Epilepsy, a common neurological condition characterized by recurrent, unprovoked seizures, affects many women of childbearing age. While epilepsy introduces specific considerations, the vast majority of women with the condition experience successful pregnancies and deliver healthy children. Managing epilepsy during this time requires a collaborative approach between the pregnant person, their neurologist, and their obstetrician. The goal is to maintain optimal seizure control using anti-epileptic drugs (AEDs) while minimizing potential risks to the developing fetus.
Pre-Conception and Early Pregnancy Planning
The period before conception represents the best opportunity to optimize a mother’s health and medication regimen. Consulting with a specialized care team, including an obstetrician and a neurologist, should happen well before attempting to conceive. The primary objective is to achieve seizure freedom or the best possible seizure control on the most appropriate medication.
This proactive planning allows for a thorough review of the mother’s current anti-epileptic drugs, focusing on simplifying treatment to monotherapy whenever feasible. Starting pregnancy with stable seizure control on a single medication is associated with a lower risk of birth defects compared to using multiple drugs.
Taking a folic acid supplement is also an important step, as some AEDs interfere with the body’s ability to process folate, which is necessary for proper fetal spinal and brain development. Current guidelines often recommend a daily dose of 0.4 to 0.8 milligrams of folic acid, starting before conception and continuing through the first trimester. This supplementation helps to counteract the folate-depleting effects of some AEDs, thereby reducing the risk of neural tube defects.
Adjusting Anti-Epileptic Medications
Maintaining seizure control during pregnancy is paramount, as uncontrolled tonic-clonic seizures carry a higher risk of harm to the fetus than exposure to most anti-epileptic medications. Certain AEDs, such as lamotrigine and levetiracetam, are considered lower-risk options for use during pregnancy. Conversely, medications like valproate are avoided due to a significantly higher risk of major congenital malformations and adverse neurodevelopmental outcomes.
Physiological changes during pregnancy can dramatically alter how the body processes anti-epileptic drugs. Increased plasma volume and changes in metabolic clearance cause the concentration of many AEDs to drop. For drugs like lamotrigine and levetiracetam, this increased clearance can be marked, potentially leading to breakthrough seizures.
Therapeutic Drug Monitoring (TDM) is often used to measure the level of medication in the mother’s blood. Monitoring these levels allows the care team to adjust the dosage to maintain the concentration needed for seizure control, often requiring a dose increase throughout the pregnancy. The goal is to use the lowest effective dose of a single medication that prevents seizures while minimizing fetal exposure.
Potential Effects on the Developing Fetus
Exposure to anti-epileptic drugs in utero slightly increases the risk of major congenital malformations (MCMs). The general population has a baseline risk of about 2 to 3%, which increases to approximately 3 to 7% for mothers taking AEDs. These malformations can include cleft lip or palate and certain heart defects.
Specific anti-epileptic drugs carry distinct risk profiles. Medications like phenobarbital, topiramate, and zonisamide have been associated with intrauterine growth restriction (IUGR), meaning the baby may be smaller than expected at birth. The risk of developmental issues, such as lower cognitive scores or language delays, is also linked more strongly to certain medications like valproate.
Uncontrolled maternal seizures, especially generalized tonic-clonic seizures, pose a direct danger to the baby. A seizure can cause trauma, oxygen deprivation (hypoxia), and abnormal heart rhythms, potentially leading to injury or even death. Therefore, the strategy of continuing effective medication to prevent seizures is considered the safer course for both the mother and the developing baby. Some infants may also experience mild withdrawal symptoms, such as jitteriness or irritability, immediately after birth due to the sudden cessation of in-utero drug exposure.
Managing Labor, Delivery, and Postpartum
The risk of a seizure occurring during labor and delivery is relatively low, but planning is essential to manage this possibility. The mother should continue to take all scheduled anti-epileptic medication doses throughout the labor process, using intravenous administration if she is unable to take them orally. Using an epidural for pain relief is often encouraged, as it can help reduce stress and fatigue, which are potential seizure triggers.
Epilepsy alone does not typically require a mother to have a Cesarean section; a vaginal delivery is the usual course unless obstetric complications arise. Immediately following delivery, the mother’s metabolism rapidly returns to its pre-pregnancy state, which can cause the concentration of anti-epileptic drugs in the blood to rise quickly. The care team must promptly review and often reduce the mother’s AED dosage, usually within days of delivery, to avoid medication toxicity.
The postpartum period introduces new challenges, with sleep deprivation being a significant trigger for seizures in many mothers. A plan to prioritize “sleep as medicine” through the support of family and partners is necessary to reduce the risk of a seizure. Breastfeeding is generally encouraged for mothers taking AEDs, as the amount of medication transferred to the baby through breast milk is substantially lower than the exposure the baby received in the womb.