Epilepsy In Pregnancy

More than 90% of women with epilepsy have normal, healthy babies. Optimal care requires looking into various issues as with regards to seizure, anti-epileptic drugs usage, birth defects and later breastfeeding when the child is born. This page hope to address some of these concerns. Please refer any questions that may remain to your doctor. This will give you peace of mind and a better understanding of what to expect and what to do and reduce your stress during pregnancy.

Questions and Answers

"Will my child have epilepsy?"

The average risk of inheriting epilepsy is 6-10%. This figure varies, depending on the type of epilepsy. If only the father has epilepsy, the child's chances of having epilepsy are about 3-5%. The incidence of epilepsy in the general population is 1-2%.

"Does my anti-epileptic medication harm the baby?"

Children with a parent who takes anti-epileptic medication have a 7% risk of a congenital abnormality. If the mother has epilepsy, but does not take anti-epileptic medication, the risk of having a child with a malformation is 4.5%. In the general, non-epileptic population, the risk is 3%. 

Increase risk of tetratogenicity (birth defects in foetus) with AED can be reduced via limiting the treatment to use of one single drug. The most significant abnormalities reported have been spinal malformations, cleft lip/palate and heart and hand malformations. This is particularly true in women taking carbamazepine, phenytoin, phenobarbital and valproate and are best avoided in pregnancy. Check out AED risk classification in pregnacy

"Should my anti-epileptic medication be changed before the pregnancy?"

Some medications carry less risk than others. The lower the dosage and number of medications the better, provided that seizure control remains optimal. However, do not reduce or stop your medication without the recommendation from your doctor to do so. Abrupt withdrawal of drugs can cause a life-threatening condition called status epilepticus and can risk your pregnancy. Malformations develop early in the pregnancy. By the time most women realize they are pregnant, malformations may have already developed. At this point, controlling maternal seizures is the first priority. You can monitor the development of your baby through fetal diagnostic techniques.

"Which are the safest drugs during pregnancy?"

The anti-epileptic medication raises the chance of a birth defect by only 2.5%. Some drugs are more favourable than others, but your type of epilepsy may not allow a switch to another drug. This issue is complex and has to be discussed with your physician.

"Do seizures harm the growing baby?"

Frequent major and prolonged seizures should be avoided, because they result in major metabolic changes, including a diminished oxygen supply to the fetus. However, it is rare for women to begin to have seizures when pregnant and most women with epilepsy report no change or a decline in seizures during pregnancy. For many women, improving levels of anti-epileptic drugs in the blood and ensuring adequate sleep can reduce the number of seizures. The mother's seizures during pregnancy, while hazardous for other reasons, do not appear to increase the risk of defects in the baby.

"Will my seizures be less well controlled during the pregnancy?"

Seizure frequency does not change in 50%, decreases in 25%, and increases in 25% of pregnancies. During the first and last three months of the pregnancy the seizures may increase. Blood levels will determine how your medication has to be changed.

"Are any precautions, investigations or laboratory tests necessary during my pregnancy?"

Maintain a healthy diet with vitamin supplements and avoid lack of sleep. Regular doctor visits, ultrasound, blood levels and adjustment of the medication may be necessary.

"Will I get seizure in labour?"

The onset of labour is unlikely to precipitate a seizure. Seizures during labour or shortly thereafter can be controlled with intravenous medication. However, you may be more susceptible to having seizures after giving birth because of exhaustion and other factors. Lack of sleep or missed drugs during labour can be contributing factors. In addition, as your metabolism changes after birth, your drug dosage may need to be adjusted.

"Can I safely nurse my baby?"

In general, nursing is safe, depending on dosage and type of medication.

Recommendations Before Pregnancy

1.    Consult your doctor when you plan a pregnancy.

2.Ask your family doctor if a consultation with a specialist would be helpful.

3.    Find or be aware of prenatal diagnosis/screening (ultrasound, alpha-fetoprotein test, acetylcholinesterase test via amniocentesis) and pregnancy termination services in your area. If a severely malformed fetus is detected, your attitude and beliefs with respect to prenatal diagnosis and options for termination of your pregnancy must also be considered.

4.    Ask your doctor the risk of major malformations, minor anomalies and developmental disturbances in your fetus or infant, taking into account the family history, type and severity of your epilepsy and/or intrauterine AED exposure.

