Epilepsy and pregnancy

The first thing to say is that if you have epilepsy, the most likely thing is that you will have a healthy pregnancy with a good outcome for you and your baby. There are a few things to think of in advance. Pre-pregnancy counseling should be offered to all women with epilepsy. High dose (5mg) folic acid should taken be if you are considering pregnancy, for three months prior to conception and until the end of the first trimester. Studies have shown that folic acid supplementation is taken by <50% of Irish women.  This is in part due to lack of knowledge about folic acid supplementation and also due to unplanned pregnancies. Prior to pregnancy it is also important to review antiepileptic medications with your doctor. It is now rare for women of childbearing age to be taking sodium valproate due to a 10-fold increased risk in birth defects. For a woman who is taking it and considering pregnancy it is important to discuss this with your neurologist. The EURAP study group suggests that the lowest rates of birth defects are observed in those taking lamotrigine/lamictal (2 per 100), carbamazepine/tegretol (3.4 per 100) and levetiracetam/keppra (0.7 per 100). Furthermore, there appears to be no effect on neurodevelopmental outcomes in children of women taking lamotrigine and carbamazepine in pregnancy.

So what happens in pregnancy if you have epilepsy? At least two thirds will not have any increase in seizure frequency during pregnancy. Potential causes of increased seizure frequency include stopping medications, altered blood level of medications  during pregnancy (most commonly with lamotrigine, so levels are monitored), and stress or sleep deprivation. Women will often put the wellbeing of their unborn child ahead of their own health and wellbeing and stop their medication when they have a positive pregnancy test. In fact the risk of stopping medication and having a seizure probably has a higher adverse effect on pregnancy than the small potential risk of birth defects.

Ideally you should be offered review appointments with an epilepsy nurse specialist in early pregnancy and again in the third trimester to discuss lifestyle safety advice including the use of buccal midazolam for seizure control and so that you have the opportunity to discuss pregnancy specific concerns. You should be offered an anatomy scan between 18 and 22 weeks gestation and possibly a third trimester growth scan to check the size of your baby as epilepsy and some medications are associated with slightly smaller babies.

You can be reassured that spontaneous labour and delivery of a healthy baby is the most common outcome. Pethidine, a medication for pain control in labour, should be avoided as it lowers the seizure threshold and an early epidural may be required for some women for pain control. Avoiding prolonged sleep deprivation, a potential trigger for a seizure, can be difficult around this time.  Induction of labour can be considered on a case basis where prolonged sleep deprivation due to pains is putting you at risk of a seizure. However, epilepsy is not a specific reason to induce labour and most women will go into labour spontaneously. Seizures during labour affect about 1% of women with epilepsy, therefore medications for epilepsy should be taken during labour and postpartum.

So what about after delivery? Well, you can breastfeed if you chose to do so. Breastfeeding is safe even if you are taking medications for epilepsy. Again it is important to minimize sleep deprivation and involve your partner and all supports available to you in the first few weeks postpartum. Other safety precautions for caring for a newborn baby such as include not bathing the baby alone are important. Contraceptive options should be discussed with your doctor. Some medications for epilepsy are enzyme inducers (carbamazepine, phenytoin and topiramate) and will interfere with oestrogen and progesterone containing contraception including progesterone implants and injections. Lamotrigine levels are reduced in women taking oestrogen containing contraceptive pills. Other options you can use that are effective include intrauterine contraceptive devices (IUCDs) such as the mirena coil. A recent study showed that only one third of women with epilepsy receive counseling about contraception and those counseled about IUCDs were more likely to choose this than other methods of contraception. It is also suitable if you are breastfeeding.