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People with epilepsy can have safe, healthy pregnancies and healthy babies. However, proper planning and care is essential. The goal of planning is to minimize the risk of congenital malformations and neurodevelopmental disorders for the fetus while maintaining the parent's seizure control. [1]
To reduce the risk of birth defects caused by anti-seizure medications (ASMs) and to preserve the parent's health, unplanned pregnancies should be prevented. [2]
For people taking hormonal contraceptives, the use of enzyme-inducing ASMs is associated with an elevated risk of unplanned pregnancies.
The following hormonal contraceptives are preferred for people with epilepsy, especially if they are on enzyme-inducing ASMs. [3]
Patients should avoid estrogen for the first six postpartum weeks to avoid deep vein thrombosis.
There do not appear to be any differences in pregnancy rates, time to conceive, or pregnancy outcomes in people with epilepsy compared to the general population. People with epilepsy experience infertility at the same rate as people who do not have epilepsy and may need to consider fertility treatment to help them get pregnant.
People with epilepsy who have been actively trying to get pregnant for six months or longer should see a fertility specialist like an OB-GYN (Obstetrics and Gynecology) or reproductive endocrinologist.
Clinicians should pay particular attention to anti-seizure medication (ASM) levels in patients undergoing ART (e.g., egg retrieval, egg preservation or IVF) For example, estrogen can be a common component of some fertility regimens, and its use may reduce lamotrigine levels. [4]
For most patients with epilepsy, the risk of passing the disease to a child is only slightly higher than the risk of a member of the general population having a child with epilepsy (1–2%). Specifically, the hereditary rates for patients with:
The above statistics do not apply if a person has a known genetic cause of their epilepsy. In those cases, the risks of passing on epilepsy to a child may be significantly higher. Some indications that epilepsy may have a genetic cause are:
Several studies [7] following children exposed to ASMs during pregnancy found that:
Valproic acid exposure during the first 13 weeks of pregnancy has been associated with adverse neurodevelopmental outcomes (cognitive and behavioral) in children when compared to children born to mothers without epilepsy and children born to mothers taking other ASMs. Specifically, children exposed to valproic acid during pregnancy may exhibit lower IQ, lower verbal abilities, and have an increased risk of autism spectrum disorder. [8] Risk of major congenital malformations that exposure to valproic acid may impact is generally complete by 13 weeks of pregnancy.
Limited data is available about the neurodevelopment of children born to patients who take other ASMs during pregnancy.
Topiramate and zonisamide [9] exposure during pregnancy has been linked to a risk of infants being born small for their gestational age.
Monthly monitoring of anti-seizure medication (ASM) levels is important for minimizing the possibility of seizures during pregnancy. Pregnancy can increase ASM clearance, and the extent of clearance changes will vary from patient to patient, so frequent monitoring and adjustment of medication dosages can help maintain optimal seizure control and support the safety and health of both patient and fetus. [10]
Maintaining seizure control is crucial throughout the pregnancy of a person with epilepsy, including during labor and delivery.
Tonic-clonic seizures or any type of seizure with impaired awareness can result in falls or car wrecks, leading to multiple complications in obstetric patients, including:
Any type of convulsive seizure resulting in trauma could cause fetal heart rate changes and lactic acid build-up. [11]
Throughout the pregnancy, the patient's OB or other pregnancy care providers should assess the patient for an increase in all types of seizures, including:
An uptick in milder seizures also should be tracked, as this can often signal an increased likelihood of convulsive seizures.
Pregnant patients with epilepsy should keep track of their seizure activity and report all breakthrough seizures, regardless of severity, to their healthcare providers.
Sleep deprivation, which often happens in the third trimester of pregnancy and the postpartum period, is a common seizure trigger (particularly for frontal lobe and idiopathic generalized epilepsy seizures). Pregnant people with epilepsy should collaborate with their healthcare providers and support system to develop a comprehensive sleep plan during their second trimester.
Research shows that different ASMs are associated with different levels of teratogenic risk. For best outcomes, people with epilepsy need to start planning for pregnancy with their clinician 12 months in advance, as it can take 3–12 months to switch or adjust their ASM if they are on an ASM with a higher level of teratogenic risk. [2]
When switching ASMs or adjusting dosages, the goal is to identify the lowest effective ASM dosage that will pose the least teratogenic risk to the fetus while maintaining the patient's seizure control. [12] This transition should start well before pregnancy — for those who will undergo major changes in their ASM regimen, this could be as much as 12 months before the patient attempts to become pregnant.
