Epilepsy Management During Pregnancy: Medication Safety and Seizure Control

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• Pre-Pregnancy Planning with Specialists
• Anti-Seizure Medication Safety Data
• The Breastfeeding Controversy
• The Neurological Goal in Pregnancy
• Clinical Monitoring Strategies
• Delivery Planning Considerations
• Managing Medication Dosage

Pre-Pregnancy Planning with Specialists

Pre-pregnancy planning is a critical first step for women with epilepsy. Dr. Marc Dommergues, MD, emphasizes the necessity of a specialist consultation before discontinuing contraception or pursuing assisted reproductive techniques. This multidisciplinary approach should involve a neurologist and an obstetrician. In complex cases, an obstetrician with specific expertise in neurological disorders or an epilepsy specialist familiar with pregnancy management may be required.

Anti-Seizure Medication Safety Data

Patients are highly concerned about the safety of their anti-seizure medications during pregnancy. Dr. Marc Dommergues, MD, notes that for a medication like Lamotrigine (Lamictal), a substantial body of reassuring safety data exists. For a patient with well-controlled idiopathic generalized epilepsy on a well-tolerated medication, and who has been seizure-free for a year, the pregnancy will likely proceed very smoothly. Addressing these medication safety questions before conception provides essential reassurance.

The Breastfeeding Controversy

The issue of breastfeeding while on anti-epileptic drugs is highly controversial. Dr. Marc Dommergues, MD, explains that some physicians advocate for breastfeeding, citing cohort studies that show no health differences in children. However, Dr. Dommergues personally aligns with a more prudent approach. He advises avoiding giving any neurological drug to a developing brain when possible, thus preferring to avoid breastfeeding to minimize Lamictal exposure. He acknowledges that the opposing opinion is also understandable.

The Neurological Goal in Pregnancy

The primary neurological objective during pregnancy for a woman with epilepsy is to avoid status epilepticus. As Dr. Marc Dommergues, MD, states, this prolonged seizure condition is extremely dangerous. This overarching goal guides all subsequent management decisions, from medication adjustments to delivery planning. The strategy focuses on maintaining stability to protect both the mother's and the developing baby's health.

Clinical Monitoring Strategies

Close clinical monitoring is the cornerstone of achieving seizure control. Dr. Marc Dommergues, MD, recommends that a neurologist sees the patient several times throughout the pregnancy. Obstetricians should consistently ask simple, direct questions about how the woman feels, any seizure activity, or any prodromal symptoms that might suggest a seizure is imminent. This proactive dialogue helps identify changes in the patient's condition early.

Delivery Planning Considerations

Specialized planning for labor and delivery is essential for women with epilepsy. Dr. Marc Dommergues, MD, highlights the importance of limiting stress, a known seizure trigger. Adequate pain treatment, often via epidural anesthesia, is crucial. In some cases, inducing labor slightly earlier, around 39 weeks, can be a valuable option if the mother feels excessively tired or on the verge of a seizure, helping to preempt a potential neurological crisis.

Managing Medication Dosage

If clinical symptoms or signs suggest a change in condition, the next step is to check the concentration of the anti-seizure drug in the blood. As Dr. Marc Dommergues, MD, explains, a neurologist may then decide to increase the medication dosage. This step is a straightforward but vital part of the management protocol to maintain therapeutic drug levels and prevent breakthrough seizures, especially as pregnancy can alter how the body processes medications.

Full Transcript

Dr. Marc Dommergues, MD: Epilepsy in pregnancy is a complicated issue, but epilepsy seizures are common. How to best manage epilepsy during pregnancy? What are the issues to think about for women with epilepsy if they consider becoming pregnant?

It is certainly important to have a clinic beforehand, before discontinuing contraception or before planning a pregnancy with assisted medical reproductive techniques. It is important to have a clinic with a specialist in epilepsy, the neurologist, and obstetrician. In some cases, an obstetrician specialized in neurological disorders is needed. An epilepsy specialist familiar with managing pregnancy may be needed, but not in all cases.

For example, a patient may have idiopathic epilepsy with generalized seizures that are well controlled with a medication, which is well tolerated during pregnancy, such as Lamictal. If a patient had no seizures in the year before pregnancy, things would probably go very smoothly throughout pregnancy. However, it is necessary to discuss a few things beforehand.

First, the patients are very keen on having data regarding the safety of the anti-seizure medicines they are taking. If we consider Lamictal, there is a lot of reassuring data on safety.

Dr. Anton Titov, MD: So this is an easy question to answer, but it needs to be answered.

Dr. Marc Dommergues, MD: There is the question of breastfeeding with Lamictal, and it's very controversial. Some doctors advocate for breastfeeding while on Lamictal. They say that in studied patient cohorts, there is no difference regarding the health of a child between breastfeeding mothers and non-breastfeeding mothers who take Lamictal.

Other doctors say, "Let's be prudent and let's avoid giving any neurological drug to a developing brain when it is possible not to give it. Let's prefer to avoid breastfeeding to give as little as possible Lamictal to this developing brain." I would rather be in the latter category, but I know this is quite controversial. I do admit that another opinion is understandable.

We talked about epilepsy medications and pregnancy. Another question is, what is the goal during pregnancy from a neurological point of view? I'd like to make a long story short and to say things in an oversimplified view.

Dr. Anton Titov, MD: I am an obstetrician, so as an obstetrician, I like to oversimplify by nature.

Dr. Marc Dommergues, MD: The goal during pregnancy is to avoid status epilepticus, which is very dangerous. How are we going to achieve that? First, by having close clinical monitoring of epilepsy. This can be achieved by seeing a neurologist a few times during pregnancy.

Obstetricians should ask very simple questions. How does a pregnant woman feel? Does she have any seizures? Does she have symptoms making her think she might have a seizure in the future? Then if there are symptoms or signs that show a change in her clinical condition, the second step will be to check the anti-seizure drug concentration in her blood. A neurologist may decide to increase the dose of anti-epileptic medication. All these steps are rather simple.

Regarding the delivery of the baby, it will be important to limit stress before delivery because stress is known to be able to trigger seizures. Treating pain during labor and delivery adequately is very important. Some women with epilepsy benefit from epidural anesthesia.

Sometimes it may be useful to induce labor a little bit earlier. This is especially true in cases where a woman may feel very tired. She may tell us, "I feel on the verge of having a seizure. A seizure doesn't come, but really I don't feel comfortable." If a woman is at 39 weeks of pregnancy, induction of labor is an option.