Women living with epilepsy can absolutely have successful pregnancies, but this requires specialized planning and diligent medical oversight. Epilepsy, a chronic neurological disorder marked by recurrent, unprovoked seizures, introduces unique considerations for maternal and fetal health during gestation. Success hinges on confirming the possibility of pregnancy with a specialized medical team, including a neurologist or epileptologist and a high-risk obstetrician, well before conception. Open communication allows for a tailored plan that minimizes risks while maintaining seizure control.
Pre-Conception Planning and Medication Review
The most impactful step a woman with epilepsy can take is to ensure her pregnancy is planned, allowing for the optimization of her anti-epileptic drug (AED) regimen beforehand. Unplanned pregnancies carry a significantly higher risk of adverse outcomes because there is no opportunity to adjust medication safely. The primary goal is to achieve stable seizure control using the lowest effective dose of a single, preferred AED, a practice known as monotherapy.
Many older AEDs are associated with higher risks of major congenital malformations (MCMs), such as neural tube defects, heart problems, or cleft palate, compared to newer alternatives. Certain medications carry the highest risks and should be avoided or switched well in advance of trying to conceive. Preferred AEDs, such as lamotrigine and levetiracetam, have low rates of physical birth abnormalities, often comparable to the background risk in the general population.
The process of switching or tapering AEDs can take months, making early consultation important. Once a stable, optimized regimen is achieved, remaining seizure-free for at least nine months prior to conception is associated with a high likelihood of remaining seizure-free throughout pregnancy. This stability is important for the safety of the mother and the developing fetus.
High-dose folic acid supplementation is a non-negotiable component of pre-conception planning, starting at least one to three months before stopping contraception. Certain AEDs interfere with the body’s metabolism of folate, increasing the risk of neural tube defects like spina bifida. To counteract this, women on AEDs are advised to take 4 to 5 milligrams of folic acid daily, substantially higher than the standard dose. Consulting with a maternal-fetal medicine specialist and a high-risk obstetrician helps establish the specialized care team.
Managing Epilepsy During Pregnancy
Once pregnancy is confirmed, active management and monitoring become the focus, as gestation presents dynamic challenges to maintaining seizure control. Physiological changes, including increased blood volume and changes in kidney and liver function, accelerate the clearance of many AEDs from the body. This causes drug levels in the bloodstream to drop, potentially leading to breakthrough seizures.
Therapeutic drug monitoring (TDM) is frequently utilized, involving regular blood tests to measure the AED concentration. If the level falls below the therapeutic range established before pregnancy, the dosage is increased to compensate for the body’s faster processing. This adjustment maintains the stable concentration necessary for seizure prevention, rather than exposing the fetus to higher drug levels.
While some women see no change in seizure frequency, approximately 15 to 30% experience an increase, most often during the first and third trimesters. Maintaining seizure control is paramount, especially avoiding generalized tonic-clonic seizures, which pose the greatest risk to the fetus. These seizures can lead to fetal hypoxia (low oxygen) due to changes in the mother’s breathing, maternal trauma, falls, or placental abruption.
To monitor fetal health and development, the obstetrical team increases surveillance, often scheduling more frequent ultrasounds. These scans check for adequate fetal growth and screen for potential birth defects linked to AED exposure. Women with epilepsy may also have a slightly higher risk of certain obstetrical complications, such as preeclampsia and gestational hypertension, necessitating increased maternal and fetal care.
Labor, Delivery, and Postpartum Care
The management strategy during labor and delivery minimizes stress and fatigue, which can lower the seizure threshold. Most women with epilepsy can safely have a vaginal delivery; the condition alone is not a reason to mandate a Cesarean section. Epidural anesthesia is safe and often recommended to manage pain and reduce the physical stress of labor, helping prevent a seizure.
The immediate postpartum period requires adjustment to the AED regimen because the physiological changes of pregnancy reverse quickly. Drug clearance rapidly returns to pre-pregnancy levels, meaning the high doses used during gestation can quickly become toxic. The neurologist must implement a plan immediately after delivery to reduce the dosage back to the maintenance level, often over a few weeks, to prevent adverse effects.
Breastfeeding is encouraged, as the benefits outweigh the small risk of drug exposure in breast milk. For most common AEDs, only small amounts are transferred, which is significantly less than the exposure the infant had in the womb. Consultation with the care team ensures the specific medication is safe for the newborn and that the infant is monitored for signs of sedation or poor feeding.
Planning for infant safety is a practical consideration for the postpartum period, especially since new parents often experience sleep deprivation, a potential seizure trigger. Simple protective measures include changing the baby on a padded surface on the floor to prevent a fall, or bathing the baby only when another adult is present. These steps ensure the mother can safely care for her child while managing her health.