Management of Epilepsy in Pregnancy: Counseling and Treatment Recommendations
For a pregnant woman with epilepsy on levetiracetam, phenytoin, and clonazepam, continuing the pregnancy is reasonable with appropriate medication adjustments and monitoring.
Counseling Points for the Patient
- Pregnancy in women with epilepsy is generally safe when properly managed, though it requires specialized care and monitoring 1
- The risk of major congenital malformations is increased in women with epilepsy on antiepileptic drugs (AEDs), but most women (>90%) will have normal, healthy children 1
- Seizure control during pregnancy is crucial for both maternal and fetal health, as uncontrolled seizures pose greater risks than most medication effects 1
- Valproic acid should be avoided during pregnancy due to higher risks of fetal malformations and neurodevelopmental delays 1, 2
Medication Management Recommendations
Immediate Medication Adjustments
- Discontinue phenytoin (Eptoin) and switch to an alternative AED due to its association with higher risk of congenital malformations 1, 3
- Continue levetiracetam 1000mg as it has a favorable safety profile in pregnancy with minimal risks of congenital malformations 4, 5
- Consider tapering and discontinuing clonazepam if possible, as benzodiazepines may be associated with neonatal withdrawal symptoms 1
Monotherapy vs. Polytherapy
- Aim for monotherapy with levetiracetam if seizure control can be maintained, as polytherapy carries higher risks of congenital malformations 1
- If polytherapy is necessary for seizure control, use the lowest effective doses of medications with better pregnancy safety profiles 1
Monitoring During Pregnancy
- Schedule more frequent prenatal visits (every 2-4 weeks) to monitor seizure frequency and medication levels 1
- Monitor levetiracetam blood levels monthly, as pregnancy can alter drug metabolism requiring dose adjustments 4
- Recommend high-dose folic acid supplementation (4-5 mg daily) to reduce the risk of neural tube defects 1
- Arrange for detailed fetal ultrasound and fetal echocardiography at 18-22 weeks of gestation 1
Delivery and Postpartum Care
- Develop a delivery plan with the obstetric team that includes seizure management protocols 1
- Continue antiepileptic medications during labor and delivery 1
- Be prepared for potential dose readjustments in the postpartum period as drug metabolism returns to pre-pregnancy state 4
- Breastfeeding is generally safe with levetiracetam, as the benefits outweigh potential risks 1, 4
Special Considerations
- Avoid sleep deprivation during pregnancy as it may trigger seizures 1
- Register the patient in a pregnancy registry for women with epilepsy (such as the North American Antiepileptic Drug Pregnancy Registry) 4
- Consider vitamin K supplementation in the last month of pregnancy to prevent bleeding disorders in the newborn 1
Potential Complications and Management
- If breakthrough seizures occur during pregnancy, first check medication levels before adding new drugs 3, 6
- For status epilepticus (rare but serious), benzodiazepines remain first-line treatment followed by levetiracetam as a safer second-line option 3, 6
- Monitor for potential mood changes or depression, as both pregnancy and levetiracetam can affect mood 5
Follow-up Plan
- Schedule monthly visits during pregnancy to monitor seizure control and medication levels 1
- Plan for postpartum follow-up within 2 weeks of delivery to assess seizure control and adjust medications if needed 1
- Provide guidance on safe childcare practices for women with epilepsy (bathing infant with supervision, changing diapers on floor) 1
The management of epilepsy during pregnancy requires balancing seizure control with minimizing fetal exposure to potentially harmful medications. With proper management and close monitoring, most women with epilepsy can have successful pregnancies and healthy children.