Pregnancy and epilepsy. Which medications to avoid? Epileptic seizures during pregnancy. Clinical case. 9
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, pain. All those things that may induce a seizure. A woman should ask, ‘How am I going to manage not to harm my baby if I’ve got a seizure?’ Dr. Anton Titov, MD. 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. Dr. Marc Dommergues. Medical second opinion. 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 3-4-6 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. Dr. Marc Dommergues. 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. Dr. Anton Titov, MD. So the whole story was very complicated. Eventually, young woman decided to have an early termination of a pregnancy. This was a very unusual story. 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 the 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. Dr. Anton Titov, MD. 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. Certainly! Medical second opinion. And a seizure during pregnancy is usually without major consequences. 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? 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. Can you do EEG to predict a more calm pattern of brain waves? 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. That is a very practical and good advice, thank you!
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