Last data update: Jan 27, 2025. (Total: 48650 publications since 2009)
Records 1-17 (of 17 Records) |
Query Trace: Meador S[original query] |
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A trial of automated outbreak detection to reduce hospital pathogen spread
Baker MA , Septimus E , Kleinman K , Moody J , Sands KE , Varma N , Isaacs A , McLean LE , Coady MH , Blanchard EJ , Poland RE , Yokoe DS , Stelling J , Haffenreffer K , Clark A , Avery TR , Sljivo S , Weinstein RA , Smith KN , Carver B , Meador B , Lin MY , Lewis SS , Washington C , Bhattarai M , Shimelman L , Kulldorff M , Reddy SC , Jernigan JA , Perlin JB , Platt R , Huang SS . NEJM Evid 2024 3 (5) EVIDoa2300342 BACKGROUND: Detection and containment of hospital outbreaks currently depend on variable and personnel-intensive surveillance methods. Whether automated statistical surveillance for outbreaks of health care-associated pathogens allows earlier containment efforts that would reduce the size of outbreaks is unknown. METHODS: We conducted a cluster-randomized trial in 82 community hospitals within a larger health care system. All hospitals followed an outbreak response protocol when outbreaks were detected by their infection prevention programs. Half of the hospitals additionally used statistical surveillance of microbiology data, which alerted infection prevention programs to outbreaks. Statistical surveillance was also applied to microbiology data from control hospitals without alerting their infection prevention programs. The primary outcome was the number of additional cases occurring after outbreak detection. Analyses assessed differences between the intervention period (July 2019 to January 2022) versus baseline period (February 2017 to January 2019) between randomized groups. A post hoc analysis separately assessed pre-coronavirus disease 2019 (Covid-19) and Covid-19 pandemic intervention periods. RESULTS: Real-time alerts did not significantly reduce the number of additional outbreak cases (intervention period versus baseline: statistical surveillance relative rate [RR]=1.41, control RR=1.81; difference-in-differences, 0.78; 95% confidence interval [CI], 0.40 to 1.52; P=0.46). Comparing only the prepandemic intervention with baseline periods, the statistical outbreak surveillance group was associated with a 64.1% reduction in additional cases (statistical surveillance RR=0.78, control RR=2.19; difference-in-differences, 0.36; 95% CI, 0.13 to 0.99). There was no similarly observed association between the pandemic versus baseline periods (statistical surveillance RR=1.56, control RR=1.66; difference-in-differences, 0.94; 95% CI, 0.46 to 1.92). CONCLUSIONS: Automated detection of hospital outbreaks using statistical surveillance did not reduce overall outbreak size in the context of an ongoing pandemic. (Funded by the Centers for Disease Control and Prevention; ClinicalTrials.gov number, NCT04053075. Support for HCA Healthcare's participation in the study was provided in kind by HCA.). |
Recovery of measles-containing and HPV vaccine ordering post-COVID-19 pandemic: Trends by public vs. private funding source, urbanicity, and state - United States, January 2018 - December 2022
Kang Y , Meador S , Black C , Vogt T . Prev Med 2024 107936 OBJECTIVE: To assess recovery in childhood and adolescent vaccine ordering since initial declines in 2020 due to COVID-19 pandemic-related disruptions. METHODS: Using vaccine ordering data provided by Merck & Co., Inc., Rahway, NJ, USA, the number of measles-containing vaccine doses ordered each month in the U.S. during January 1, 2020-May 31, 2022 were compared to doses ordered during the corresponding month in 2018 and human papillomavirus (HPV) vaccine doses ordered during January 1, 2020-December 31, 2022 were compared to corresponding month in 2019. Differences stratified by public vs. private funding source and state and urbanicity of the county where the provider is located were examined. RESULTS: The cumulative deficit for measles-containing vaccines was 1,314,179 doses (-5.7%) as of May 2022 and 3,911,020 doses (-13.6%) for HPV vaccine as of December 2022. Deficits in publicly funded doses and HPV doses ordered in rural counties were greater than deficits in privately funded doses and HPV doses ordered in urban counties. CONCLUSIONS: Findings show that monthly measles-containing and HPV vaccine ordering has recovered; however, deficits remain. Greater deficits in publicly funded vaccine doses and HPV ordering in rural counties suggest varying level of recovery. To reduce gaps in deficits, health care providers are strongly encouraged to use every visit to recommend needed vaccines. |
