Management of Increased Seizures in Pregnancy Despite Recent Keppra Dose Increase
This pregnant patient with breakthrough seizures requires immediate comprehensive evaluation including serum levetiracetam levels, assessment of medication adherence, and urgent coordinated care with maternal-fetal medicine and neurology, while ensuring she is on high-dose folic acid supplementation (4 mg daily) and understanding that her Keppra dose will likely need further increases due to pregnancy-related pharmacokinetic changes. 1, 2
Immediate Assessment Priorities
Check Levetiracetam Serum Levels
- Pregnancy causes progressive decline in antiepileptic drug levels even with constant dosing, requiring frequent monitoring and dose adjustments throughout gestation 2
- The recent dose increase from 500 mg to 750 mg twice daily may be insufficient, as levetiracetam clearance increases significantly during pregnancy 3
- Obtain serum drug levels immediately to determine if therapeutic concentrations are being achieved 1
Verify Medication Adherence
- Directly address adherence concerns, as the patient admits to not seeing her provider "in a while" 2
- Counsel that uncontrolled seizures pose greater risks to both mother and fetus than medication exposure 1, 4
- Approximately one-third of women with epilepsy experience increased seizure frequency during pregnancy, making adherence critical 5, 1, 6
Essential Laboratory Testing
- Check serum glucose and sodium levels, as metabolic abnormalities can lower seizure threshold 5
- Confirm pregnancy status if not already documented 5
- Consider toxicology screening if substance use is suspected 2
Medication Management Strategy
Optimize Levetiracetam Dosing
- Levetiracetam has a favorable safety profile in pregnancy and should be continued 1, 6, 3
- Most patients require dose increases during pregnancy to maintain therapeutic levels; lamotrigine, oxcarbazepine, and levetiracetam specifically need upward titration 3
- Titrate based on serum levels and clinical response rather than fixed dosing schedules 1, 7
- The goal is monotherapy at the lowest effective dose that achieves seizure control 1, 6
Critical Folic Acid Supplementation
- Prescribe high-dose folic acid (4 mg daily) immediately if not already taking it 1, 2, 6
- This should be continued through the first trimester to reduce neural tube defect risk 5, 1
- Women with seizure disorders have increased rates of neural tube defects with many antiepileptic drugs, making supplementation essential 5
Coordinated Specialty Care
Arrange Urgent Consultations
- Schedule immediate consultation with maternal-fetal medicine specialist and neurologist for coordinated management 1, 2
- Establish frequent prenatal visits to monitor both seizure control and pregnancy progression 1, 2
- Plan for specialized care during labor and delivery with appropriate monitoring 1
Ongoing Monitoring Protocol
- Monitor levetiracetam levels frequently throughout pregnancy due to physiological changes affecting drug metabolism 1, 7
- Assess seizure frequency and characteristics at each visit 2
- Perform continuous risk assessment as health status may change throughout pregnancy 1
Patient Education and Counseling
Address Seizure Risks
- Explain that uncontrolled seizures, particularly tonic-clonic seizures, pose significant risks including maternal injury, fetal hypoxia, intrauterine growth restriction, preterm birth, and fetal death 5, 4
- Emphasize that breakthrough seizures pose catastrophic risks and medication should never be abruptly discontinued 1, 2
- Counsel that maintaining seizure control is more important for fetal well-being than avoiding medication exposure 4, 8
Provide Realistic Expectations
- Acknowledge that seizure disorders are associated with miscarriage, low birth weight, developmental disabilities, and microcephaly 5
- However, reassure that with good prenatal care and seizure control, the great majority of babies born to women with epilepsy are normal 9, 4
- Women with epilepsy have an increased risk of congenital anomalies regardless of medication status, but proper management minimizes these risks 5, 1
Safety Precautions
Seizure Safety Planning
- Counsel on safety precautions to minimize injury risk during potential seizures 1
- For women with well-controlled epilepsy, encourage participation in moderate physical activity according to general pregnancy guidelines 5
- Ensure the patient has a caregiver who can observe for signs of worsening seizures and seek prompt intervention 2
Emergency Planning
- Educate patient and family that any seizure in pregnancy represents a critical medical emergency requiring immediate EMS activation 1, 2
- Seizures lasting >5 minutes require immediate emergency intervention with anticonvulsant medications 2
- Provide clear instructions on when to seek emergency care 2
Common Pitfalls to Avoid
- Never abruptly discontinue antiepileptic medications during pregnancy due to concerns about fetal effects, as breakthrough seizures have potentially catastrophic consequences 1, 2
- Do not fail to adjust medication doses in response to pregnancy-related pharmacokinetic changes; inadequate monitoring leads to subtherapeutic levels 1, 2
- Avoid underestimating the psychological impact of managing a chronic condition during pregnancy; provide adequate support and information 1
- Do not delay specialist consultation when seizures are not adequately controlled; early intervention improves outcomes 1, 2
Postpartum Planning
Anticipate Dose Adjustments
- Plan for rapid dose reduction after delivery, as baseline drug levels are reached relatively quickly postpartum 3
- Down-titration is performed empirically but must be done promptly to avoid medication toxicity 7, 3
- Sleep deprivation and hormonal fluctuation can increase seizure risk postpartum, requiring careful monitoring 7