Epilepsy and Pregnancy: Managing Seizure Risks and Medication Safety

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• Seizure Risks During Pregnancy and Postpartum
• Safety Precautions for New Mothers
• Postpartum Depression and Epilepsy
• The Valproic Acid Dilemma in Pregnancy
• Switching Epilepsy Medications Before Pregnancy
• Pregnancy's Impact on Seizure Frequency
• Diagnosing Seizures During Pregnancy

Seizure Risks During Pregnancy and Postpartum

Pregnancy can decrease blood levels of anti-seizure medications. This increases the risk of an epileptic seizure. Dr. Marc Dommergues, MD, emphasizes that standard safety precautions must continue. These include restrictions on driving and swimming.

The postnatal period carries an especially high risk. Factors like fasting, insomnia, stress, and pain can all induce a seizure. This makes vigilant management essential for both mother and baby's safety.

Safety Precautions for New Mothers

Dr. Marc Dommergues, MD, offers specific, practical advice to prevent harm to a baby if a mother has a seizure. He recommends changing the baby on a low surface, like a bed, instead of a high table. This prevents a dangerous fall.

When bottle-feeding, the mother should sit comfortably on the floor. Bathing the baby should ideally be done with another person present for safety. These simple steps can significantly reduce risk.

Postpartum Depression and Epilepsy

Women with epilepsy face a higher risk of postpartum depression. Dr. Marc Dommergues, MD, advises new mothers to be vigilant for symptoms. Feeling like a bad person or unable to do anything are key warning signs.

He strongly recommends against suffering in silence. Women should immediately tell their neurologist if these feelings arise 3 to 6 months after delivery. Seeking help is a critical part of postnatal care for epileptic mothers.

The Valproic Acid Dilemma in Pregnancy

Dr. Marc Dommergues, MD, illustrates a complex clinical case involving valproic acid. This medication is highly effective for genetic epilepsy but is known to cause severe fetal malformations. In one family, withdrawing valproic acid had previously led to a fatal status epilepticus.

This created an impossible choice for a pregnant 18-year-old: continue a drug that could harm her baby or stop it and risk death. The situation was so severe it resulted in a termination of pregnancy. This case highlights the extreme challenges some women face.

Switching Epilepsy Medications Before Pregnancy

A more common scenario involves switching from valproic acid to a safer drug before pregnancy. Dr. Marc Dommergues, MD, explains this is a difficult and gradual process. Seizure control may not be as effective with the new medication.

However, the benefits of avoiding valproic acid exposure largely exceed the risks of a few breakthrough seizures. A single seizure is usually not very dangerous if it does not progress to status epilepticus. Accepting this short-term risk can be a reasonable choice to protect the baby.

Pregnancy's Impact on Seizure Frequency

The effect of pregnancy on epilepsy is highly variable. Dr. Anton Titov, MD, asked Dr. Dommergues how pregnancy influences seizures. The strongest factor is often the need to stop an effective medication, which increases seizure risk.

For some patients, seizure frequency increases for unknown reasons. For others, epilepsy drastically improves during pregnancy. This unpredictability makes individualized care and close monitoring absolutely essential.

Diagnosing Seizures During Pregnancy

Dr. Marc Dommergues, MD, provides a crucial piece of advice for diagnosing events. If a seizure is suspected, the best tool is often a smartphone. Filming the symptoms provides invaluable information for a neurologist.

He notes that for non-specialists, an iPhone video can be more immediately helpful than an EEG. While an EEG remains important for specialists, a video allows a doctor to visually confirm whether an event was an epileptic seizure. This practical tip can lead to a faster, more accurate diagnosis.

Full Transcript

Dr. Marc Dommergues, MD: The very important question is that pregnancy may decrease the blood level of the drugs, and so this may increase the risk of having a seizure. This means that the usual precautions for everyday life must be followed during pregnancy—regarding driving, regarding the swimming pool, etc.

These precautions need to be continued in the postnatal period, which has an increased risk of seizures because you have fasting, insomnia, stress, and pain. All those things may induce a seizure.

