What medication is recommended to treat seizures in a pregnant woman undergoing termination, ensuring safety for both mother and fetus?

Seizure Management During Pregnancy Termination

For seizures occurring during pregnancy termination, benzodiazepines are the first-line treatment, followed by levetiracetam or phenytoin as second-line agents, with valproate reserved only as a last resort if other medications fail. 1

First-Line Treatment: Benzodiazepines

• Intravenous benzodiazepines remain the drugs of choice for acute seizure management in pregnancy, including during termination procedures 1, 2
• Benzodiazepines provide rapid seizure control with established safety profiles in pregnancy 2
• This recommendation applies regardless of whether the pregnancy is continuing or being terminated, as maternal seizure control is the immediate priority 1

Second-Line Agents

Levetiracetam (Preferred)

• Levetiracetam is the most suitable second-line agent due to its favorable safety profile and lack of significant teratogenic effects 1, 3
• Levetiracetam has consistently demonstrated the lowest teratogenic potential among antiepileptic drugs 3, 4
• Standard dosing of 30 mg/kg IV can be administered if benzodiazepines fail to control seizures 5

Phenytoin/Fosphenytoin (Alternative Second-Line)

• Phenytoin or fosphenytoin represents an acceptable alternative second-line option with extensive historical use in pregnancy 1, 2
• Load with 20 mg/kg IV of phenytoin equivalents at appropriate infusion rates 5
• Monitor for hypotension, which occurs more commonly with phenytoin than with levetiracetam 5

Valproate: Use Only as Last Resort

• Valproate should be avoided, particularly in first-trimester terminations, and used only if all other antiseizure medications have failed 1, 3
• Valproate is a known teratogen causing neural tube defects and major congenital malformations, and is absolutely contraindicated in females of childbearing potential under normal circumstances 6
• Even during termination procedures, valproate carries risks to the woman herself and should be reserved for refractory cases 1
• If valproate must be used, it should be administered only after benzodiazepines, levetiracetam, and phenytoin have all failed 1

Refractory Seizures/Status Epilepticus

• For refractory status epilepticus, anesthetic drugs are required, with propofol and midazolam as preferred agents 1
• In extreme cases where general anesthetics fail, termination of pregnancy via delivery or abortion may be necessary to save the mother's life 1
• A multidisciplinary team approach is essential for managing severe seizures during pregnancy or termination 1

Critical Timing Considerations

• The first trimester represents the highest risk period for drug-induced teratogenicity due to organogenesis 6
• However, during an active termination procedure, maternal seizure control takes absolute priority over fetal considerations 1, 2
• Uncontrolled seizures pose greater immediate risk to the mother than antiseizure medication exposure 2, 7

Common Pitfalls to Avoid

• Do not delay treatment due to concerns about medication effects during termination - rapid seizure control is paramount for maternal safety 1, 2
• Do not use magnesium sulfate for non-eclamptic seizures - it lacks true anticonvulsant properties and is specific to eclampsia management 2
• Do not withhold phenytoin or levetiracetam due to pregnancy concerns - these medications are significantly safer than uncontrolled seizures 1, 7