Epilepsy and Pregnancy: Preparation, Management, and Postpartum Care

Struggles with Conception

Struggles with Conception

Women with epilepsy have a fertility rate that is between 25% and 33% lower than average. Reasons for this include: higher rates of some conditions that can cause infertility, such as polycystic ovarian syndrome; a higher chance of irregular menstrual cycles; a higher chance of anovulatory cycles; and a higher chance of abnormal hormone levels involved in pregnancy. In addition, some antiepileptic drugs (AEDs) may affect ovarian hormone levels which can affect reproductive functions, and seizures around the time of ovulation can also disrupt the process and complicate conception.
AEDs and the Risk of Birth Defects

AEDs and the Risk of Birth Defects

Some of the most common AEDs increase the risk of birth defects. In the general population, the risk of birth defects is 2-3%, but in women with epilepsy, the risk increases to 4-8%. The risks are highest with AED polypharmacy, and especially if a form of valproate (Depacon, Depakote, Depakote ER,etc.) or phenobarbitol are used. Ideally, switching AEDs should be done 1 year in advance. A few women can safely taper off their medications before pregnancy, but for most women with epilepsy, it is best to continue taking the safest type and dose of medication for their particular seizures. To help decrease the chance of birth defects, it is recommended that women with epilepsy take at least 0.4 mg of folic acid supplements per day at least 3 months before conception. Folic acid has been shown to reduce the risk of some birth defects by 60-70%.
Monitoring AEDs and the Fetus

Monitoring AEDs and the Fetus

As pregnancy progresses, frequent ultrasounds and other prenatal tests may be necessary to monitor the health of both the mother and fetus. As the mother’s metabolism changes, her blood volume will also increase, as much as 50% greater at 9 months than before pregnancy. The increase in blood volume may cause AEDs to be diluted, therefore medication levels in the blood should be monitored and the dose increased if levels fall below target.
Seizures During Pregnancy

Seizures During Pregnancy

Women who experience a seizure while they are pregnant should report it promptly to their health care provider. Medication adjustments may be needed to prevent further seizures, and a seizure in the last few months of pregnancy may warrant closer monitoring of the fetus at a hospital or clinic.
Seizures During Delivery

Seizures During Delivery

While they are not very common, seizures do occur during delivery. In order to help reduce seizure risk during labor, the “focus is generally on pain relief, stress reduction, and sleep promotion for the mother,” Thomas McElrath, MD, an obstetrician at Brigham and Women's Hospital and an associate professor at Harvard Medical School, told Neurology Advisor. In the event of a seizure, medication may be administered intravenously, and a cesarean section may be necessary. Although most women with epilepsy have normal vaginal deliveries, they do have a higher rate of cesarean sections.
Postpartum Epilepsy Management

Postpartum Epilepsy Management

Fortunately, most women with epilepsy give birth to healthy infants. With careful monitoring, the chance of having a healthy child is 90%. Clinicians should encourage women not to become anxious, but to be aware of the risks and carefully follow the advice they are given. Mothers should be advised to not bathe or change an infant alone in case of the event of a seizure. Breast-feeding is encouraged for most women who have epilepsy, even if they are taking AEDs. Previous studies have indicated no adverse effects associated with breast-feeding while on AEDs at 3 and 6 years, with some showing a cognitive benefit for the child.
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While the vast majority of women with epilepsy who are of childbearing age are capable of having a healthy pregnancy, the risk of negative outcomes for both the mother and child is greater than that of a healthy individual.

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