What are the risks to my baby if I become pregnant?

Both seizures and medications are associated with some risks. The risk of seizures is associated with seizure type. Partial seizures probably do not carry as much risk as generalized seizures. Yet, they can lead to a generalized seizure. Generalized tonic-clonic seizures are associated with increased risk to both the mother and baby. These risks include:

  • Trauma from falls or burns 
  • Increased risk of premature labor 
  • Miscarriages
  • Lowering of the baby's heart rate
  • Change in seizures

Seizure control is critical because the risks from seizures are greater than the risks from medications. 

What are the risks of seizure medications to the baby?

The risk to the developing baby from seizure medications taken during pregnancy is primarily that of congenital malformation or birth defects.

  • In the general population, there is a 2 to 3 of every 100 babies born may have a congenital  malformation that cannot always be predicted or prevented.
  • In women with epilepsy, the risk is doubled to about 4 to 6 of every 100 babies (which is a 4 to 6 % risk). While this risk is higher in women wtih epilepsy, the number remains low.  
  • There may be a higher risk when a woman is taking more than one drug, especially if one of the medicines is valproic acid/valproate.  
  • There clearly is a genetic role, with a previous pregnancy or family history of a congenital malformation raising the risk during the current pregnancy. Genetic counseling is needed in this circumstance.
  • The most common malformations include cleft lip and clef palate (which can be surgically corrected), problems with the heart, urinary or genital systems. 
  • Some medications, for example valproic acid/valproate, may also affect a child's development. Research continues in this area. 

What is the 'best drug' to take during pregnancy? 

  • There is limited information available on new antiepileptic drugs and only slightly more on the classic antiepileptic drugs.
  • Given available information, it is recommended that the most effective drug with the fewest side effects be used.
  • Most of the seizure medications can be used safely, though some carry increased specific risks.
  • Valproate used in the early days of pregnancy carries a 1% to 2% risk of neural tube defects (lack of spinal cord closure) and an overall 10% risk of any major congential malformation.  
  • Moreover,  research from the NEAD study (Neurodevelopmental Effects of Antiepileptic Drugs) found that children of women taking valproic acid during pregnancy had children with lower IQ and and increased risk of autism. 
  • The risks associated with VPA are greater when higher doses of VPA are used. 

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 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), taking it all the time is a good idea.
  • During pregnancy, a daily multivitamin containing 0.4 mg folate, as well as an additional 1- to 4-mg folate supplement, is recommended for all women of childbearing age.
  • Selenium and zinc, contained in a multivitamin with minerals, also may be of some benefit.
  • Women with epilepsy on certain seizure medications (enzyme-inducing AED such as carbamazepine, phenytoin, phenobarbital, primidone) may be asked to take Vitamin K in the last month of pregnancy to prevent rare bleeding complications in the newborn.
  • Babies of women taking one of these enzyme-inducing seizure medications should be given an injection of Vitamin K at birth. 

What else can I do?

  • Most importantly, women should get accurate information prior to and during pregnancy.
  • See the doctor before becoming pregnant, keep regular appointments, and check blood levels during pregnancy as recommended by your health care team. 
  • If anti-epileptic drugs are not needed, multiple medications are being taken, or medications are given at high dosages, changes should be considered with a neurologist prior to a planned pregnancy.
  • The lowest possible drug dose that will continue to maintain seizure control is needed. 
  • Being on a single drug may lower the risk of birth defects and result in fewer drug interactions, fewer side effects, and improve compliance.
  • Taking the appropriate medications as prescribed.
  • Monitoring drug levels is also very important. Anti-epileptic drug levels should be checked throughout the pregnancy and following delivery.
    • The levels of all anti-epileptic drugs 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.
    • Paying attention to nutrition with adequate weight gain and taking a multivitamin and additional folate before, during, and after pregnancy are needed.
    • Avoiding cigarettes, alcohol, and caffeine are important for all women 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?

While the anti-epileptic drugs are present in breast milk, breastfeeding is encouraged.

  • 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* have found no side effects from breastfeeding in infants whose mothers were taking AEDs, when the children were tested at 3 years old. One study has folllowed children up to 6 years old 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 the antiepileptic drugs 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 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 antiepileptic drugs.

Early child development and exposure to antiepileptic drugs prenatally and through breastfeeding. 

Meador KJ, Baker GA, Browning N, et al: NEAD Study Group. Breastfeeding in children of women on antiepileptic drugs: Cognitive outcomes at age 6 years. JAMA Pediatrics 2014 (in press)

 

Reviewed by: Joseph I. Sirven MD | Patricia O. Shafer RN MN | Kimford J. Meador MD on 3/2014
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