Managing Epilepsy During Pregnancy: Seizure Control and Medication Safety

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• Pre-Pregnancy Planning and Seizure Control
• Anti-Epileptic Medication Safety Profile
• The Critical Role of Folic Acid
• Medication Monitoring During Pregnancy
• Childbirth and Delivery Considerations
• Benefits of Breastfeeding with Epilepsy
• Full Transcript

Pre-Pregnancy Planning and Seizure Control

Dr. Tracey Milligan, MD, emphasizes that over 90% of women with epilepsy have healthy pregnancies and healthy babies. She stresses that pre-pregnancy seizure control is the strongest predictor of seizure control during pregnancy. A woman with epilepsy must work closely with her neurologist before conception to optimize her treatment plan.

Dr. Tracey Milligan, MD, explains that the body's metabolism changes significantly during pregnancy. This can alter how medications are processed. Knowing a patient's therapeutic drug levels before pregnancy allows doctors to maintain those same levels throughout gestation, ensuring continued seizure protection.

Anti-Epileptic Medication Safety Profile

Dr. Tracey Milligan, MD, makes a crucial distinction between the risks of seizures and the risks of medication. She states unequivocally that seizures are more dangerous for both the mother and the developing baby than most anti-epileptic drugs. Stopping medication is far riskier than continuing a carefully managed regimen.

Dr. Milligan identifies three specific anti-epileptic medications to avoid in women of childbearing potential due to a higher risk of birth defects: divalproex sodium, phenobarbital, and topiramate. Conversely, she notes that many newer anti-epileptic medications have a good safety profile based on clinical trial data and are considered appropriate choices.

The Critical Role of Folic Acid

Dr. Tracey Milligan, MD, highlights folic acid supplementation as a vital preventive measure. She recommends that all women with epilepsy who could become pregnant take 1 mg of folic acid daily. This is crucial because many pregnancies are unplanned, and the neural tube forms very early, often before a woman knows she is pregnant.

Folic acid, also known as folate, is proven to dramatically reduce the risk of neural tube defects. Dr. Milligan points out that women with epilepsy may be at greater risk for lower folate levels, making supplementation even more essential for a healthy pregnancy outcome.

Medication Monitoring During Pregnancy

Dr. Tracey Milligan, MD, explains that maintaining a steady level of anti-epileptic medication in the bloodstream is a primary goal during pregnancy. Due to metabolic changes, this often requires increasing the dosage of the medication as the pregnancy progresses to keep blood concentrations stable.

This means a woman may need to take more pills to achieve the same therapeutic effect she had before pregnancy. Dr. Milligan assures that this careful titration is a standard and necessary part of prenatal care for women with epilepsy to prevent breakthrough seizures.

Childbirth and Delivery Considerations

Dr. Tracey Milligan, MD, discusses the need for specialized obstetric care during delivery. While there is no medical indication for a cesarean section solely because a woman has epilepsy, there is a recognized, slightly increased risk of complications during childbirth that requires preparedness.

Dr. Milligan advises that delivery should be managed by a trained obstetrician in a setting equipped for closer monitoring of both mother and baby. The care team must be aware of the potential for complications and be ready to perform an emergency cesarean section if the situation arises.

Benefits of Breastfeeding with Epilepsy

Dr. Tracey Milligan, MD, strongly encourages women with epilepsy to breastfeed their infants. The numerous health benefits of breastfeeding for the baby are well-established and are generally considered to outweigh the minimal risk of exposure to anti-epileptic drugs through breast milk.

This recommendation aligns with guidance from major medical organizations. Dr. Milligan's support for breastfeeding reinforces the overall message that women with epilepsy can successfully navigate motherhood with proper medical guidance from experts like Dr. Tracey Milligan, MD, and Dr. Anton Titov, MD.

Full Transcript

Dr. Anton Titov, MD: Epilepsy and pregnancy. What are the nuances of treating epilepsy during pregnancy? What are the major risks for mother and for a child? Because there is a risk of epileptic seizures. There is also risk of the side effects of anti-epileptic medications.

