Therapy Insight: Clinical Management of Pregnant Women With Epilepsy

Alison M. Pack

Disclosures

Nat Clin Pract Neurol. 2006;2(4):190-200. 

In This Article

Breastfeeding

Breastfeeding a newborn baby has many advantages, including maternal transfer of antibodies, as well as promoting bonding between mother and child. In addition, for many women, breastfeeding is an integral and important part of the experience of motherhood. Given these considerations, the American Academy of Neurology and the American Academy of Pediatrics advise that women with epilepsy taking AEDs can breastfeed.[48] During breastfeeding the baby will, however, continue to be exposed to the AED in varying concentrations depending on the prescribed AED. If mothers receiving ethosuximide, phenobarbital or primidone choose to breastfeed, they should exercise caution and closely monitor the infant for sedation, lethargy and any significant clinical findings.[49] On the basis of small studies, including single-dose studies, case reports and short-term studies, phenytoin, carbamazepine and valproate are probably safe. These AEDs are all moderately to highly protein-bound, and are not transferred in high concentrations in breast milk. A small study of four infants indicates that lamotrigine might be transferred to the infant through breast milk in concentrations similar to those seen in the mother, as lamotrigine is extensively metabolized by glucuronidation, which is immature in infants.[50] Given these findings, infants who are breastfed by mothers receiving lamotrigine should be monitored.

In eight women receiving levetiracetam, concentrations of the drug were approximately equal in milk and plasma.[51] In their babies, however, levels of levetiracetam in the serum were very low, indicating extensive transfer in milk and rapid elimination of levetiracetam in infants. Similarly, 2-3 weeks after delivery in five mother-child pairs in which the mother was treated with topiramate, the mean milk : maternal plasma concentration ratio of topiramate was 0.86,[52] yet topiramate concentrations of the drug in the infants were very low, indicating efficient elimination by the infant. It should be noted, however, that in this small study four of the five mothers were also taking carbamazepine, which induces metabolism of topiramate, as well as inducing fetal metabolism in general (including metabolism of carbamazepine). The pharmacokinetics of gabapentin during lactation was studied in six infants.[53] The milk : maternal plasma concentration ratio was 1.0 (range 0.7-1.3) from 2 weeks to 3 months. Plasma concentrations were low in suckling infants, however, and no adverse effects were reported. Studies also indicate that oxcarbazepine and zonisamide are transferred extensively in breast milk.

In summary, breastfeeding is a viable option for women with epilepsy who are being treated with AEDs. Caution and clinical monitoring should be exercised if the mother is using phenobarbital, primidone, ethosuximide or lamotrigine. Larger scale studies are needed to better understand drug transfer in breast milk and metabolism in infants for all AEDs.

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