What are the risks to my baby if I become pregnant?
Both seizures and seizure medications pose certain risks to a developing baby.
Seizures during pregnancy can cause harm to the baby due to:
- Trauma from falls, burns, motor vehicle crashes
- Premature labor
- Dangerous lowering of the baby's heart rate
Seizure control is critical during pregnancy because the risks from uncontrolled seizures are greater than the risks from medications.
What are the risks of seizure medications to a developing baby?
- In the general population (“healthy controls," not on seizure medication), 2.2% of babies born will have a congenital malformation (“birth defect”) that cannot always be predicted or prevented.
- In women with epilepsy treated with seizure medications, the risk of birth defects is increased to 6.1% on average, based on currently available data.1
- The most common malformations associated with exposure to seizure medications in utero are cardiac (heart) malformations. Others include cleft lip/palate, skeletal, urologic, and neural tube defects (such as spina bifida).
- In pregnant women with epilepsy NOT taking seizure medication, the risk of having a baby with a congenital malformation is still slightly higher than in other women (2.8%), and untreated epilepsy carries additional risks to mother and baby as noted above.
- Risks are presumed to be higher in women taking multiple seizure medications and when doses are higher.
- With some seizure medications – particularly valproic acid (Depakote) – there is also an increased risk of the developing baby having cognitive/behavioral impairments later in life, such as lower IQ, and autism spectrum disorders.
1 Meador KJ, Loring DW. Developmental effects of anti-epileptic drugs and the need for improved regulations. Neurology 2016; 86:297-306.
Do different seizure drugs have different risks?
- Based on currently available data, valproic acid (Depakote) has the highest risk of causing both anatomical and cognitive/behavioral abnormalities in a developing child. Therefore, it should generally be avoided in women of childbearing potential. Higher doses confer higher risk, but there is no known “safe dose” of valproic acid during pregnancy.
- Phenobarbital and topiramate pose intermediate risk.
- Pregabalin may also be in the intermediate to high risk category based on a recent study.
- Carbamazepine, lamotrigine, and levetiracetam pose lower risks than the above mentioned seizure medications.
- There is not enough data about other seizure medications to make specific recommendations.
- The risk for cognitive impairment in a developing child is increased with exposure to multiple seizure medications, but it is not yet known how different combinations of seizure medications compare with respect to risk.
What can be done to lower the risk of birth defects?
- In the general population, the risk of birth defects is decreased by taking folate (folic acid) at the time when the brain and spinal cord are forming, early in the first trimester of pregnancy.
- Although it may not be as protective in women with epilepsy, folate should be taken daily prior to becoming pregnant. Since most women do not know they are pregnant until after the time of neural tube closure (24-28 days after conception), women of childbearing age should take folate every day consistently.
- A daily prenatal multivitamin containing 0.4 mg folate, as well as an additional 2 mg folate supplement daily, is recommended for all women of childbearing age.
What else can I do?
- See your doctor BEFORE becoming pregnant to discuss whether changes to your seizure medications are recommended (such as decreasing doses while maintaining seizure control).
- Keep taking your medications as prescribed – do not make changes unless directed by your doctor.
- Anti-epileptic drug (AED) levels may need to be checked frequently throughout the pregnancy and following delivery (especially if you are taking lamotrigine).
- The levels of all AEDs decline during pregnancy, with some being more affected than others. Dosage adjustments may be needed.
- Since the levels then rise following delivery, monitoring in the post-partum period is also needed to minimize side effects.
- Monitoring the baby with maternal serum-alpha-fetoprotein testing and a high resolution or level II ultrasound should be performed by the obstetrician.
- Epilepsy is not an indication alone for a cesarean section, and most women deliver vaginally.
- Remember to stay healthy!
- Get enough rest and sleep.
- Pay attention to nutrition, with adequate weight gain
- Take a multivitamin and additional folate before, during, and after pregnancy
- Avoid cigarettes, alcohol, and caffeine during pregnancy.
Keeping all these factors in mind, the overwhelming majority of women with epilepsy will have a normal healthy baby!
Can I breastfeed my baby?
Although some amount of seizure medication will be present in breast milk, breastfeeding is encouraged even in women with epilepsy.
- Breastfeeding can generally be done safely, since the baby has been exposed to the seizure medication throughout the pregnancy and the absolute amounts of drug are low.
- Recent research has found no side effects from breastfeeding in infants whose mothers were taking AEDs, when the children were tested at 3 years of age. One study followed children up to 6 years of age and found that the children who were breastfed while their mothers were taking AEDs actually had higher IQs than children of women with epilepsy who were not breastfed.
- Other health benefits of breastfeeding to the baby are very important to consider.
- Strategies such as taking an AED immediately after a feeding should be considered to lessen the amount of drugs in a feeding.
How can I help?
Pregnancy registries have been established to help gain information.
- All pregnant women with epilepsy in North America are encouraged to enroll in the North American Anti-Epileptic Drug Pregnancy Registry prior to having the initial pregnancy screening to help add to our knowledge base.
- Women outside North America are encouraged to enroll in their pregnancy registry via their neurologist.
References for Breastfeeding
- NEAD Study Group. Effects of breastfeeding in children of women taking anti-epileptic drugs.
- Early child development and exposure to anti-epileptic drugs prenatally and through breastfeeding.
- Meador KJ, Baker GA, Browning N, et al: NEAD Study Group. Breastfeeding in children of women on anti-epileptic drugs: Cognitive outcomes at age 6 years. JAMA Pediatrics 2014; 168(8):729-736.