What are the recommendations for managing epilepsy during pregnancy?

Managing Epilepsy During Pregnancy

Women with epilepsy who are pregnant or planning pregnancy should continue antiepileptic drug (AED) therapy, as uncontrolled seizures—particularly generalized tonic-clonic seizures—pose greater risks to both mother and fetus than most AED exposures. 1, 2, 3

Pre-Pregnancy Planning: The Critical Window

The most important intervention occurs before conception: reviewing and optimizing AED selection based on teratogenic risk profiles. 4

Medication Review Algorithm

• Identify high-risk AEDs, particularly valproate, which carries substantially higher risks of major congenital malformations and neurodevelopmental impairment compared to other AEDs 4, 3
• Valproate shows dose-dependent teratogenicity with significantly increased risks at doses >1000 mg/day 3
• Switch from valproate to lower-risk alternatives before conception if the seizure type permits 4
• Polytherapy (multiple AEDs) increases birth defect rates compared to monotherapy and should be avoided when possible 3

Addressing Valproate-Related Endocrine Issues

• Women on valproate require special attention due to reproductive endocrine complications including polycystic ovary syndrome (PCOS), which affects 60-64% of women on valproate monotherapy 5
• Valproate causes hyperinsulinemia, hyperandrogenism, and polycystic ovaries, which can reverse upon discontinuation 5
• Obese patients or those with significant weight gain on AEDs need evaluation for reproductive endocrine disorders before pregnancy 4

During Pregnancy: Maintaining Seizure Control

The Fundamental Principle

Never discontinue AEDs during pregnancy due to concerns about fetal effects—breakthrough seizures carry catastrophic risks that outweigh medication risks. 1, 2

• Seizure control is paramount for reducing maternal and fetal morbidity and mortality 1, 2
• Abrupt AED discontinuation can precipitate breakthrough seizures or status epilepticus 1
• Changing medications during pregnancy introduces unnecessary risks if seizures are already controlled 1

Monitoring and Dose Adjustments

• AED plasma concentrations decline during pregnancy, particularly for lamotrigine and oxcarbazepine, which can cause breakthrough seizures 3
• Regular monitoring of drug concentrations is recommended throughout pregnancy, especially for lamotrigine and oxcarbazepine 3
• Most women with epilepsy experience no change in seizure frequency during pregnancy, but approximately one-third may have increased seizures 2, 3
• If seizure control worsens, increase AED doses rather than switching medications 1

Specific AED Considerations

Levetiracetam: Pregnancy Category C with limited human data, but should be continued if seizures are well-controlled 6

• Animal studies showed developmental toxicity at doses similar to or greater than human therapeutic doses 6
• The principle remains: seizure control takes priority over theoretical medication risks 1

Labor and Delivery: Emergency Preparedness

Critical Safety Protocols

• Seizures during labor constitute a medical emergency requiring immediate EMS activation 2
• Metabolic disturbances during labor (hypoglycemia, electrolyte imbalances, hypoxia) can precipitate seizures 2
• Plan for specialized care during labor with continuous supervision and emergency protocols 2
• Seizures lasting >5 minutes require immediate anticonvulsant intervention 2

Emergency Management Steps

• Activate EMS immediately for any seizure in a pregnant patient 2
• Position patient on their side in recovery position and clear the area 2
• Do not restrain or place anything in the patient's mouth 2
• Monitor seizure duration carefully 2

Imaging Considerations

Radiopharmaceuticals for nuclear medicine imaging (PET/SPECT) are generally contraindicated in pregnancy. 5

• If clinically necessary, decisions require multidisciplinary team analysis of benefits versus fetal risks 5
• Otherwise, imaging should be postponed until after pregnancy 5

Breastfeeding Guidance

• Levetiracetam is excreted in breast milk; decisions about breastfeeding should weigh risks to the infant against the importance of the drug to the mother 6
• For nuclear medicine procedures: no interruption needed for [18F]FDG; 12-hour pause recommended for other 18F-labeled compounds 5

Common Pitfalls to Avoid

• Assuming all AEDs carry equal pregnancy risks—valproate is distinctly more teratogenic 4, 3
• Attempting to taper or discontinue AEDs during pregnancy when seizures are controlled 1
• Failing to monitor AED levels during pregnancy, particularly lamotrigine and oxcarbazepine 3
• Not planning for emergency seizure management during labor and delivery 2
• Making medication changes during pregnancy rather than before conception 4, 1

Renal Function Considerations

• Levetiracetam clearance decreases in renal impairment and correlates with creatinine clearance 6
• Dose reduction is required in moderate to severe renal impairment 6
• Supplemental doses are needed after dialysis 6