Keppra (Levetiracetam) in Pregnancy
Levetiracetam is one of the safest antiepileptic drugs for use during pregnancy and should be continued to maintain seizure control, as uncontrolled seizures pose greater risks to both mother and fetus than the medication itself. 1, 2
Why Continue Levetiracetam During Pregnancy
Levetiracetam has emerged as one of the two safest antiseizure medications during pregnancy (along with lamotrigine), with favorable safety profiles for both teratogenic risk and breastfeeding. 1, 3, 4
Approximately one-third of women with epilepsy experience increased seizure frequency during pregnancy, making medication adherence critical. 5, 1, 3
Abruptly stopping antiepileptic medications due to pregnancy concerns can lead to breakthrough seizures with potentially catastrophic consequences for both mother and fetus. 1, 2
Women with epilepsy have an increased risk of congenital anomalies regardless of medication status, meaning the epilepsy itself carries inherent risks. 5, 1, 3
Essential Preconception and Early Pregnancy Management
High-Dose Folic Acid Supplementation
Prescribe 4 mg of folic acid daily starting at least one month before conception and continuing through the first trimester to reduce the risk of neural tube defects and major congenital malformations. 5, 1, 2, 3
This is a higher dose than the standard 0.4-0.8 mg recommended for women not taking antiseizure medications, as women with epilepsy taking antiepileptic drugs are at increased risk for neural tube defects. 5
Medication Optimization
Aim for monotherapy at the lowest effective dose whenever possible, as polytherapy increases teratogenic risk. 1, 3
If the patient is currently on valproate, carbamazepine, phenytoin, or phenobarbital, consider transitioning to levetiracetam or lamotrigine before conception, as these older medications are more teratogenic. 1, 3
Levetiracetam monotherapy is preferred over combinations that include valproate or topiramate, which carry significantly higher malformation risks. 6
Pregnancy Monitoring Requirements
Frequent Drug Level Monitoring
Monitor serum levetiracetam levels frequently throughout pregnancy (ideally monthly or more often if seizures occur), as pregnancy-related physiological changes significantly affect drug metabolism and clearance. 1, 2, 7
Levetiracetam levels decline progressively during pregnancy even with constant dosing, requiring dose adjustments to maintain therapeutic levels and seizure control. 2, 7
Be prepared to increase doses during pregnancy to maintain seizure control, then reduce back to prepregnancy levels within 3 weeks postpartum. 7
Coordinated Specialty Care
Arrange consultation with both maternal-fetal medicine specialists and neurology for coordinated care throughout pregnancy. 1, 2
Schedule more frequent prenatal visits than standard obstetric care to monitor both seizure control and pregnancy progression. 1
FDA Pregnancy Classification and Registry
Levetiracetam is FDA Pregnancy Category C, meaning animal studies showed developmental toxicity at doses similar to or greater than human therapeutic doses, but there are no adequate well-controlled studies in pregnant women. 8
Enroll patients in the North American Antiepileptic Drug (NAAED) Pregnancy Registry by having them call 1-888-233-2334 to contribute to ongoing safety data collection. 8
Breastfeeding Considerations
Breastfeeding should be encouraged in women taking levetiracetam, as it has a favorable safety profile for nursing infants. 1, 3, 7, 9
While levetiracetam is excreted in breast milk, the benefits of breastfeeding typically outweigh theoretical risks, though monitoring the infant for possible adverse effects is prudent. 3, 8
Labor and Delivery Planning
Plan for specialized care during labor and delivery with appropriate monitoring, as seizures during labor represent a critical medical emergency. 1, 2
Any seizure during pregnancy or labor requires immediate activation of emergency medical services. 2
Critical Pitfalls to Avoid
Never abruptly discontinue levetiracetam due to pregnancy concerns, as breakthrough seizures pose greater risks than continued medication use. 1, 2
Do not fail to adjust medication doses in response to pregnancy-related pharmacokinetic changes—maintaining therapeutic drug levels is essential. 1, 2
Avoid switching to less safe antiepileptic drugs (particularly valproate, which must be avoided due to high teratogenic risk including cognitive/behavioral impairments). 1, 6, 9
Do not overlook the psychological impact of managing epilepsy during pregnancy—provide adequate counseling about both maternal and fetal risks of treatment versus risks of uncontrolled epilepsy. 1
Counseling Approach
Provide nondirective counseling regarding potential risks and benefits, including short- and long-term implications of epilepsy and current medication regimen. 1
Emphasize that medication adherence is crucial despite concerns about fetal effects, as uncontrolled seizures pose greater risks to both mother and fetus. 1
Reassure patients that the majority of pregnancies in women with epilepsy are uneventful when properly managed. 9