How is epilepsy treated during pregnancy?

Updated: Aug 20, 2019
  • Author: Carmel Armon, MD, MSc, MHS; Chief Editor: Stephen A Berman, MD, PhD, MBA  more...
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Specific treatment recommendations for epilepsy in pregnant women should be individualized. The risk to the fetus should be balanced with the risk to the woman posed by generalized tonic-clonic seizures or, if the woman is seizure-free before conception, by breakthrough seizures of any type during pregnancy.

The authors’ standard practice is to try to achieve monotherapy before pregnancy, if possible, by aiming for the best medication for the specific seizure type. Valproic acid and phenobarbital are avoided if possible. Concomitant nonepileptic medications are reviewed, and those that can be eliminated should be discontinued.

The authors also recommend supplementation with folic acid at a dose of 4 mg/day, while conceding that no evidence supports the use of this dosage rather than a lower dosage, such as 0.4 mg/day.

In addition, increased fetal surveillance is recommended if the woman requires treatment with AEDs. This surveillance should include a detailed anatomic survey with high-resolution ultrasonography, fetal echocardiography, and maternal serum screening for alpha-fetoprotein, which assists in diagnosing neural tube defects.

The authors prefer to check AED levels frequently (eg, monthly) because levels may drop during pregnancy and rise after delivery. The dosage is adjusted if necessary.

Pregnant women taking antiepileptic medications should be encouraged to enroll in the NAAED Pregnancy Registry online or at 888-233-2334.

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