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  • Updated 01.04.2022
  • Released 10.02.2014
  • Expires For CME 01.04.2025

Pregnancy and epilepsy

Introduction

Overview

Women with epilepsy in childbearing age should be properly counseled for safe pregnancy planning (including optimization of treatment choices aiming at seizure freedom prior to pregnancy), be informed about anatomical, behavioral, and cognitive teratogenicity of antiseizure medications, and be reminded of the importance of preconception folic acid supplementation. During pregnancy, there should be active and early monitoring of antiseizure medication dose adjustments due to changes in bioavailability and impact of hormonal changes to avoid an outbreak of seizures. In this article, the author summarizes new pregnancy outcome information from the newest antiseizure medications as well as neurodevelopment disorders in children born from women with epilepsy.

Key points

• The cornerstone for care of women with epilepsy who wish to become pregnant is preconception management, including folic acid supplementation, which can reduce risks of anatomical and neurodevelopmental (behavioral or cognitive) teratogenicity.

• Seizure freedom in the year prior to conception is a good predictor of remaining seizure-free during pregnancy.

• The bioavailability of various antiseizure medications changes considerably during different pregnancy stages, resulting in the need for planned and timely dose adjustment to avoid seizure recurrence.

• Valproic acid remains the antiseizure medication with the highest teratogenicity risks. Prescription of this drug to women with epilepsy of childbearing age should only be done as a joint patient-doctor informed decision, with the patient’s full understanding of risks and only after ruling that no adequate treatment alternative could be prescribed.

• Antiseizure medication polytherapy is associated with high risks of fetal malformation, particularly when including valproic acid or topiramate.

• To ensure women with epilepsy who are of reproductive age can make informed decisions about prescriptions, the lack of data regarding newer antiseizure medications should be discussed.

Introduction

Women with epilepsy planning to become pregnant are generally as likely to conceive as women without epilepsy if there are no previously known fertility issues (60). The outlook for pregnant women with epilepsy and their offspring is usually excellent, and 95% of women with epilepsy have uncomplicated pregnancies and deliver normal babies. Because up to 79% of women with epilepsy report having at least one unintended pregnancy (29), neurologists should conduct ongoing counseling for pregnancy planning during longitudinal assessment of women with epilepsy.

For women with epilepsy who experience seizure onset during childhood and adolescence, it is important to discuss aspects of reproduction, contraception, and pregnancy planning before transition to adult care to minimize risks of unplanned pregnancy (43). For all women with epilepsy, it is recommended to obtain updated information about pregnancy plans and the use of contraceptive methods at every follow-up visit. These discussions allow clinicians to optimize treatment towards seizure freedom (or best seizure control), establish treatment goals, adjust antiseizure medication dosages, obtain baseline antiseizure medication serum levels when applicable, and change antiseizure medication if a more favorable pregnancy outcome could be envisaged at preconception. If antiseizure medication treatment changes, at least 6 months of follow-up before conception is required to ensure epilepsy remains stable and doses are adjusted accordingly.

Safe antiseizure medication choices are limited for women with pharmacoresistant epilepsies. These patients might have experienced many medication failures, be of older age, and postponed pregnancy plans in hopes of achieving better seizure control.

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