Estimating county-level vaccination coverage using small area estimation with the National Immunization Survey-Child
Seeskin ZH , Ganesh N , Maitra P , Herman P , Wolter KM , Copeland KR , English N , Chen MP , Singleton JA , Santibanez TA , Yankey D , Elam-Evans LD , Sterrett N , Smith CS , Gipson K , Meador S . Vaccine 2023 The National Immunization Survey-Child (NIS-Child) provides annual vaccination coverage estimates in the United States for children aged 19 through 35 months, nationally, for each state, and for select local areas and territories. There is a need for vaccination coverage estimates for smaller geographic areas to support local authority planning and identify counties with potentially low vaccination coverage for possible further intervention. We describe small area estimation methods using 2008-2018 NIS-Child data to generate county-level estimates for children up to two years of age born 2007-2011 and 2012-2016. We applied an empirical best linear unbiased prediction method to combine direct estimates of vaccination coverage with model-based prediction using county-level predictors regarding health and demographic characteristics. We review the predictors commonly selected for the small area models and note multiple predictors related to barriers to vaccination. |
Self-measured blood pressure telemonitoring programs - a pragmatic how-to guide
McGrath D , Meador M , Wall HK , Padwal RS . Am J Hypertens 2023 36 (8) 417-427 Self-measured blood pressure (SMBP) telemonitoring is the process of securely storing and tele-transmitting reliably measured, patient self-performed blood pressure (BP) measurements to healthcare teams, while ensuring that these data are viewable and clinically actionable for the purposes of improving hypertension diagnosis and management. SMBP telemonitoring is a vital component of an overall hypertension control strategy. Herein, we present a pragmatic guide for implementing SMBP in clinical practice and provide a comprehensive list of resources to assist with implementation. Initial steps include defining program goals and scope, selecting the target population, staffing, choosing appropriate (clinically validated) BP devices with proper cuff sizes, and selecting a telemonitoring platform. Adherence to recommended data transmission, security, and data privacy requirements is essential. Clinical workflow implementation involves patient enrollment and training, review of telemonitored data, and initiating or titrating medications in a protocolized fashion based upon this information. Utilizing a team-based care structure is preferred and calculation of average BP for hypertension diagnosis and management is important to align with clinical best practice recommendations. Many stakeholders in the US are engaged in overcoming challenges to SMBP program adoption. Major barriers include affordability, clinician and program reimbursement, availability of technological elements, challenges with interoperability, and time/workload constraints. Nevertheless, it is anticipated that uptake of SMBP telemonitoring, still at a nascent stage in many parts of the world, will continue to grow, propagated by increased clinician familiarity, broader platform availability, improvements in interoperability, and reductions in costs that occur with scale, competition, and technological innovation. |
Impact of COVID-19-related care disruptions on blood pressure management and control in community health centers.
