Pregnancy and epilepsy: what should we tell our patients?

Abstract

Women with epilepsy that plan to become pregnant can in general look forward to uneventful pregnancies and to giving birth to normal children. However, there are certain risks associated with epilepsy and antiepileptic drug (AED) treatment, and it is likely that these risks can be reduced with appropriate prepregnancy counseling. Women with epilepsy should be informed that maintained control of tonic-clonic seizures is important for their health as well as for the well-being of the fetus; that pregnancy in general has little effect on seizure control; but that pregnancy may affect plasma concentrations of AEDs, and that drug level monitoring and dosage adjustments may be needed. They should be informed of the moderately increased risk of birth defects, and that this risk appears to be higher with the use of valproate, in particular at doses above 800 mg/day. The possibility of changing from valproate to another AED should be considered, but such changes should be tried out before conception. Withdrawing or changing an AED should generally be avoided during pregnancy. Women with epilepsy on AED treatment should be encouraged to breast-feed.

Epilepsy: recent advances

“…This is very much in line with the now well accepted guidance that optimizing the treatment of pregnant women with epilepsy, ideally prior to conception, can improve maternal and foetal outcomes. The available data were comprehensively reviewed by two well established authorities in the field [28]. Pulling together data from a wealth of studies, including the various international prospective pregnancy registries that now exist, their conclusions reassuringly reflect what some might consider simple common sense: generalized convulsive seizures should be prevented if possible, using drugs which minimize the risk to the mother and foetus, ideally as monotherapy at the lowest effective dose.…”

Maternal epilepsy and adverse pregnancy outcomes

“…The extent of these changes depends on the AED, but also varies between patients [7]. Enhanced drug elimination due to enzyme induction is the most important mechanism.…”

“…Seizure frequency and severity may change, and there is an increased risk of malformations in the offspring. The major reason for treating patients with epilepsy is that seizures can cause harm, and this is also true in pregnancy [7]. In the UK in 2000-2002, 13 maternal deaths were reported to be due to epilepsy; nine of these met criteria for sudden unexplained death in epilepsy [11].…”

“…Epilepsy often requires continuous drug treatment during pregnancy, and antiepileptic drugs (AEDs) constitute one of the most frequent potentially teratogenic exposures [3,7]. Unnecessary AED treatment should be avoided during pregnancy [8].…”

Antiepileptic drugs: the risks and benefits during pregnancy

“…7 Furthermore, the majority of women with epilepsy will maintain seizure control during pregnancy and obstetric complications are uncommon. 8 For women who are already taking AEDs, the main reason for remaining on them during pregnancy is her continued risk of seizure. AED treatment is the mainstay for the majority of people and requires a balance to be struck between the need to reduce the likelihood and severity of seizures versus the potential risks resulting from fetal exposure to AEDs.…”