Folate in Young Women With Epilepsy: Start Early, Remind Often

Pauline Anderson

December 17, 2019

BALTIMORE — Neurologists should repeatedly remind young female patients with epilepsy, particularly those who are black, to take folic acid, new research suggests.

Deepti Zutshi, MD

A new pregnancy-outcomes study showed that black women with epilepsy are about half as likely to take folic acid as their counterparts of other racial backgrounds and are significantly more likely to have an unplanned pregnancy and later complications.

Clinicians should discuss the importance of taking folic acid with their female patients with epilepsy not just once but at every visit, said study investigator Deepti Zutshi, MD, assistant professor of neurology, Comprehensive Epilepsy Center, Wayne State University, Detroit, Michigan.

"It's important to really enforce this message and start when patients are young; start at puberty," Zutshi told Medscape Medical News.

The findings were presented here at the American Epilepsy Society (AES) 73rd Annual Meeting 2019.

Significant Discrepancy

The study included 104 pregnancies in patients at the High Risk Pregnancy and Epilepsy Clinic in Detroit. Of these pregnancies, 79.8% were among black women.

"I had a unique opportunity to add to what we know already about pregnancy outcomes in this population," Zutshi said.

Black participants were comparable to the other participants in terms with a mean age of 26 years, duration of epilepsy of just over 10 years, and seizure type, which was mostly focal and generalized.

Nevertheless, black participants were significantly more likely to have an unplanned pregnancy (83% vs 63%, respectively; P = .02).

"The next step is to figure out the reason for this discrepancy," said Zutshi.

This includes looking at cultural differences, stigma, and whether they receive or have access to birth control counseling and counseling on the potential risks of birth defects associated with antiepileptic drugs, she added.

The study also showed that black women were less likely to have taken folic acid pre-conception (22% vs 55%), possibly because they weren't counseled to do so, said Zutshi.

"The problem could be lack of access to prenatal care, lack of access to an OB-GYN, maybe lack of access to a neurologist who needs to prescribe folic acid to women who are on antiepileptic drugs," Zutshi said.

However, even if women are prescribed folic acid, they may not take it, she added.

"Anecdotally, that's because they don't know why they should be taking it. When you prescribe it, you have to explain what it is and what it does" to help prevent complications such as neural tube defects, Zutshi noted.

"All About Repetition"

Most doctors already counsel their female patients with epilepsy to take folic acid, but patients need reminding as they may be taking antiseizure medicines and dealing with numerous other issues, Zutshi said. "It's all about repetition," she added.

Barriers to prenatal care for black women, especially those with epilepsy, include younger age at pregnancy, no means of transportation, not realizing they are pregnant until later gestation, and lack of education.

About 48% of black participants, vs 41% of the other women in the study, had at least one seizure during pregnancy.

Pregnancy complications, including miscarriages and premature deliveries, were skewed toward black women — and again, likely reflects lack of prenatal care, Zutshi said.

In the nonblack participant group, there was one case of threatened miscarriage vs five cases in the group of black women. The latter group also had six cases of premature delivery and three cases each of eclampsia/preeclampsia and congenital malformation vs zero cases in the group of nonblack participants.

Black women are not well represented in national pregnancy registries; and most of these registries recruit women in the first trimester — before they have their 18- to 22-week ultrasound, Zutshi noted.

"I'm getting patients way into their second and third trimester. Why weren't they referred to me beforehand?" said Zutshi.

Future studies should compare pregnancy outcomes in black women with, and without, epilepsy, Zutshi said.

"That research needs to control for whether [black patients] receive prenatal care. I think that's probably one of the biggest confounding factors you have to consider when you do that comparison," she added.

Important Message

Commenting on the study for Medscape Medical News, Anna Serafini, MD, director of the Epilepsy Monitoring Unit and assistant professor in the Department of Neurology and Rehabilitation, University of Illinois, Chicago, said the new information is useful.

"It shows that we need to target the African American population even more, and we need to remember that the majority of pregnancies in this population are unplanned," said Serafini, who was not involved in the research.

She said she prescribes 1 mg of folate per day to all her patients with epilepsy of childbearing age, even if they insist they are not planning to become pregnant. She raises the dose to 4 mg once a woman does become pregnant. Many multivitamins geared to women contain folate.

However, she acknowledged that many patients don't follow her advice.

A limitation cited by Serafini was that there were relatively few nonblack women in the study. "It would be interesting to increase that number to have a better comparison," she said.

She also agreed that data in national pregnancy registries come from very select patient populations.

"We need to start to include more populations such as African Americans because the data might be different," said Serafini.

American Epilepsy Society (AES) 73rd Annual Meeting 2019: Abstract 3.24. Presented December 9, 2019.

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