Epilepsy is one of the most common medical conditions in women of reproductive age. It has been estimated that more than 1.1 million women with epilepsy in the United States are of childbearing age. With a birth rate of 3-5 per 1000 births, approximately 24,000 babies are born to women with epilepsy each year. Women with epilepsy have a number of unique concerns during pregnancy. Nevertheless, the overwhelming majority of these women will have a normal baby and the pregnancy will not significantly affect their epilepsy. Using strategies to lessen risks will promote a good outcome for mother and baby.
What are the risks of seizures during pregnancy?
Seizure frequency fortunately declines or remains the same in the majority of women during pregnancy.
- Yet in 15% to 30% of women, there may be an increase in seizure frequency, most often in the first or third trimester.
- The increased seizure frequency is not predictable by the type of seizures the woman has, how long she has had epilepsy, or even the presence of seizures in a previous pregnancy. Even having catamenial epilepsy, seizures occurring with the menstrual cycle, does not predict whether the woman will have more seizures during pregnancy.
- A number of factors have been suggested as possible triggers for these seizures, including hormone changes, water and sodium retention, stress, and decreasing blood levels of antiepileptic medications.
- Not enough sleep and not taking medications as prescribed may be the most important factors that women with epilepsy can control, along with consulting her neurologist during this time.
- There is good news though! Women who are seizure free for the 9 months prior to pregnancy have a very high chance of remaing seizure free during pregnancy!
What other risks may be associated with seizures?
Having seizures during pregnancy can cause injury or problems for the mother and child. The extent of risks are associated with seizure type.
- Partial seizures probably do not carry as much risk as generalized seizures.
- Yet partial seizures can secondarily generalize. These generalized seizures (especially tonic clonic ones) carry more risk to both mother and baby.
- These risks include trauma from falls or burns, increased risk of premature labor, miscarriages, and lowering of the fetal heart rate.
- Getting and keeping good seizure control during pregnancy is crucial. Most epilepsy specialists feel that the risks from seizures in the mother during pregnancy are greater than the risks from seizure medications.
What are the risks of seizure medications during pregnancy?
- The risk to the developing baby from anti-epileptic drugs taken during pregnancy is primarily that of congenital malformation or birth defects. In the general population, there is a 2% to 3% occurrence of congenital malformations that cannot always be predicted or prevented. In women with epilepsy, the risk is doubled to about 4% to 6%, but overall remains low.
- Risks to the developing baby may be greater when more than one type of medication is used and with a higher dose of medication.
- 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 most often can be corrected surgically. Cardiac and urogenital defects also occur. Research is ongoing concerning the risks for developmental delays.
Which AEDs have the greatest risks?
There is limited information available on our new anti-epileptic 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.
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.
While most of our anti-epileptic drugs can be and are used safely, some carry increased specific risks.
Valproate or valproic acid (VPA):
- When VPA is used in the early days of pregnancy, there is a 1% to 2% risk of neural tube defects (lack of spinal cord closure) and an overall 10% risk of any major congenital malformation in newborns.
- The NEAD study found that children of women taking valproic acid during pregnancy had children with lower IQ and an increased risk of autism.
- All of these risks are worse when higher doses of valproate are used.
What can help lower risks or problems for the baby?
- The risks of major birth defects is decreased in the general population when women take folate before the time of neural tube closure early in the first trimester.
- 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).
- A daily multivitamin containing 0.4 mg folate, as well as an additional 1- to 4-mg folate supplement, is recommended for all women taking AEDs who are of childbearing age.
- Selenium and zinc, contained in a multivitamin with minerals, also may be of some benefit.
- Vitamin K may be given to women taking enzyme-inducing AEDs in the last month of pregnancy to prevent rare bleeding complications in the newborn. Also, children born to women taking these medications should be given Vitamin K (usually 1 mg IM) at the time of birth.
What other strategies may lessen these risks?
- Most importantly, women should get accurate information prior to and during pregnancy.
- If antiepileptic 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 dose of seizure medication that will control seizures is recommended. Being on a single drug will decrease the risk of birth defects and result in fewer drug interactions, fewer side effects, and improve compliance.
- Monitoring drug levels is also very important. Antiepileptic drug levels should be checked throughout the pregnancy and following delivery. The levels of 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.
- While AEDs are present in breast milk, breastfeeding is encouraged. Breastfeeding can generally be done safely, since the baby has been exposed to these drugs throughout the pregnancy and the absolute amounts of drug are low. Strategies such as taking seizure medicationsthe immediately after a feeding should be considered to lessen the amount of drug in a feeding. Breastfeeding is generally safe and recommended for its important benefits to the infant.
- Caring for the baby can also be a concern. Changing diapers on the floor and bathing the infant with other adults present or with a sponge bath are some useful strategies.
More tips to remember:
- Seeing the doctor before becoming pregnant, keeping regular appointments, and checking antiepileptic drug blood levels during pregnancy are recommended.
- Taking the appropriate medications as prescribed, as well as having adequate rest and sleep are of utmost importance.
- 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.