Dr. Tracey Milligan, MD: Yes, epilepsy and pregnancy is a very important topic. I always like to start by emphasizing that women with epilepsy will have wonderful pregnancies and beautiful healthy babies. The vast majority of pregnant women with epilepsy will have a healthy pregnancy course and a healthy baby.

That is something that not everybody knows. Sometimes patients think that women with epilepsy can't have children. They think that women with epilepsy shouldn't have children or will have problems. That is not true in over 90% of pregnancies.

It is very important that a woman with epilepsy work with a doctor. She must get good epileptic seizure control before pregnancy. Because how well the epileptic seizures are controlled before pregnancy predicts how perfectly epileptic seizures will be controlled during pregnancy.

The body's metabolism really changes during pregnancy. That is why we want to know the true level of anti-epilepsy medications.

Dr. Anton Titov, MD: What is the amount of anti-epilepsy medication in the bloodstream prior to the pregnancy?

Dr. Tracey Milligan, MD: We work to keep that anti-epilepsy medication at the same level. I also want to emphasize how important it is to take anti-epileptic medications during pregnancy.

Dr. Anton Titov, MD: That is so important. Many women are afraid that the epilepsy medication will hurt the baby. So they stop the epilepsy medication and that causes problems for the mother and for the baby.

Dr. Tracey Milligan, MD: In women with epilepsy, they should continue to take epilepsy medication all through pregnancy. They have to maintain control of the epileptic seizures. Seizures are worse for the baby than the epilepsy medication.

There are some anti-epileptic medications that we think are relatively safe during pregnancy. There are other epilepsy medications, for example, Divalproex Sodium, that we know are harmful to the baby.

There are anti-epileptic medications that we try to avoid in a woman who could become pregnant. These medications are divalproex sodium, phenobarbital and topiramate. Those three anti-epileptic medications we know have a higher risk of birth defects.

Some of the newer anti-epileptic medications seem to be fairly safe. We have good clinical trials that show good safety. Such newer medications seem to be fairly safe during pregnancy.

But the bottom line is this. A woman who is thinking about becoming pregnant should first talk to their doctor. She should discuss the epilepsy medication that she is taking.

A woman may not be thinking about being pregnant. But their doctor should talk to them. Because many pregnancies are not planned.

That is why we also recommend an important preventive step. All women with epilepsy who could become pregnant must take folic acid. Folic acid is a vitamin that is known to reduce the risk of birth defects.

Dr. Anton Titov, MD: Folate is the other name for folic acid. In the United States, for example, we started adding folate to our grain products. Then there was a dramatic decrease in neural tube defects among all women in the United States.

Dr. Tracey Milligan, MD: Women with epilepsy might have a greater risk of having a lower level of folic acid. We recommend women take one milligram of folic acid every day. Even if they are not planning to become pregnant.

Because many pregnancies are unplanned. When the woman is aware that she's pregnant, the neural tube has already formed. Neural tube will become the spinal cord and the brain.

During pregnancy, we will make sure that the true level of medications stays the same in their system. That usually requires increasing the dose of epilepsy medication.

The dose of anti-epilepsy medication may increase quite a bit. The number of pills a woman takes during pregnancy may increase. But that anti-epilepsy medication level in the blood will stay steady. It just requires more pills to keep that level steady.

We also encourage women to breastfeed their infants after birth. We know that breastfeeding has a number of benefits. Those benefits outweigh the risk of the medication in the breast milk.

Most women have very healthy pregnancies. They give birth to healthy babies. But there is a little increased risk in women with epilepsy.

Because we do know that there's an increased risk during childbirth. It is important to seek the care of a trained obstetrician. It is crucial to have an obstetrician involved in the childbirth.

Dr. Anton Titov, MD: Is there a particular reason to have a cesarean section delivery in a woman with epilepsy?

Dr. Tracey Milligan, MD: There is no reason for a woman with epilepsy to have a cesarean section simply because she has epilepsy. But there is a need for increased monitoring of woman and fetus during childbirth.

There has to be an awareness that more complications could happen during the delivery. A pregnant woman must have a trained physician present and ready to perform a Cesarean section operation, if necessary. But it is not because the woman has epilepsy.