Meador M , Coronado F , Roy D , Bay RC , Lewis JH , Chen J , Cheung R , Utman C , Hannan JA . BMC Public Health 2022 22 (1) 2295 BACKGROUND: Uncontrolled hypertension is a leading risk factor for cardiovascular disease. To ensure continuity of care, community health centers (CHCs) nationwide implemented virtual care (telehealth) during the pandemic. CHCs use the Centers for Medicare & Medicaid Services (CMS) 165v8 Controlling High Blood Pressure measure to report blood pressure (BP) control performance. CMS 165v8 specifications state that if no BP is documented during the measurement period, the patient's BP is assumed uncontrolled. METHODS: To examine trends in BP documentation and control rates in CHCs as telehealth use increased during the pandemic compared with pre-pandemic period, we assessed documentation of BP measurement and BP control rates from December 2019 - October 2021 among persons ages 18-85 with a diagnosis of hypertension who had an in-person or telehealth encounter in 11 CHCs. Rates were compared between CHCs that did and did not implement self-measured BP monitoring (SMBP). RESULTS: The percent of patients with hypertension with no documented BP measurement was 0.5% in December 2019 and increased to 15.2% (overall), 25.6% (non-SMBP CHCs), and 11.2% (SMBP CHCs) by October 2021. BP control using CMS 165v8 was 63.5% in December 2019 and decreased to 54.9% (overall), 49.1% (non-SMBP), and 57.2% (SMBP) by October 2021. When assessing BP control only in patients with documented BP measurements, CHCs largely maintained BP control rates (63.8% in December 2019; 64.8% (overall), 66.0% (non-SMBP), and 64.4% (SMBP) by October 2021). CONCLUSIONS: The transition away from in-person to telehealth visits during the pandemic likely increased the number of patients with hypertension lacking a documented BP measurement, subsequently negatively impacting BP control using CMS 165v8. There is an urgent need to enhance the flexibility of virtual care, improve EHR data capture capabilities for patient-generated data, and implement expanded policy and systems-level changes for SMBP, an evidence-based strategy that can build patient trust, increase healthcare engagement, and improve hypertension outcomes. |
COVID-19 Vaccine Provider Availability and Vaccination Coverage Among Children Aged 5-11 Years - United States, November 1, 2021-April 25, 2022.
DeCuir J , Meng L , Pan Y , Vogt T , Chatham-Stevens K , Meador S , Shaw L , Black CL , Harris LQ . MMWR Morb Mortal Wkly Rep 2022 71 (26) 847-851 COVID-19 can lead to severe outcomes in children, including multisystem inflammatory syndrome, hospitalization, and death (1,2). On November 2, 2021, the Advisory Committee on Immunization Practices issued an interim recommendation for use of the BNT162b2 (Pfizer-BioNTech) vaccine in children aged 5-11 years for the prevention of COVID-19; however, vaccination coverage in this age group remains low (3). As of June 7, 2022, 36.0% of children aged 5-11 years in the United States had received 1 of COVID-19 vaccine (3). Among factors that might influence vaccination coverage is the availability of vaccine providers (4). To better understand how provider availability has affected COVID-19 vaccination coverage among children aged 5-11 years, CDC analyzed data on active COVID-19 vaccine providers and county-level vaccine administration data during November 1, 2021-April 25, 2022. Among 2,586 U.S. counties included in the analysis, 87.5% had at least one active COVID-19 vaccine provider serving children aged 5-11 years. Among the five assessed active provider types, most counties had at least one pharmacy (69.1%) or public health clinic (61.3%), whereas fewer counties had at least one pediatric clinic (29.7%), family medicine clinic (29.0%), or federally qualified health center (FQHC)* (22.8%). Median county-level vaccination coverage was 14.5% (IQR=8.9%-23.6%). After adjusting for social vulnerability index (SVI)() and urbanicity, the analysis found that vaccination coverage among children aged 5-11 years was higher in counties with at least one active COVID-19 vaccine provider than in counties with no active providers (adjusted rate ratio [aRR]=1.66). For each provider type, presence of at least one provider in the county was associated with higher coverage; the largest difference in vaccination coverage was observed between counties with and without pediatric clinics (aRR=1.37). Ensuring broad access to COVID-19 vaccines, in addition to other strategies to address vaccination barriers, could help increase vaccination coverage among children aged 5-11 years. |
Census tract socioeconomic indicators and COVID-19-associated hospitalization rates-COVID-NET surveillance areas in 14 states, March 1-April 30, 2020.