Most ASMs may require higher doses during pregnancy due to changes in drug clearance. However, people with epilepsy should reduce these increased doses in the first few weeks after giving birth to prevent potential toxicity. Symptoms of toxicity include dizziness, vomiting, and blurry/double vision.
The postpartum tapering plan may involve maintaining a slightly higher ASM dose than pre-pregnancy levels. The higher dose can protect the patient from the effects of sleep deprivation and added stressors during the postpartum period. For most ASMs, the initial step is to hold at the delivery dose for 48 hours. After this period, a gradual tapering process should be implemented over the appropriate interval for the specific ASM, typically lasting three weeks.
There is little evidence to suggest that ASM exposure from breast milk has clinical effects on newborns and several studies examined the neurodevelopment of babies exposed to ASMs via breast milk and the results were positive.
Babies of nursing parents who take benzodiazepines, barbiturates, and clobazam should be carefully monitored for wakefulness and growth. More testing is needed to determine the neurodevelopmental effects of these drugs on babies.
When a patient stops breastfeeding their ASM distribution levels may change; it is important to assess and carefully monitor ASM levels before, during, and after pregnancy.
Carbamazepine, sold under the brand name Tegretol among others, is an anticonvulsant medication used in the treatment of epilepsy and neuropathic pain. It is used as an adjunctive treatment in schizophrenia along with other medications and as a second-line agent in bipolar disorder. Carbamazepine appears to work as well as phenytoin and valproate for focal and generalized seizures. It is not effective for absence or myoclonic seizures.
Epilepsy is a group of non-communicable neurological disorders characterized by recurrent epileptic seizures. An epileptic seizure is the clinical manifestation of an abnormal, excessive, and synchronized electrical discharge in the brain cells called neurons. The occurrence of two or more unprovoked seizures defines epilepsy. The occurrence of just one seizure may warrant the definition in a more clinical usage where recurrence may be able to be prejudged. Epileptic seizures can vary from brief and nearly undetectable periods to long periods of vigorous shaking due to abnormal electrical activity in the brain. These episodes can result in physical injuries, either directly such as broken bones or through causing accidents. In epilepsy, seizures tend to recur and may have no immediate underlying cause. Isolated seizures that are provoked by a specific cause such as poisoning are not deemed to represent epilepsy. People with epilepsy may be treated differently in various areas of the world and experience varying degrees of social stigma due to the alarming nature of their symptoms.
Valproate are medications primarily used to treat epilepsy and bipolar disorder and prevent migraine headaches. They are useful for the prevention of seizures in those with absence seizures, partial seizures, and generalized seizures. They can be given intravenously or by mouth, and the tablet forms exist in both long- and short-acting formulations.
Anticonvulsants are a diverse group of pharmacological agents used in the treatment of epileptic seizures. Anticonvulsants are also increasingly being used in the treatment of bipolar disorder and borderline personality disorder, since many seem to act as mood stabilizers, and for the treatment of neuropathic pain. Anticonvulsants suppress the excessive rapid firing of neurons during seizures. Anticonvulsants also prevent the spread of the seizure within the brain.
Topiramate, sold under the brand name Topamax among others, is a medication used to treat epilepsy and prevent migraines. It has also been used in alcohol dependence and essential tremor. For epilepsy this includes treatment for generalized or focal seizures. It is taken orally.
Lamotrigine, sold under the brand name Lamictal among others, is a medication used to treat epilepsy and stabilize mood in bipolar disorder. For epilepsy, this includes focal seizures, tonic-clonic seizures, and seizures in Lennox-Gastaut syndrome. In bipolar disorder, lamotrigine has not been shown to reliably treat acute depression for all groups except in the severely depressed; but for patients with bipolar disorder who are not currently symptomatic, it appears to reduce the risk of future episodes of depression.
Absence seizures are one of several kinds of generalized seizures. In the past, absence epilepsy was referred to as "pyknolepsy," a term derived from the Greek word "pyknos," signifying "extremely frequent" or "grouped". These seizures are sometimes referred to as petit mal seizures ; however, usage of this terminology is no longer recommended. Absence seizures are characterized by a brief loss and return of consciousness, generally not followed by a period of lethargy. Absence seizures are most common in children. They affect both sides of the brain.