5.    Discuss the need for starting folic acid supplementation.

6.    Know your risk for pregnancy complications such as bleeding, toxemia and prematurity due to AED therapy.

7.    Discuss the chances of your child having epilepsy.

8.    If you have had frequent major seizures during the past year, you should postpone pregnancy until better seizure control has been attained.

9.    Ask if your medication can be reduced or replaced by safer medications, especially during the first four months of the pregnancy. 

10.    Discuss options for AED withdrawal. Any drug withdrawal should be completed at least six months before planned conception, because the risk of recurrence after AED withdrawal is the greatest in the first 6 months.  

11.    Ask if your epilepsy can be controlled with one drug.

12.    If there is a family history of neural tube defects, women taking carbamazepine (Tegretol®) or valproate (Depakene®, Depakote®, Epival®) are advised to find an alternative AED when pregnant. Do not take felbamate when pregnant.  

13.    Try to avoid combinations of Mysoline (primidone), Dilantin (phenytoin) and Phenobarbital (phenobarbitone).

14.    Maintain a healthy lifestyle, don't smoke, and avoid alcohol. 

15.    Do not take any other medication unless it is approved by your health care provider.

16.    Tegretol can cause a false-negative pregnancy test. Have it repeated when in doubt.

Recommendations During Pregnancy

1.    Consult your doctor at regular intervals in order to monitor your antiepileptic drug levels, routinely discuss any drug compliance issues during pregnancy, evaluate the number and frequency of seizures, perform prenatal diagnosis by ultrasound and the alpha-fetoprotein test to detect malformations, as well as continuous monitoring to assess fetal well-being throughout your pregnancy. 

2.    If you have to take Mysoline, Phenobarbital, or Dilantin, don't panic. At least 90% of women on these medications deliver healthy babies. Having major seizures can do more harm.

3.    Control of nausea and management of vomiting during pregnancy is important, because vomiting may interfere with your antiepileptic drug intake, absorption and compliance. Only increased seizures require adjustment of the medication.

4.    Avoid alcohol and smoking. 

5.    Vitamins are generally recommended, particularly folic acid because certain anti-epileptic medications tend to lower its levels and become less available for the baby. 

6.    Vitamin K supplements are given during the last three months to reduce blood loss during delivery, since certain anti- epileptic drugs can cause an increased bleeding tendency.

7.    After the third month an ultrasound examination is indicated and, if there is a possibility of congenital abnormalities, it should be repeated, combined with laboratory tests and other specialized investigations when indicated.

8.    At the end of the third month all major organ systems have been developed. Therefore, one should not be overly concerned when the medication has to be increased after the third month

Recommendations After Pregnancy

1.    Depending on seizure control and medication changes during the pregnancy, adjustment of the medication may be necessary following labour because your metabolism will change after birth.

2.    Vitamin K is administered to the newborn, when an increased bleeding tendency is suspected.

3.    When a mother has been taking antiepileptic medication (particularly phenobarbital/phenobarbitone and sodium valporate) during pregnancy, there is a possibility that her baby will appear sedated during the first few hours or days after birth. 

4.    Some babies will develop withdrawal symptoms. These can consist of irritability (excessive crying, not feeding well, etc.), involuntary trembling, vomiting, poor sucking, fast breathing, and sleep disturbances. One or more of these symptoms may last from a few days to about three months. Often these are transient. 

5.    In general, breastfeeding is safe and should be encouraged despite the fact that all antiepileptic medications cross into the breast milk. The benefits outweight the risks in this situation as long as you watch your baby carefully for any signs of sedation. Certainly if your baby fails to gain weight because it is too sedated to eat, you'll need to stop breast feeding. Do not breastfeed if you're taking Phenobarbital and ethosuximide (Mysoline) concurrently because excessive sedation can occur.

6.    Discuss issues of postpartum depression, especially if you are a new mother.

7.    Feed infants in bed, or place the baby in a secure infant seat.

8.    Change diapers and clothing on the floor to minimize any risk of falling.

9.    Keep baby supplies and toys on every level of the house to decrease the need for stair climbing, especially if you have frequent seizures.

10.    Wash your baby on a mat in the crib, with a bowl of water outside the crib.

11.    Nursing the baby can become a tiring experience. Sleep deprivation can trigger seizures. Therefore, family members should assist with non-nursing activities to provide more rest for the mother. Incomplete seizure control and exhaustion make formula feeing at an early stage sometimes necessary.

Posted on 6th May 2001