Problems in Managing Epilepsy During and After Pregnancy

This chapter inspects the case of a patient suffering from juvenile myoclonic epilepsy. The 30-year-old woman had a history of epilepsy since the age of 13. Her epilepsy began with myoclonic jerks of the hands and arms, occasionally associated with falling down. She also developed brief staring spells associated with thought interruptions, and she had extremely rare convulsions. She underwent trials of valproate, carbamazepine, ethosuximide, and phenytoin, but had difficulty with side effects from each medicine. The patient's general and neurological examinations were unremarkable. The patient became pregnant while taking valproate at 875 mg/day and folate. At16 weeks' gestation, fetal ultrasound showed evidence of spina bifida, cleft palate, and hydrocephalus. The pregnancy was terminated. The patient wanted to become pregnant again but insisted on not taking any medicine to prevent seizures this time. She continued a high-folate diet and also took a prenatal vitamin preparation plus an additional 3 mg/day of folate (with her prenatal vitamin preparation she would be getting 4 mg), since it was thought that a genetic component was present in the outcome of the first pregnancy. However, she noted that now that she was off valproate, taking the extra folate seemed to produce myoclonic jerks and she gradually tapered off the folate with resolution of the myoclonus. She gradually developed increasing myoclonus as the pregnancy advanced, but she did not take antiepileptic drugs. A normal girl was delivered at term. This case illustrates many of the difficulties in managing women of reproductive potential with epilepsy.