Wortham JM , Meador SA , Hadler JL , Yousey-Hindes K , See I , Whitaker M , O'Halloran A , Milucky J , Chai SJ , Reingold A , Alden NB , Kawasaki B , Anderson EJ , Openo KP , Weigel A , Monroe ML , Ryan PA , Kim S , Reeg L , Lynfield R , McMahon M , Sosin DM , Eisenberg N , Rowe A , Barney G , Bennett NM , Bushey S , Billing LM , Shiltz J , Sutton M , West N , Talbot HK , Schaffner W , McCaffrey K , Spencer M , Kambhampati AK , Anglin O , Piasecki AM , Holstein R , Hall AJ , Fry AM , Garg S , Kim L . PLoS One 2021 16 (9) e0257622 OBJECTIVES: Some studies suggested more COVID-19-associated hospitalizations among racial and ethnic minorities. To inform public health practice, the COVID-19-associated Hospitalization Surveillance Network (COVID-NET) quantified associations between race/ethnicity, census tract socioeconomic indicators, and COVID-19-associated hospitalization rates. METHODS: Using data from COVID-NET population-based surveillance reported during March 1-April 30, 2020 along with socioeconomic and denominator data from the US Census Bureau, we calculated COVID-19-associated hospitalization rates by racial/ethnic and census tract-level socioeconomic strata. RESULTS: Among 16,000 COVID-19-associated hospitalizations, 34.8% occurred among non-Hispanic White (White) persons, 36.3% among non-Hispanic Black (Black) persons, and 18.2% among Hispanic or Latino (Hispanic) persons. Age-adjusted COVID-19-associated hospitalization rate were 151.6 (95% Confidence Interval (CI): 147.1-156.1) in census tracts with >15.2%-83.2% of persons living below the federal poverty level (high-poverty census tracts) and 75.5 (95% CI: 72.9-78.1) in census tracts with 0%-4.9% of persons living below the federal poverty level (low-poverty census tracts). Among White, Black, and Hispanic persons living in high-poverty census tracts, age-adjusted hospitalization rates were 120.3 (95% CI: 112.3-128.2), 252.2 (95% CI: 241.4-263.0), and 341.1 (95% CI: 317.3-365.0), respectively, compared with 58.2 (95% CI: 55.4-61.1), 304.0 (95%: 282.4-325.6), and 540.3 (95% CI: 477.0-603.6), respectively, in low-poverty census tracts. CONCLUSIONS: Overall, COVID-19-associated hospitalization rates were highest in high-poverty census tracts, but rates among Black and Hispanic persons were high regardless of poverty level. Public health practitioners must ensure mitigation measures and vaccination campaigns address needs of racial/ethnic minority groups and people living in high-poverty census tracts. |
COVID-19 Vaccination Coverage Among Adolescents Aged 12-17 Years - United States, December 14, 2020-July 31, 2021.
