44%), and admission to the neonatal intensive care unit (12.5 per 100 pregnancies; 95% CI 9.6-15.8, I2=60.63%). There were significant differences across the WHO regions, with the highest rates of caesarean section (37%, 95% CI 32%-42%); spontaneous miscarriage (39%, 95% CI 35%-44%) and preterm birth (10%, 95% CI 8%-12%) in the Americas; postpartum haemorrhage (9%, 95% CI 7%-12%), hypertensive disorders (14%, 95% CI 8%-21%) and perinatal death (2%, 95% CI 1%-7%) in the Western Pacific; induction of labour (30%, 95% CI 19%-41%) in South East Asia and antepartum haemorrhage (10%, 95% CI 5%-17%) in the Eastern Mediterranean. The reported rates of antepartum haemorrhage, caesarean section, gestational diabetes and spontaneous miscarriage were highest in high income and high-middle income countries. Over time, there was a significant increase in caesarean section, and reduction in stillbirths, perinatal deaths and admission to the neonatal intensive care unit in women with epilepsy.

CONCLUSION: There is significant variation in reported maternal and offspring outcomes in pregnant women with epilepsy across geographical regions, economic status of country and over time, which needs to be considered in setting priorities for clinical management and research.