Epilepsy in pregnancy

Definition:

Epilepsy is a neurological disorder characterized by recurrent, unprovoked seizures. Managing epilepsy during pregnancy involves balancing the need to control seizures with the safety of antiepileptic drugs (AEDs) for both the mother and the developing fetus.

Epidemiology:

Epilepsy affects approximately 0.5-1% of the population.
It is one of the most common neurological disorders encountered in pregnancy.

Impact on Pregnancy:

The majority of women with epilepsy have healthy pregnancies and deliveries.
The risk of congenital malformations is slightly increased in women with epilepsy, particularly related to the use of certain AEDs.

Management Principles:

Preconception counseling is crucial for women with epilepsy to optimize AED therapy and ensure vitamin supplementation, particularly folic acid, to reduce the risk of neural tube defects.
AED therapy should be reviewed and adjusted if necessary before pregnancy. The goal is to use the minimum effective dose and, if possible, monotherapy to reduce teratogenic risks.
Serum AED levels should be monitored throughout pregnancy, as physiological changes may alter drug levels.

Antiepileptic Drug Use in Pregnancy

Risks Associated with AEDs:

Certain AEDs have a higher risk of fetal malformations, including valproate and high-dose topiramate.
Other AEDs considered relatively safer include lamotrigine and levetiracetam.

Monitoring and Adjustments:

AED levels can fluctuate during pregnancy due to changes in volume of distribution and metabolism, necessitating close monitoring and dosage adjustments.
The risk of seizures may increase during pregnancy due to these changes in AED levels.

Postpartum Considerations:

Breastfeeding is generally encouraged, although some AEDs may be present in breast milk. The benefits of breastfeeding often outweigh the risks, but it’s important to discuss specific medications with a healthcare provider.
The risk of postpartum seizures is a concern, particularly in the context of sleep deprivation. Continuation of AEDs postpartum is important for seizure control.

Fetal and Neonatal Considerations

Congenital Malformations:

The risk of congenital malformations is estimated to be approximately twice that of the general population but varies depending on the specific AED.
Neural tube defects, cleft lip and palate, and cardiac defects are among the most common malformations associated with certain AEDs.

Neonatal Care:

Newborns exposed to AEDs in utero may be at risk for withdrawal symptoms and require monitoring.
Vitamin K supplementation may be recommended for the mother before delivery and for the newborn to prevent bleeding complications associated with certain AEDs.

Seizure Control During Pregnancy

Maintaining seizure control is paramount, as seizures can pose risks to both the mother and fetus, including trauma, hypoxia, and increased risk of fetal mortality and maternal injuries.
Status epilepticus, although rare, is a neurological emergency that requires immediate treatment.

Summary

Epilepsy management during pregnancy requires a multidisciplinary approach to ensure the safety and well-being of both the mother and fetus. Key considerations include optimizing AED therapy before conception, careful monitoring of AED levels during pregnancy, and managing the risks of seizures and AED-related teratogenicity. With appropriate planning and management, most women with epilepsy can expect to have a healthy pregnancy and delivery.