epilepsy

• Approximately 30 per cent of those with epilepsy are women in their

childbearing years, which means pregnancies occur in
women with a history of epilepsy.
• Pregnancy has no consistent effect on epilepsy: some women will
have an increased frequency of fits, others a decrease, and some no
difference.
• Nonetheless, there is a in mortality among pregnant
women with epilepsy, and maternal deaths occur in women
with epilepsy.
• The principles of epilepsy management are that while the risks to
pregnancy from seizures outweigh those from anticonvulsant
medication, seizures should still be controlled with the minimum
possible dose of the optimal drug.
Pre-pregnancy counselling

• Alter medication according to seizure frequency

• Reduce to monotherapy where possible
• Stress importance of compliance with medication
• Pre-conceptional folic acid 5 mg
• Explain risk of congenital malformation
• Explain risk from recurrent seizures
• The principal concern related to epilepsy in pregnancy is the
increased risk of congenital abnormality caused by anticonvulsant
medications.
• All of these drugs are associated with a two- to three-fold increased
risk of fetal abnormality (5–6 per cent) compared to the general
population, and an approximate doubling of the risk compared to
unexposed epileptic mothers.
• Polytherapy further increases the risk (15–25 per cent).
• The major fetal abnormalities associated with anticonvulsant drugs
(including sodium valproate, carbamazepine, phenytoin,
phenobarbitone) are neural tube defects, facial clefts and cardiac
defects.
• Many of these abnormalities are detectable by ultrasound and
therefore all women should be offered detailed anomaly scanning.
• In addition, each drug is associated with a specific syndrome that
includes developmental delay, nail hypoplasia, growth restriction and
mid-face abnormalities.
• In the case of valproate, the likelihood of these effects is dose dependent
(>1000mg/day) and it should be generally avoided in women, with the
exception of idiopathic generalized epilepsy where it controls tonic-clonic
seizures.
• Despite the risks of continuing anticonvulsants in pregnancy, failure to do
so may lead to an increased frequency of epileptic seizures that may result
in both maternal and fetal hypoxia.
• Therefore, women on multiple drug therapy should, wherever possible, be
converted to monotherapy before pregnancy, and all epileptic women
should be advised to start taking a 5mg daily folic acid supplement prior to
conception.
• In women who have been free of seizures for two years, consideration may
be given pre-pregnancy to discontinuing medication.
• Many factors contribute to altered drug metabolism in pregnancy and
result in a fall in anticonvulsant drug levels.
• The reasons for increased fit frequency in pregnancy therefore
include the effect of pregnancy on the metabolism of anticonvulsant
drugs, as well as sleep deprivation or stress and poor compliance with
medication.
• Monitoring of drug levels in pregnancy is difficult. An increase in
dosage to combat the anticipated fall may lead to an increased fetal
risk.
• In the majority of cases, provided there is no increase in frequency of
seizures, the prenatal drug dosage can be continued.
• However, an increase in seizure frequency or a recurrence of seizures,
especially in the context of subtherapeutic drug levels, should prompt
an increase in dosage.
Delivery
• Delivery mode and timing is largely unaltered by epilepsy, unless
there has been accelerated seizure frequency in pregnancy, and
anticonvulsant medication should be continued during labour.
• Breastfeeding can be encouraged, although feeding is best avoided
for a few hours after taking medication.
• Information on safe handling of the neonate should be given to all
epileptic mothers.