Epilepsy in pregnancy

If woman fitting now

Epilepsy is the most common neurological problem in pregnancy. Always consider eclampsia or cerebral venous thrombosis as a cause of fitting in pregnancy — even if woman has history of epilepsy
Risks during pregnancy for women using antiepileptic medicines
  • Woman may be concerned about risk to their baby when using antiepileptic medicines during pregnancy
    • Any antiepileptic drug can cause birth abnormalities
    • Risks need to be balanced against the effects of uncontrolled fits on both mother and baby
  • Adverse effects of antiepileptic medicines
    • Lamotrigine and levetiracetam are the safest options
    • There is not much information about newer drugs, eg perampanel
    • Increased risk of depression and anxiety during pregnancy and the postpartum period
  • Change in seizure frequency
    • About ⅓ of women with epilepsy have more fits while pregnant
    • Women who had fits in the year before getting pregnant are at the highest risk of increased number of seizures
    • Women who haven’t had a fit for at least 9 months before getting pregnant have a 90% chance of staying seizure free during pregnancy
  • If epilepsy is not controlled there is a higher risk of illness and death for woman
  • Woman is not able to drive for 3 months if doses are changed

Do 

For woman not yet pregnant

Talk about importance of reliable contraception

  • If taking enzyme-inducing antiepileptics, eg phenobarbital, phenytoin, carbamazepine, primidone, topiramate, oxcarbazepine, felbamate
    • Best methods —  IUDs or Depo-Provera injection
    • Not recommended — ENG-implant and progestogen-only pill
    • If emergency contraception needed — give double dose of ECP OR use copper IUD
  • If not taking enzyme-inducing antiepileptics — all methods are effective
  • If woman using lamotrigine and oral contraceptives — refer for specialist advice

For woman planning pregnancy

  • Arrange health check
  • Medical consult — arrange physician/neurologist review (can use telehealth) to decide on best antiepileptic and dose
  • Best to change to safest antiepileptic at lowest dose needed for seizure control before getting pregnant
  • Give folic acid oral — 5mg, once a day 3 months before and after conception

For woman already pregnant

  • Medical consult as soon as you know woman with epilepsy is pregnant
  • Give folic acid oral once a day
    • In first 12 weeks of pregnancy — 5mg
    • More than 12 weeks pregnant — 0.5mg OR at least 0.4mg in multivitamin designed for pregnancy and breastfeeding
  • Arrange dating ultrasound
  • Refer to physician and neurologist for joint management plan. May need
    • Monthly monitoring of medicine levels
    • Serial ultrasounds for foetal growth
  • Talk with woman about antenatal screening tests for baby. Recommend she has tests, especially
    • Second trimester maternal serum screen, which detects neural tube defect — best done at 14–17 weeks but can be done up to 20 weeks
    • 18 week morphology ultrasound
    • Note type of antiepileptic being used on request form
  • Plan for hospital birth — risk of fit in labour and in first 24 hours after birth
  • Talk with woman about any known triggers for her fits (eg when she is very tired) and strategies to try to avoid these triggers during pregnancy
  • Tell woman to let clinic know any time she has a fit — needs medical consult

Unplanned birth in community

  • Medical consult
  • Continue oral antiepileptic during labour
    • If can't tolerate oral medicine — medical consult about alternatives
  • Have equipment and medicines ready in case woman has fit. See Fits — seizures
  • See Labour and birth
  • Watch baby closely for breathing problems — some medications are sedating
  • Give baby vitamin K IM at birth
    • If baby 1.5kg or more — 1mg (0.1mL)
    • If baby less than 1.5kg — 0.5mg (0.05mL)
  • Send mother and baby to hospital with escort

Breastfeeding

  • Encourage breastfeeding — antiepileptics pass into breast milk, but benefits of breastfeeding outweigh the small risk to baby
  • If any concerns — get specialist advice, eg lactation consultant

Postnatal care

  • If antiepileptic dose adjusted during pregnancy
    • Need to monitor antiepileptic blood levels, especially important if using lamotrigine
    • Plan to return to pre-pregnancy dose over first 1–2 weeks after birth
  • Sleep deprivation can increase frequency of seizures — ensure woman is aware of this and has support
  • Medical follow-up to plan monitoring of levels and dose adjustment