Oxcarbazepine, sold under the brand name Trileptal among others, is a medication used to treat epilepsy. For epilepsy it is used for both focal seizures and generalized seizures. It has been used both alone and as add-on therapy in people with bipolar disorder who have had no success with other treatments. It is taken by mouth.
Levetiracetam, sold under the brand name Keppra among others, is a medication used to treat epilepsy. It is used for partial-onset, myoclonic, or tonic–clonic seizures and is taken either by mouth as an immediate or extended release formulation or by injection into a vein.
Primidone, sold under various brand names, is a barbiturate medication that is used to treat partial and generalized seizures and essential tremors. It is taken by mouth.
Valnoctamide has been used in France as a sedative-hypnotic since 1964. It is a structural isomer of valpromide, a valproic acid prodrug; unlike valpromide, however, valnoctamide is not transformed into its homologous acid, valnoctic acid, in vivo.
Felbamate is an anticonvulsant used in the treatment of epilepsy. It is used to treat partial seizures in adults and partial and generalized seizures associated with Lennox–Gastaut syndrome in children. However, an increased risk of potentially fatal aplastic anemia and/or liver failure limit the drug's usage to severe refractory epilepsy.
Generalized epilepsy is a form of epilepsy characterised by generalised seizures with no apparent cause. Generalized seizures, as opposed to focal seizures, are a type of seizure that impairs consciousness and distorts the electrical activity of the whole or a larger portion of the brain.
Brivaracetam, sold under the brand name Briviact among others, is a chemical analog of levetiracetam, a racetam derivative with anticonvulsant (antiepileptic) properties. It is marketed by the pharmaceutical company UCB.
Lacosamide, sold under the brand name Vimpat among others, is a medication used for the treatment of partial-onset seizures and primary generalized tonic-clonic seizures. It is used by mouth or intravenously.
Eslicarbazepine acetate (ESL), sold under the brand names Aptiom and Zebinix among others, is an anticonvulsant medication approved for use in Europe and the United States as monotherapy or as additional therapy for partial-onset seizures epilepsy.
Drospirenone/ethinylestradiol/levomefolic acid (EE/DRSP/LMF), sold under the brand name Beyaz among others, is a combination of ethinylestradiol (EE), an estrogen, drospirenone (DRSP), a progestogen, antimineralocorticoid, and antiandrogen, and levomefolic acid (LMF), a form of vitamin B9, which is used as a birth control pill to prevent pregnancy in women. The formulation contains folate as the calcium salt of levomefolic acid to lower the risk of complications such as fetal neural tube defects should the medication fail as a form of birth control. EE/DRSP/LMF was approved for use by the US Food and Drug Administration (FDA) in September 2010.
Jeavons syndrome is a type of epilepsy. It is one of the most distinctive reflex syndromes of idiopathic generalized epilepsy characterized by the triad of eyelid myoclonia with and without absences, eye-closure-induced seizures, EEG paroxysms, or both, and photosensitivity. Eyelid myoclonia with or without absences is a form of epileptic seizure manifesting with myoclonic jerks of the eyelids with or without a brief absence. These are mainly precipitated by closing of the eyes and lights. Eyelid myoclonia is the defining seizure type of Jeavons syndrome.
Combined hormonal contraception (CHC), or combined birth control, is a form of hormonal contraception which combines both an estrogen and a progestogen in varying formulations.
Antimanic drugs are psychotropic drugs that are used to treat symptoms of mania. Though there are different causes of mania, the majority is caused by bipolar disorder, therefore antimanic drugs are mostly similar to drugs treating bipolar disorder. Since 1970s, antimanic drugs have been used specifically to control the abnormal elevation of mood or mood swings during manic episodes. One purpose of antimanic drugs is to alleviate or shorten the duration of an acute mania. Another objective is to prevent further cycles of mania and maintain the improvement achieved during the acute episode. The mechanism of antimanic drugs has not yet been fully known, it is proposed that they mostly affect chemical neurotransmitters in the brain. However, the usage of antimanic drugs should be consulted with a doctor or pharmacist due to their side effects and interactions with other drugs and food.