Most women with epilepsy (WWE) will experience stable seizure control during pregnancy. Adverse fetal outcomes with epilepsy include spontaneous abortion, preterm birth, fetal growth restriction, major congenital malformation (MCM), hypertensive disorders of pregnancy, postpartum hemorrhage, peripartum depression, and—rarely—maternal death. Studies reporting these increased risks may be biased by differences in preexisting medical conditions, other patient characteristics, and anti-seizure medication (ASM) use and type. Poor seizure control preceding pregnancy, unplanned pregnancy, and polytherapy are associated with higher risks. Antenatal care should be coordinated by an experienced multidisciplinary team. Monotherapy with an appropriate ASM at the lowest effective dose is the goal, and drug levels should be monitored. Second trimester fetal anatomical sonography is the best screening modality for neural tube defects and other MCMs. Serial third trimester fetal growth ultrasounds are recommended. WWE are likely to have an uncomplicated labour and delivery. Epilepsy is not an indication for induction of labour or caesarean delivery. The risk of intrapartum seizures is 2−3%, and intractable seizures necessitating urgent delivery are rare. Attention is needed to avoid dehydration, missed ASM doses, sleep deprivation, and pain during labour and postpartum. WWE should be screened and counselled regarding their heightened risk of peripartum depression.

Sleep and epilepsy have bidirectional relationships, and various endocrine interactions. Besides the commonly observed increase in seizure frequency in association with sleep loss or with sleep disorders, such as sleep apnea, seizures themselves may lead to sleep fragmentation. Furthermore, nocturnal seizures may be associated with more severe and longer lasting respiratory consequences, as well as higher risk of sudden death. It is common for sleep to change during pregnancy in relation to endocrine changes and these changes may in turn affect seizure frequency. Overall, estrogens may have excitatory effects and may increase the consolidation of wakefulness and decrease REM sleep duration. Progesterone tends to have a sedative effect and the decrease in level may lead to more complaints of insomnia pre-menstrual and after menopause. Common sleep disorders are discussed. Obstructive sleep apnea becomes much more common after menopause, and sometimes may be seen in the third trimester of pregnancy as a result of weight gain. Restless legs syndrome is more common in pregnancy. Overall, insomnia is more common in women. Consideration should be given to comorbid primary sleep disorders whenever symptoms of insomnia or hypersomnolence are reported by patients with epilepsy.

Enzyme-inducing antiepileptic drugs (EI-ASMs) such as phenytoin, carbamazepine, oxcarbazepine, and phenobarbital may decrease contraceptive efficacy. When considering contraception for women with epilepsy (WWE), the intrauterine device (IUD) is a first line choice. It is important to keep in mind that hormonal contraception with estrogenic components induces the metabolism of lamotriginePreconception counseling should be started early and revisited frequently for WWE of childbearing age. Pre-partum optimization of ASMs ideally should be done 9−12 months before a planned pregnancy. The majority of WWE are likely to have a safe pregnancy and a healthy newborn.

Shortly after microRNAs were discovered in humans they were found to be present in blood samples. This led to another branch of microRNA research with the potential to transform medicine, answering the question healthcare professionals ask every day. What’s wrong with my patient? This chapter introduces circulating microRNAs as biomarkers and their emergence as potential diagnostic tools. Core arguments in their favour as indicators of health and disease include tissue specificity, their known locations in the body enabling doctors to zero in on where a problem lies. It looks at what shelters microRNAs as they circulate in the bloodstream and the disruptive thinking that has interpreted such findings as evidence that extracellular microRNAs are conveyors of information between distant tissues in the body. It moves to efforts to probe ever-smaller volumes of biofluids to find the least-invasive source of microRNA biomarkers and the diseases for which microRNA-based diagnostic tests already exist or may emerge in the future. Finally, it looks at developments in RNA detection technology that might allow point-of-care testing and perhaps microRNA-based health monitoring at home.

The genome is the totality of information that directs the making and the maintenance of you and every other living organism. Scattered among the familiar genes that code for the proteins of life are other genes. This is a book about the genes we call microRNA. It is 30 years since their discovery. They are gene regulators, every bit as vital as their more famous gene cousins. MicroRNAs fine-tune how much protein is made in our cells, each one coordinating the activity of hundreds of genes and bringing precision to the ‘noise’ of gene expression. Without them, life is virtually impossible. This introduction provides a personal account of what fascinated the author about these genes enough to make him redirect his research to microRNAs. The journey from studying pharmacology in the UK, to the USA where his interest in the brain disease epilepsy began, and later to Dublin, to work at the Royal College of Surgeons in Ireland. It lays out the contents and style of the book, which is part history of science, describing what we know and the experiments that underpin our understanding, and part memoir of the author’s own research, and the applications of microRNAs in medicine.

In 2010, only a decade since microRNAs were discovered in humans, the first patient was treated with a microRNA drug, miravirsen, for hepatitis C virus (HCV) infection. This chapter opens with the discovery that HCV contained binding sites for miR−122, an abundant liver-specific microRNA. It looks at the research showing how the virus hijacks miR−122 to replicate, and the groundbreaking drug development programme that took advantage of this to create the world’s first medicine to target a microRNA. It covers some of the microRNA-based therapies further back in the drug development pipeline, discussing the relative strengths but also the risks of this approach. It explores the method to target microRNAs, including recent developments to disrupt single microRNA–target interactions to create precision microRNA therapies, and the viruses being commandeered to deliver microRNA treatments into specific cell types in the body. Lastly, it looks at how new microRNAs are being identified and considers the future of microRNA-based treatments, focussing on prospects for neurological disorders and reflecting on how, by listening to patients, we can create better and safer medicines.

Neuropsychiatry has a long and fascinating history as a discipline at the interface between neurology and psychiatry that combines clinical observations with modern investigational techniques. Historically, organic psychiatry has focused on clinical syndromes with regional connections affecting the four cortical lobes and the corpus callosum. Behavioural neurology has developed from early observations of classical neurocognitive syndromes, including aphasia, alexia, apraxia, agnosia and Gerstmann syndrome. A number of common neurological conditions often present with specific psychiatric symptoms: traumatic brain injury, cerebrovascular disease, brain tumours, epilepsy, movement disorders, infectious diseases and autoimmune neurological disorders such as multiple sclerosis, systemic lupus erythematosus and autoimmune encephalopathies. The differential diagnosis between delirium, dementia and pseudodementia can pose significant challenges. Finally, several toxic, metabolic and endocrine disorders can have clinically relevant neuropsychiatric manifestations.