Murthy BP , Zell E , Saelee R , Murthy N , Meng L , Meador S , Reed K , Shaw L , Gibbs-Scharf L , McNaghten AD , Patel A , Stokley S , Flores S , Yoder JS , Black CL , Harris LQ . MMWR Morb Mortal Wkly Rep 2021 70 (35) 1206-1213 Although severe COVID-19 illness and hospitalization are more common among adults, these outcomes can occur in adolescents (1). Nearly one third of adolescents aged 12-17 years hospitalized with COVID-19 during March 2020-April 2021 required intensive care, and 5% of those hospitalized required endotracheal intubation and mechanical ventilation (2). On December 11, 2020, the Food and Drug Administration (FDA) issued Emergency Use Authorization (EUA) of the Pfizer-BioNTech COVID-19 vaccine for adolescents aged 16-17 years; on May 10, 2021, the EUA was expanded to include adolescents aged 12-15 years; and on August 23, 2021, FDA granted approval of the vaccine for persons aged ≥16 years. To assess progress in adolescent COVID-19 vaccination in the United States, CDC assessed coverage with ≥1 dose* and completion of the 2-dose vaccination series(†) among adolescents aged 12-17 years using vaccine administration data for 49 U.S. states (all except Idaho) and the District of Columbia (DC) during December 14, 2020-July 31, 2021. As of July 31, 2021, COVID-19 vaccination coverage among U.S. adolescents aged 12-17 years was 42.4% for ≥1 dose and 31.9% for series completion. Vaccination coverage with ≥1 dose varied by state (range = 20.2% [Mississippi] to 70.1% [Vermont]) and for series completion (range = 10.7% [Mississippi] to 60.3% [Vermont]). By age group, 36.0%, 40.9%, and 50.6% of adolescents aged 12-13, 14-15, and 16-17 years, respectively, received ≥1 dose; 25.4%, 30.5%, and 40.3%, respectively, completed the vaccine series. Improving vaccination coverage and implementing COVID-19 prevention strategies are crucial to reduce COVID-19-associated morbidity and mortality among adolescents and to facilitate safer reopening of schools for in-person learning. |
Accelerating use of self-measured blood pressure monitoring (SMBP) through clinical-community care models
Meador M , Hannan J , Roy D , Whelihan K , Sasu N , Hodge H , Lewis JH . J Community Health 2020 46 (1) 127-138 Self-measured blood pressure monitoring (SMBP), the regular measurement of blood pressure by a patient outside the clinical setting, plus additional support, is a proven, cost-effective but underutilized strategy to improve hypertension outcomes. To accelerate SMBP use, the Centers for Disease Control and Prevention (CDC) funded the National Association of Community Health Centers, the YMCA of the USA, and Association of State and Territorial Health Officials to develop cross-sector care models to offer SMBP to patients with hypertension. The project aimed to increase the use of SMBP through the coordinated action of health department leaders, community organizations and clinical providers. From 1/31/2017 to 6/30/2018, nine health centers in Kentucky, Missouri, and New York partnered with seven local Y associations (local Y) and their local health departments to design and implement care models that adapted existing primary care SMBP practices by leveraging capacities and resources in community and public health organizations. Nine collaborative care models emerged, shaped by available community assets, strategic priorities, and organizational culture. Overall, 1421 patients were recommended for SMBP; of those, 795 completed at least one cycle of SMBP (BP measurements morning and evening for at least three consecutive days). Of those recommended for SMBP, 308 patients were referred to a local Y to receive additional SMBP and healthy lifestyle support. Community and public health organizations can be brought into the health care delivery process and can play valuable roles in supporting patients in SMBP. |
Who are the undiagnosed Disparities in hypertension diagnoses in vulnerable populations
Meador M , Lewis JH , Bay RC , Wall HK , Jackson C . Fam Community Health 2020 43 (1) 35-45 This study builds upon a project that developed clinical criteria to identify undiagnosed hypertension patients "hiding in plain sight" (HIPS) by examining patient characteristics to understand whether there are disparities in hypertension diagnosis. We examined electronic health record demographic data for patients identified by the HIPS criteria and subgroups at 3 Missouri health centers. Identified patients who returned for a follow-up visit and were subsequently diagnosed with hypertension tended to be older, black/African American, uninsured, and classified as having obesity. Younger, white, healthy weight females were less likely to be diagnosed. These findings point to exploring possible biases/other nonclinical factors in hypertension diagnosis. |
