The American Academy of Neurology just published an evidence-based review of best practices for treating women with epilepsy (WWE) who are or are considering becoming pregnant. The full article citation on-line is Harden C, et al., "Practice parameter update: management issues for women with epilepsy-focus on pregnancy (an evidence-based review): obstetrical complications and change in seizure frequency" Neurology 2009; DOI: 10.1212/WNL.0b013e3181a6b2f8. The article simultaneously appeared in the journal, Epilepsia.

These reviews perform an exhaustive and critical search of published evidence to formulate conclusions. The best level of evidence is graded Class I, solid but not completely conclusive as Class II, suggestive evidence as Class III and weak evidence as Class IV. The following conclusions were drawn.

1. The risk of major clinical malformations in the offspring of women with epilepsy is possibly decreased by folic acid supplementation (Class III).
2. Antiepileptic drugs (AEDs) have been said to increase the risk of hemorrhage (bleeding) in babies born to WWE. The systematic review concluded that this claim is neither proven nor disproven by available evidence.
3. Many AEDs, including phenobarbital, primidone (Mysoline), phenytoin (Dilantin), carbamazepine (Tegretol), levetiracetam (Keppra) and valproate (Depakote, Depakene) probably cross the placenta to reach the fetus in potentially clinically important amounts (Class I and II evidence).
4. Should WWE breastfeed? The review concludes that Class I and II evidence indicate that several drugs pass into breast milk in potentially significant amounts, including primidone (Mysoline), levetiracetam (Keppra), gabapentin (Neurontin), lamotrigine (Lamictal), topiramate (Topamax). In contrast, valproic acid (Depakote, Depakene), phenobarbital, phenytoin (Dilantin) and carbamazepine (Tegretol) probably do not pass into breast milk in significant quantities. The report made no recommendation about whether or not to breastfeed, since evidence of resulting problems in breastfed newborns exposed to AEDs in the breast milk was not available.
5. Blood levels of AEDs can change during pregnancy, particularly for lamotrigine (Lamictal), carbamazepine (Tegretol), phenytoin (Dilantin), levetiracetam (Keppra) and oxcarbazepine (Trileptal). Consideration should be given to monitoring levels of these drugs during pregnancy and possibly other AEDs as well.

This article reviewed only the above selected topics. Many other issues, such as risks of taking valproic acid or phenobarbital during pregnancy were not addressed. Further information on issues of epilepsy and pregnancy can be found at:

Health Outcomes in Pregnancy and Epilepsy (HOPE) | Forum – Overview
http://www.epilepsy.com/node/4147 and
http://professionals.epilepsy.com/page/ar_1191430420.html

Pregnancy Registries - Release of Negative Information
http://professionals.epilepsy.com/page/ar_1191514203.html

Physician's Discussion Checklist for Women with Epilepsy
http://professionals.epilepsy.com/page/women_checklist.html

Discussion guide
http://professionals.epilepsy.com/page/women_guide.html also published in Epilepsy and Behavior (Cramer et al, 2007)