Management of Epilepsy During Pregnancy: Evidence-based Strategies

Swapna Putta; Page B Pennell

Disclosures

Future Neurology. 2015;10(2):161-176. 

In This Article

Abstract and Introduction

Abstract

Child-bearing years are often the most precarious management period in the life of a woman with epilepsy. This article reviews the results of many different studies with findings that enable the healthcare team to make confident decisions and recommendations during these critical periods. Preconceptional planning, effective contraception and folic acid supplementation are important fundamentals in preparation for pregnancy. There is growing evidence to avoid valproic acid use during the child-bearing years. Emerging data on congenital malformations and neurocognitive outcomes are available for some of the second-generation antiepileptic drugs and appear reassuring for lamotrigine and levetiracetam. Also reviewed are the benefits of postpartum drug tapers and favorable breastfeeding facts. Counseling the mother and her family on medication choices enables the healthcare team to implement informed decisions that are beneficial for the mother and child.

Introduction

The management of epilepsy during pregnancy is challenging and complicated. Epilepsy is the fourth most common neurologic disorder, but one of the most common chronic medical disorders of any kind that requires daily treatment with known teratogens during pregnancy. Over 1 million women with epilepsy in the USA are of reproductive age, and these women give birth to approximately 20,000 infants every year.[1] The majority of patients with epilepsy maintain seizure control during pregnancy, with actual seizure freedom reported in 66% of pregnant women in one large, international pregnancy registry.[2] But while some studies report that 63% of women experience no change in seizure activity, 17% experience an increase, and 16% a decrease in seizure frequency.[3] Seizures pose a risk to the developing fetus, especially if generalized tonic clonic convulsions. They can cause direct injuries from a fall, compromise the blood supply to the fetus, cause postictal hypoxia and lactic acidosis. This argues for stricter vigilance about seizure control during pregnancy than in any other period of a woman's life. However, the treatment of epilepsy during pregnancy is a double-edged sword, because many of the antiepileptic drugs (AEDs) that most effectively control seizures are also teratogenic to various degrees, posing another obvious risk to the developing fetus. This makes the management of the pregnant patient with epilepsy a unique challenge (Figure 1). With the increasing use of AEDs for various nonepileptic disorders like chronic or neuralgic forms of pain, migraines and mood disorders, it is necessary to understand the best evidence based strategies for using AEDs in pregnant women. This review presents numerous prospective studies, registry data and updated results describing treatment strategies and outcomes for treating epileptologists, general neurologists, internists, family practitioners, obstetricians and pediatricians.

Figure 1.

Complex tridirectional interactions and influences.
AED: Antiepileptic drug.

processing....