Pregnancy and epilepsy

C P Panayiotopoulos MD PhD (Dr. Panayiotopoulos of St. Thomas' Hospital has no relevant financial relationships to disclose.)
John M Stern MD, editor. (Dr. Stern, Director of the Epilepsy Clinical Program at the University of California in Los Angeles, received honorariums from Sunovion and UCB as an advisor and from Cyberonics, Eisai, Lundbeck, and UCB as a lecturer.)
Originally released October 2, 2014; last updated December 1, 2016; expires December 1, 2019

Overview

Approximately 20,000 to 25,000 children are born in the United States each year to mothers with epilepsy, and between 0.3% and 0.5% of all pregnancies occur among women with epilepsy. Most of these women need to continue taking medication during pregnancy because uncontrolled convulsive seizures may be harmful to the women as well as to their fetuses. The challenge to physicians is to prescribe a treatment that is effective in controlling seizures but has minimal associated risks. Overall, 95% of women with epilepsy have uncomplicated pregnancies and deliver normal babies. This rate can be significantly improved with proper management; any serious harm to the baby or mother, particularly if it is avoidable, is too much for the family that is affected. The highest risks for major congenital malformations and adverse cognitive outcomes are associated with polytherapy (mainly combination of valproate and lamotrigine). With monotherapy, the highest risk is found with valproate followed by topiramate. In utero exposure to monotherapy with lamotrigine, carbamazepine, and levetiracetam have a low risk of major congenital malformations, near 2.5%. Furthermore, the concentration of antiepileptic drugs may change significantly during pregnancy and the puerperium, resulting in an increase in seizures (mainly with lamotrigine and oxcarbazepine) or toxicity. Women should be made fully aware of all aspects of antiepileptic drug treatment and be able to make informed decisions. In this article, the author details the various issues that women with epilepsy face before, during, and after pregnancy.

Key points

 

• Pregnancy of women with epilepsy is complicated by significant considerations, such as the potential teratogenicity, risks of having seizures, and other complications.

 

• The highest risks for major congenital malformations and adverse cognitive outcomes are associated with polytherapy (mainly combination of valproate and lamotrigine).

 

• With monotherapy, the highest risk is found with valproate followed by topiramate.

 

• Monotherapy with lamotrigine, carbamazepine, and levetiracetam have a low risk of major congenital malformations, near 2.5%.

 

• The bioavailability of antiepileptic drugs may change considerably during pregnancy and the puerperium, resulting in an increase in seizures (mainly with lamotrigine and oxcarbazepine) or toxicity.

 

Folic acid taken at the time of conception decreases the risk of adverse outcomes.

 

• Seizure freedom before pregnancy is a good predictor of remaining seizure-free during pregnancy.

 

• Preconception management is the cornerstone for care of women with epilepsy who wish to become pregnant.

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