Halani Sheliza, Tshering Lhab, Bui Esther, Clark Sarah J, Grundy Sara J, Pem Tandin, Lhamo Sonam, Dema Ugyen, Nirola Damber K, Dorji Chencho, Mateen Farrah J
Faculty of Medicine, University of Toronto, 27 King's College Circle, Toronto, ON M5S 1A1, Canada.
Department of Psychiatry, Jigme Dorji Wangchuck National Referral Hospital, Gongphel Lam, Thimphu, Bhutan.
Epilepsy Res. 2017 Dec;138:116-123. doi: 10.1016/j.eplepsyres.2017.10.012. Epub 2017 Oct 18.
Reports on the reproductive health of women with epilepsy (WWE) in low- and middle-income countries (LMICs) are limited. Bhutan is a lower income country with a high estimated prevalence of epilepsy and no out-of-pocket payment requirements for health visits or medications.
We developed a 10-category survey to interview WWE ages 20-59 years in the Kingdom of Bhutan to understand their contraceptive use and peripartum experiences. WWE were recruited from 2016-2017 from an existing epilepsy cohort and their reproductive health data were merged with epilepsy and socioeconomic data obtained from initial clinical evaluations performed between 2014 and 2016.
Of the 134 WWE eligible for the study, 94 were reachable and there was 1 refusal to participate (response rate 99% among reachable WWE; 69% of all WWE in the cohort). Of the 93 WWE (median age 27 years, range 20-52), 50 (54%) reported prior pregnancies. Of the entire cohort, 55 women responded on contraception: 26 (47%) WWE had never used contraception in their lifetime. Of the 29 WWE who had ever used contraception, the most commonly reported form was male condoms (14/29, 48%), followed by depot medroxyprogesterone acetate injections (13/29, 45%), and intrauterine devices (5/29, 17%). Sixty-three percent of WWE recalled receiving information on family planning (31 of 49). Of the 50 WWE with prior pregnancies, 37 of 46 (80%) used folic acid; 6 WWE reported commencing it in the first trimester while 29 WWE began supplementation in the second trimester. Primary school education or higher was associated with folic acid supplementation during pregnancy (26/29 vs. 11/17, p=0.040). Epilepsy affected at least one of the pregnancies in 38 of the cases (76%) with an average of 2.3 pregnancies per woman). There was a total of 86 pregnancies and an average inter-pregnancy interval of 3.5 years. Ninety-five percent of women attended prenatal care (36/38), 22% had at least one miscarriage (8/37), 14% had at least one pre-term delivery (5/36), and 21% had Caesarean sections (8/38). Seventeen of 38 (45%) of WWE had seizures during pregnancy. A majority of WWE (97%, 37 of 38) with a prior pregnancy reported breastfeeding their infant.
Nearly half of Bhutanese WWE did not use contraception; among those who used it, male condoms were most common but 11% were at risk of potential drug-drug interactions between oral contraception and enzyme-inducing antiepileptic drugs. Bhutanese WWE had a high rate of prenatal visits. Folic acid was prescribed in most pregnant WWE but the majority began supplementation in the second trimester. The number of pregnancies in WWE in Bhutan (2.3 per woman) was comparable to the number of children per women in Bhutan (2.3). Breastfeeding was practiced almost universally. Points of intervention may include pre-conception initiation of folic acid, optimization of dosing of AEDs with contraceptives, guidelines for peripartum seizure treatment, and establishment of a prospective registry for WWE and their offspring.
关于低收入和中等收入国家（LMICs）癫痫女性（WWE）生殖健康的报告有限。不丹是一个低收入国家，据估计癫痫患病率很高，且就诊或用药无需自付费用。
我们设计了一项包含10个类别的调查问卷，对不丹王国年龄在20 - 59岁的癫痫女性进行访谈，以了解她们的避孕措施使用情况和围产期经历。2016 - 2017年，从现有的癫痫队列中招募癫痫女性，将她们的生殖健康数据与2014年至2016年进行的初始临床评估中获得的癫痫和社会经济数据合并。
在134名符合研究条件的癫痫女性中，94名能够联系上，有1人拒绝参与（可联系到的癫痫女性的应答率为99%；占队列中所有癫痫女性的69%）。在93名癫痫女性（中位年龄27岁，范围20 - 52岁）中，50名（54%）报告有过怀孕经历。在整个队列中，55名女性回答了避孕相关问题：26名（47%）癫痫女性一生中从未使用过避孕措施。在29名曾经使用过避孕措施的癫痫女性中，最常报告的避孕方式是男用避孕套（14/29，48%），其次是醋酸甲羟孕酮长效注射剂（13/29，45%）和宫内节育器（5/29，17%）。63%的癫痫女性回忆起曾接受过计划生育相关信息（49名中的31名）。在50名有过怀孕经历的癫痫女性中，46名中的37名（80%）使用了叶酸；6名癫痫女性报告在孕早期开始使用，而29名癫痫女性在孕中期开始补充。小学及以上教育程度与孕期补充叶酸有关（26/29 vs. 11/17，p = 0.040）。癫痫影响了38例中的至少一次怀孕（76%），平均每名女性怀孕2.3次。总共有86次怀孕，平均怀孕间隔为3.5年。95%的女性接受了产前检查（36/38），22%至少有一次流产（8/37），14%至少有一次早产（5/36），21%进行了剖宫产（8/38）。38名癫痫女性中有17名（45%）在孕期发作。大多数有过怀孕经历的癫痫女性（97%，38名中的37名）报告对婴儿进行母乳喂养。
近一半的不丹癫痫女性未采取避孕措施；在采取避孕措施的女性中，男用避孕套最为常见，但11%的女性存在口服避孕药与酶诱导抗癫痫药物之间潜在药物相互作用的风险。不丹癫痫女性的产前检查率很高。大多数怀孕的癫痫女性都开了叶酸，但大多数在孕中期开始补充。不丹癫痫女性的怀孕次数（每名女性2.3次）与不丹每名女性的子女数（2.3个）相当。几乎普遍实行母乳喂养。干预点可能包括孕前开始补充叶酸、优化抗癫痫药物与避孕药的剂量、围产期癫痫治疗指南，以及为癫痫女性及其后代建立前瞻性登记册。