Toward the Responsible Development and Commercialization of Sensor Nanotechnologies
Fadel TR , Farrell DF , Friedersdorf LE , Griep MH , Hoover MD , Meador MA , Meyyappan M . ACS Sens 2016 1 (3) 207-216 Nanotechnology-enabled sensors (or nanosensors) will play an important role in enabling the progression toward ubiquitous information systems as the Internet of Things (IoT) emerges. Nanosensors offer new, miniaturized solutions in physiochemical and biological sensing that enable increased sensitivity, specificity, and multiplexing capability, all with the compelling economic drivers of low cost and high-energy efficiency. In the United States, Federal agencies participating in the National Nanotechnology Initiative (NNI) "Nanotechnology for Sensors and Sensors for Nanotechnology: Improving and Protecting Health, Safety, and the Environment" Nanotechnology Signature Initiative (the Sensors NSI), address both the opportunity of using nanotechnology to advance sensor development and the challenges of developing sensors to keep pace with the increasingly widespread use of engineered nanomaterials. This perspective article will introduce and provide background on the NNI signature initiative on sensors. Recent efforts by the Sensors NSI aimed at promoting the successful development and commercialization of nanosensors will be reviewed and examples of sensor nanotechnologies will be highlighted. Future directions and critical challenges for sensor development will also be discussed. |
Comparing 2 national organization-level workplace health promotion and improvement tools, 2013-2015
Meador A , Lang JE , Davis WD , Jones-Jack NH , Mukhtar Q , Lu H , Acharya SD , Molloy ME . Prev Chronic Dis 2016 13 E136 Creating healthy workplaces is becoming more common. Half of employers that have more than 50 employees offer some type of workplace health promotion program. Few employers implement comprehensive evidence-based interventions that reach all employees and achieve desired health and cost outcomes. A few organization-level assessment and benchmarking tools have emerged to help employers evaluate the comprehensiveness and rigor of their health promotion offerings. Even fewer tools exist that combine assessment with technical assistance and guidance to implement evidence-based practices. Our descriptive analysis compares 2 such tools, the Centers for Disease Control and Prevention's Worksite Health ScoreCard and Prevention Partners' WorkHealthy America, and presents data from both to describe workplace health promotion practices across the United States. These tools are reaching employers of all types (N = 1,797), and many employers are using a comprehensive approach (85% of those using WorkHealthy America and 45% of those using the ScoreCard), increasing program effectiveness and impact. |
Vaccination coverage among children in kindergarten - United States, 2014-15 school year
Seither R , Calhoun K , Knighton CL , Mellerson J , Meador S , Tippins A , Greby SM , Dietz V . MMWR Morb Mortal Wkly Rep 2015 64 (33) 897-904 State and local jurisdictions require children to be vaccinated before starting school to maintain high vaccination coverage and protect schoolchildren from vaccine-preventable diseases. State vaccination requirements, which include school vaccination and exemption laws and health department regulations, permit medical exemptions for students with a medical contraindication to receiving a vaccine or vaccine component and may allow nonmedical exemptions for religious reasons or philosophic beliefs. To monitor state and national vaccination coverage and exemption levels among children attending kindergarten, CDC analyzes school vaccination data collected by federally funded state, local, and territorial immunization programs. This report describes vaccination coverage estimates in 49 states and the District of Columbia (DC) and vaccination exemption estimates in 46 states and DC that reported the number of children with at least one exemption among kindergartners during the 2014-15 school year. Median vaccination coverage* was 94.0% for 2 doses of measles, mumps, and rubella (MMR) vaccine; 94.2% for the local requirements for diphtheria, tetanus, and acellular pertussis vaccine (DTaP); and 93.6% for 2 doses of varicella vaccine among the 39 states and DC with a 2-dose requirement. The median percentage of any exemptionsdagger was 1.7%. Although statewide vaccination coverage among kindergartners was high during the 2014-15 school year, geographic pockets of low vaccination coverage and high exemption levels can place children at risk for vaccine-preventable diseases. Appropriate school vaccination coverage assessments can help immunization programs identify clusters of low coverage and develop partnerships with schools and communities to ensure that children are protected from vaccine-preventable diseases. |