A woman should ask, "How am I going to manage not to harm my baby if I have a seizure?" There are very simple things that can be done to avoid harming a baby.

When changing the baby, it's possible to change the baby on a bed or something low. Do not change the baby on those high tables. Your baby may fall if you have a seizure while feeding the baby.

It's important to be very comfortable if you bottle feed. You may stay in front of the baby to bottle feed the baby. When bathing the baby, it may be preferable, at least in the beginning, to have someone else be present with you, just in case you have a seizure.

And the last but not least point is that we now know that postpartum depression is more frequent in persons with epilepsy than in people without epilepsy. What I do is just tell people that if three, four, or six months after delivery, you feel that you are a bad person and unable to do anything, think that it might be postnatal depression.

Tell your neurologist and don't stay alone. This is a standard story of "quiet epilepsy" without complications.

Things may be far more complicated. It may be an awful story. I remember a young woman. She was 18. She was on valproic acid. She had genetic epilepsy. She had mild mental retardation. Her younger brother had just died of status epilepticus after there was a trial of withdrawing valproic acid treatment.

Dr. Anton Titov, MD: So in this family, we knew that withdrawing valproic acid could mean death. But continuing valproic acid during pregnancy could mean harming the baby.

So the whole story was very complicated. Eventually, the young woman decided to have an early termination of pregnancy. This was a very unusual story.

Dr. Marc Dommergues, MD: What may happen more often is this. Let's continue with the story of valproic acid. A woman with epilepsy may have good control of her epilepsy with valproic acid, and she wants to become pregnant.

Then the very difficult challenge for her neurologist will be to switch from valproic acid to another medication, which is less harmful during pregnancy. This will be hard because switching medications is done little by little.

Maybe epilepsy will not be as well controlled with the new drug compared with valproic acid. But probably the benefits of changing an epilepsy drug during pregnancy largely exceed the risks of continuing valproic acid, which may harm the baby.

Switching to other epilepsy medication is still a good choice. A woman may have either partial seizures or generalized seizures during pregnancy. But if she doesn't go into status epilepticus, it's usually not very dangerous.

It's probably far less dangerous than being exposed to a dangerous drug for a baby.

Dr. Anton Titov, MD: So this could be a reasonable choice—to accept a few seizures to avoid a medication that can harm her baby.

So this is another kind of story, which is also quite common. Somebody might have a risk of a single seizure that can be acutely treated with benzodiazepines. Then in the short term, it may be an acceptable risk, in theory, rather than continuing with the epilepsy medication that is known to potentially increase the risks of fetal malformations.

Dr. Marc Dommergues, MD: A seizure during pregnancy is usually without major consequences.

Dr. Anton Titov, MD: Is it known how epilepsy, in general, is affected by pregnancy? Does the pregnancy make the likelihood of seizures more or less? Or is it completely related to the levels of anti-seizure medications?

Dr. Marc Dommergues, MD: It's extremely variable between patients. Probably the strongest effect of pregnancy on seizures is when pregnancy forces us to stop a drug, which was very effective. Then the risk of seizures increases.

But in some patients, for reasons we do not know, the frequency of seizures, the frequency of any type of epileptic event, will increase without any precise explanation. On the other hand, and this is not predictable, in some patients, epilepsy will drastically improve during pregnancy.

This is very difficult to predict.

Dr. Anton Titov, MD: Can you do EEG to predict a more calm pattern of brain waves?

Dr. Marc Dommergues, MD: I am not a neurologist, but I can give this advice to a family when someone has a seizure. If you believe that someone has a seizure during pregnancy, probably the best thing is to take your telephone and to film the symptoms.

This will be extremely helpful to the neurologist, who will see the movie and say whether this is an epileptic seizure or not. For the non-specialists, an iPhone may be a better tool than EEG. Of course, EEG will be an important tool for neurologists.

Dr. Anton Titov, MD: That is a very practical and good advice. Thank you!