Management of Epilepsy and Pregnancy

Management of epilepsy and pregnancy is a major challenge for clinicians as well as women with epilepsy, and because of ethical constraints there are very few randomized controlled trials to guide decisions. Data from most of the pregnancy registries indicate that more than 90% of women with epilepsy will have a normal pregnancy and healthy babies. Most patients with epilepsy would also require continuous use of antiepileptic drugs (AEDs) during pregnancy, in order to remain seizure-free. Pre-pregnancy consultation provides an opportunity to review the clinical status of the woman, assess the risk of seizure recurrence during pregnancy and of fetal malformations, and thus optimize therapy without undue risk to the mother or baby. It may be possible to reduce the dosage of AEDs or switch some patients from polytherapy to monotherapy. Women who are considering pregnancy should be started on folic acid. All pregnant women with epilepsy should be offered detailed screening for fetal malformations in the third or fourth month of pregnancy. AED dosage may have to be escalated in the latter half of pregnancy if drug blood levels drop considerably. If seizures occur late in pregnancy with therapeutic AED levels, other causes of seizures during pregnancy, such as eclampsia and cerebral venous sinus thrombosis, need to be considered. Most patients can breast-feed their newborns even when they are taking AEDs. Interactions between AEDs and oral contraceptives need to be kept in mind while discussing the contraceptive options for women with epilepsy. The treatment of epilepsy in women needs to be individualized according to the epilepsy syndrome, seizure risk during pregnancy, risk of fetal malformations, and the healthcare that can they can access.