Antiepileptic drug use in women of childbearing age
Meador KJ , Penovich P , Baker GA , Pennell PB , Bromfield E , Pack A , Liporace JD , Sam M , Kalayjian LA , Thurman DJ , Moore E , Loring DW , NEAD Study Group . Epilepsy Behav 2009 15 (3) 339-43 Research on antiepileptic drug (AED) teratogenesis has demonstrated an increased risk for valproate. The impact of these findings on current AED prescribing patterns for women of childbearing age with epilepsy is uncertain. The Neurodevelopmental Effects of Antiepileptic Drugs (NEAD) Study is an ongoing prospective multicenter observational investigation that enrolled pregnant women with epilepsy on the most common AED monotherapies from October 1999 to February 2004 (carbamazepine, lamotrigine, valproate, and phenytoin). A 2007 survey of AED use in women of childbearing age at eight NEAD centers found a total of 932 women of childbearing age with epilepsy (6% taking no AED, 53% monotherapy, 41% polytherapy). The most common monotherapies were lamotrigine or levetiracetam. Since 2004, prescriptions of carbamazepine, phenytoin, and valproate have decreased, whereas those for levetiracetam have increased. Except for the top two AED monotherapies, there were marked differences in other monotherapies and in polytherapies between U.S. and UK centers. Future investigations are needed to examine reasons for drug choice. |
Practice parameter update: management issues for women with epilepsy--focus on pregnancy (an evidence-based review): obstetrical complications and change in seizure frequency: report of the Quality Standards Subcommittee and Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology and American Epilepsy Society
Harden CL , Hopp J , Ting TY , Pennell PB , French JA , Hauser WA , Wiebe S , Gronseth GS , Thurman D , Meador KJ , Koppel BS , Kaplan PW , Robinson JN , Gidal B , Hovinga CA , Wilner AN , Vazquez B , Holmes L , Krumholz A , Finnell R , Le Guen C , American Academy of Neurology American Epilepsy Society . Neurology 2009 73 (2) 126-32 OBJECTIVE: To reassess the evidence for management issues related to the care of women with epilepsy (WWE) during pregnancy, including the risk of pregnancy complications or other medical problems during pregnancy in WWE compared to other women, change in seizure frequency, the risk of status epilepticus, and the rate of remaining seizure-free during pregnancy. METHODS: A 20-member committee including general neurologists, epileptologists, and doctors in pharmacy evaluated the available evidence based on a structured literature review and classification of relevant articles published between 1985 and February 2008. RESULTS: For WWE taking antiepileptic drugs, there is probably no substantially increased risk (greater than two times expected) of cesarean delivery or late pregnancy bleeding, and probably no moderately increased risk (greater than 1.5 times expected) of premature contractions or premature labor and delivery. There is possibly a substantially increased risk of premature contractions and premature labor and delivery during pregnancy for WWE who smoke. Seizure freedom for at least 9 months prior to pregnancy is probably associated with a high likelihood (84%-92%) of remaining seizure-free during pregnancy. RECOMMENDATIONS: Women with epilepsy (WWE) should be counseled that seizure freedom for at least 9 months prior to pregnancy is probably associated with a high rate (84%-92%) of remaining seizure-free during pregnancy (Level B). However, WWE who smoke should be counseled that they possibly have a substantially increased risk of premature contractions and premature labor and delivery during pregnancy (Level C). |
Practice parameter update: management issues for women with epilepsy--focus on pregnancy (an evidence-based review): teratogenesis and perinatal outcomes: report of the Quality Standards Subcommittee and Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology and American Epilepsy Society
