What is the best course of treatment for a pregnant patient experiencing seizures?

Management of Seizures in Pregnant Patients

Any seizure occurring in a pregnant patient constitutes a medical emergency requiring immediate EMS activation, regardless of whether it is a first-time seizure or known epilepsy. 1, 2

Immediate First Aid Management

When a pregnant patient experiences a seizure, take the following actions immediately:

• Position the patient on their side in the recovery position to minimize aspiration risk, particularly important given the increased risk of vomiting during seizures 1, 2
• Help the patient safely to the ground if still seizing and clear all surrounding hazards from the area 1, 2
• Stay with the patient throughout the entire seizure and postictal period—do not leave them unattended 1, 2
• Do not restrain the patient under any circumstances, as this can cause injury 1, 2
• Never place anything in the patient's mouth and do not give oral medications, food, or liquids during the seizure or if consciousness is impaired 1, 2
• Monitor seizure duration carefully—seizures lasting >5 minutes require immediate emergency anticonvulsant intervention as they may not stop spontaneously 1, 3, 2

Emergency Department Evaluation

Essential Initial Testing

Upon arrival to the emergency department, the following workup is mandatory:

• Check serum glucose and sodium levels immediately, as metabolic disturbances are common precipitants of seizures during pregnancy 2
• Confirm pregnancy status if unknown 2
• Perform lumbar puncture if meningitis or encephalitis is suspected based on fever, headache, or altered mental status 2
• Order toxicology screening if drug exposure is suspected 2
• Complete a thorough neurological examination with specific attention to focal deficits that might indicate structural lesions 2

Critical Risk Stratification

Document the following to guide management:

• Whether this is a first-time seizure or recurrent epilepsy 2
• Return to neurological baseline within 5-10 minutes after seizure cessation 1, 2
• Presence of seizure-related injuries, respiratory compromise, or trauma 2
• Seizure occurred during labor (which carries catastrophic risk) 3

Management of Known Epilepsy During Pregnancy

Fundamental Principle: Never Discontinue Antiepileptic Drugs

The single most important principle is to never discontinue antiepileptic drugs (AEDs) during pregnancy due to concerns about fetal effects—breakthrough seizures carry catastrophic risks that far outweigh medication risks. 3, 2

• Approximately one-third of women with epilepsy experience increased seizure frequency during pregnancy 2
• AED levels decline progressively during pregnancy even with constant dosing, requiring frequent monitoring and dose adjustments 2
• If seizure control worsens, increase AED doses rather than switching medications, as changing medications during pregnancy introduces unnecessary risks if seizures are already controlled 3

Medication Selection and Safety

The hierarchy of AED safety in pregnancy is well-established:

Preferred agents (lowest teratogenic risk):

• Lamotrigine and levetiracetam have the most favorable safety profiles and should be encouraged for breastfeeding 2, 4
• Levetiracetam has minimal drug interactions and does not affect other AED levels 5
• Oxcarbazepine presents a favorable teratogenic profile with serum level monitoring recommended 2

Avoid at all costs:

• Valproate must be avoided or discontinued due to high teratogenic risk, particularly at doses >800 mg/day, carrying substantially higher risks of major congenital malformations and neurodevelopmental impairment compared to other AEDs 3, 2, 6
• Valproate causes reproductive endocrine complications including polycystic ovary syndrome in 60-64% of women on monotherapy 3

General principles:

• Aim for monotherapy at the lowest effective dose, as polytherapy increases teratogenic risk 2
• Not all polytherapy combinations are detrimental, especially when avoiding valproate and topiramate 4
• Carbamazepine has documented teratogenic effects including craniofacial defects and cardiovascular malformations, though less severe than valproate 7

Status Epilepticus Management in Pregnancy

For seizures lasting >5 minutes or multiple seizures without return to baseline:

• Benzodiazepines are the drugs of choice for initial treatment 8, 9
• Levetiracetam and phenytoin represent the most suitable second-line agents 8
• Valproic acid should be administered only if other ASMs failed and preferably avoided in the first trimester 8
• For refractory status epilepticus, anesthetic drugs are needed, with propofol and midazolam as preferred agents 8
• Good fetal outcome is dependent on rapid seizure control 9

Disposition and Follow-up

Admit all pregnant patients with seizures for observation, coordinated obstetrical and neurological care, and fetal monitoring. 2

• Early seizure recurrence is highest within the first 6 hours (mean 121 minutes), with >85% occurring within 360 minutes 2
• Arrange immediate consultation with maternal-fetal medicine and neurology 2
• Ensure high-dose folic acid supplementation (4 mg daily) is initiated or continued 2
• Schedule frequent prenatal visits for ongoing seizure and pregnancy monitoring 2
• Encourage enrollment in the North American Antiepileptic Drug (NAAED) Pregnancy Registry by calling 1-888-233-2334 2, 5, 6

Critical Pitfalls to Avoid

• Failing to activate EMS for any seizure in pregnancy—this is the most common and dangerous error 1, 2
• Discontinuing antiepileptic medications abruptly due to pregnancy concerns 3, 2
• Inadequate monitoring of antiepileptic drug levels during pregnancy 2
• Attempting to taper or discontinue AEDs during pregnancy when seizures are controlled 3
• Making medication changes during pregnancy rather than before conception 3
• Assuming all AEDs carry equal pregnancy risks—valproate is distinctly more teratogenic 3