AAN 2022 | Current management strategies in epilepsy during pregnancy

I think it’s very important that women understand the risks when you start prescribing the drug in the first place. Half of pregnancies are not planned, you cannot wait until the woman’s thinking about getting pregnant or you’ll miss the opportunity to maximize things in most women. We try to find a single drug that we know has lower risks to control the seizures, and if you can get seizure control for nine months before they go into pregnancy, there’s a very high likelihood that they will stay seizure free through the whole pregnancy.

There are metabolic changes in the mother with increase in clearance for a variety of the anti-convulsant drugs, and this may require adjusting the dosage. If you do that, to keep the dose about the same as it was prior to pregnancy, then the women do not have an increased risk of seizures compared to non-pregnant epilepsy women. In my own practice, I do this by checking the level about once a month and then adjusting for that. There’s some drugs that don’t require as much checking like carbamazepine or valproate, they’re fairly stable, but they may change some. There’s some drugs that change a great deal, 200% increase in clearance on average for levetiracetam, but it’s quite variable.

Another important thing to remember is to make sure the mothers are taking folic acid. I usually recommend about one milligram. We know in the general population this reduces some congenital malformations, but in the epilepsy population there are several studies showing an improved outcome for cognitive and behavioral problems if the mother is taking folate in the perinatal period. And it’s really about the first eight to 10 weeks is so critical, and I usually have the women take it regularly, because if they get pregnant it may be weeks into the pregnancy before they find out and you missed an opportunity to really maximize the child’s outcomes. Those are my major dictums.

After the baby comes, we have to then reset and taper back down over about two weeks to either the prior dosage or maybe a little bit above the prior dosage for that. I also talk to women about safety issues after pregnancy, in terms of never bathing the baby by themselves, trying to reduce carrying the baby around just with their hands, use a sling, use a little fold out stroller that’s very narrow that you can scoot around the house and play with the baby or do things with the baby on the bed or on the floor or on sofa, rather than carrying them around to reduce any risk that happens from seizures. I’m more concerned for women that are still having active seizures, I think.