Harden CL , Meador KJ , Pennell PB , Hauser WA , Gronseth GS , French JA , Wiebe S , Thurman D , Koppel BS , Kaplan PW , Robinson JN , Hopp J , Ting TY , Gidal B , Hovinga CA , Wilner AN , Vazquez B , Holmes L , Krumholz A , Finnell R , Hirtz D , Le Guen C , American Academy of Neurology American Epilepsy Society . Neurology 2009 73 (2) 133-41 OBJECTIVE: To reassess the evidence for management issues related to the care of women with epilepsy (WWE) during pregnancy. METHODS: Systematic review of relevant articles published between January 1985 and June 2007. RESULTS: It is highly probable that intrauterine first-trimester valproate (VPA) exposure has higher risk of major congenital malformations (MCMs) compared to carbamazepine and possible compared to phenytoin or lamotrigine. Compared to untreated WWE, it is probable that VPA as part of polytherapy and possible that VPA as monotherapy contribute to the development of MCMs. It is probable that antiepileptic drug (AED) polytherapy as compared to monotherapy regimens contributes to the development of MCMs and to reduced cognitive outcomes. For monotherapy, intrauterine exposure to VPA probably reduces cognitive outcomes. Further, monotherapy exposure to phenytoin or phenobarbital possibly reduces cognitive outcomes. Neonates of WWE taking AEDs probably have an increased risk of being small for gestational age and possibly have an increased risk of a 1-minute Apgar score of <7. RECOMMENDATIONS: If possible, avoidance of valproate (VPA) and antiepileptic drug (AED) polytherapy during the first trimester of pregnancy should be considered to decrease the risk of major congenital malformations (Level B). If possible, avoidance of VPA and AED polytherapy throughout pregnancy should be considered to prevent reduced cognitive outcomes (Level B). If possible, avoidance of phenytoin and phenobarbital during pregnancy may be considered to prevent reduced cognitive outcomes (Level C). Pregnancy risk stratification should reflect that the offspring of women with epilepsy taking AEDs are probably at increased risk for being small for gestational age (Level B) and possibly at increased risk of 1-minute Apgar scores of <7 (Level C). |
Practice parameter update: management issues for women with epilepsy--focus on pregnancy (an evidence-based review): vitamin K, folic acid, blood levels, and breastfeeding: report of the Quality Standards Subcommittee and Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology and American Epilepsy Society
Harden CL , Pennell PB , Koppel BS , Hovinga CA , Gidal B , Meador KJ , Hopp J , Ting TY , Hauser WA , Thurman D , Kaplan PW , Robinson JN , French JA , Wiebe S , Wilner AN , Vazquez B , Holmes L , Krumholz A , Finnell R , Shafer PO , Le Guen C , American Academy of Neurology American Epilepsy Society . Neurology 2009 73 (2) 142-9 OBJECTIVE: To reassess the evidence for management issues related to the care of women with epilepsy (WWE) during pregnancy, including preconceptional folic acid use, prenatal vitamin K use, risk of hemorrhagic disease of the newborn, clinical implications of placental and breast milk transfer of antiepileptic drugs (AEDs), risks of breastfeeding, and change in AED levels during pregnancy. METHODS: A 20-member committee evaluated the available evidence based on a structured literature review and classification of relevant articles published between 1985 and October 2007. RESULTS: Preconceptional folic acid supplementation is possibly effective in preventing major congenital malformations in the newborns of WWE taking AEDs. There is inadequate evidence to determine if the newborns of WWE taking AEDs have a substantially increased risk of hemorrhagic complications. Primidone and levetiracetam probably transfer into breast milk in amounts that may be clinically important. Valproate, phenobarbital, phenytoin, and carbamazepine probably are not transferred into breast milk in clinically important amounts. Pregnancy probably causes an increase in the clearance and a decrease in the concentration of lamotrigine, phenytoin, and to a lesser extent carbamazepine, and possibly decreases the level of levetiracetam and the active oxcarbazepine metabolite, the monohydroxy derivative. RECOMMENDATIONS: Supplementing women with epilepsy with at least 0.4 mg of folic acid before they become pregnant may be considered (Level C). Monitoring of lamotrigine, carbamazepine, and phenytoin levels during pregnancy should be considered (Level B) and monitoring of levetiracetam and oxcarbazepine (as monohydroxy derivative) levels may be considered (Level C). A paucity of evidence limited the strength of many recommendations. |
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