Ask the Expert with  Mark S. Yerby, M.D., M.P.H.

Posted: July 16, 2004

Question: How far in advance should you begin to consult your doctor about the possibility of becoming pregnant? In my case, my seizures are controlled with 3000mg Keppra and 600mg Carbatrol. I do not plan on having a child for five years or so, but I also do not want to have a child while taking antiepileptic medications. What does planning a pregnancy involve for a woman with epilepsy?

Answer: The sooner the better, but a minimum of three months to give you time to make adjustments to your medications. Planning involves getting seizures under control, preferably with a single medication. You would also want to take a daily multivitamin that has at least 0.4mg of folic acid.

It is unlikely that a woman with epilepsy will be able to stop taking medication during her pregnancy. To do so means she will be at risk for seizures. Even women taking medication have an increased risk for seizures and the increased risk for injury, memory loss, death and miscarriage and developmental delay that are associated with poor maternal seizure control.

Question: If a woman has epilepsy what are the chances of her children having epilepsy? What about the woman's sister's children having epilepsy?

Answer: Three percent and 1 percent respectively.

Question: While I was pregnant, I was in a car accident. My son has epilepsy, and the doctors asked me if there had been trauma during my pregnancy. Why do they ask that question? Could his seizures be from the trauma in the accident?

Answer: Any factor causing a lack of oxygen during pregnancy could effect fetal development and increase the risk of epilepsy. Unless there was significant abdominal injury or loss of consciousness from this accident, I believe this is unlikely.

Question: I am considering having a second child. I had my first child at age 33 without any complications. I was on Dilantin at the time and did not experience any seizures or any difficulties during my pregnancy. My first seizure after my pregnancy came almost two years later. Since then, I've had a seizure almost every two years until I turned 39, when I had three seizures in one day. At age 41, I had another seizure where I stopped breathing for almost 10 minutes.

I would very much like to have another child but am concerned that these continuous seizures might have a lasting effect on a fetus with possible birth defects. Is it possible at my age the seizures could be more serious? Since the three seizures at age 39, I've tried new medications and am now currently on Keppra and Topamax.

Answer: In addition to the increased risk of adverse pregnancy outcomes from maternal epilepsy is the risk from advanced maternal age, which include congenital malformations, developmental delay, mental retardation and Down's syndrome. Since ⅓ to ¼ of women may find that their seizures worsen during pregnancy, it would behoove you work with your neurologist to maximize seizure control prior to conception. The polytherapy and maternal epilepsy add additional complexity and risks.

Question: My sister has complex partial epilepsy and is pregnant. Her doctor has prescribed Zonisamide (Zonegran). Can you give me some information in reference to this medication's side effects and studies on pregnancy?

Answer: There is only one reported study from Japan in 1996 by Kondo et al. They studied 26 pregnancies. Two of 26 or 7.7 percent had malformation both with polytherapy. One child was also exposed to phenytoin and the other to both phenytoin and valproic acid. This study is too small to be of much value unfortunately.

Question: My wife has had seizures for the past 25 years. She is now 30 years old and her seizures are controlled with medication. We have a 3 ½ year old daughter who is healthy, intelligent and beginning school soon. So far we have noticed no signs of epilepsy. What are the chances she will develop a seizure disorder?

Answer: This does depend on your wife's epilepsy type, the rates being higher with primarily generalized epilepsy, but on average it is 3 percent.

Question: I have juvenile myoclonic epilepsy. I was diagnosed with epilepsy nine years ago, and since changing to Lamictal from Epilum four years ago have been seizure free. I am currently 32 weeks pregnant and take 300mg of Lamictal daily and have remained seizure free and well so far. I took 5mg folic acid for the first four months and now a prenatal multivitamin/mineral daily.

I am concerned about the long-term side effects of Lamictal on my baby if I breastfeed. I have recently read a paper "Concerns regarding lamotrigine and breast feeding" by Liporace et al, which makes me concerned about the baby's ability to metabolize the drug. I now think that I do not wish to breastfeed my baby, but I am wondering if my baby goes through withdrawal from Lamictal in the early stages of life will he suffer long-term side effects from this.

I know that breastfeeding and especially colostrum has long-term benefits but I am cautious due to the lack of information about what process the baby will use to metabolize it and how the build up of the drug in his system might affect his growth and development. I would be grateful for any information that you might be able to give me.

Answer: Breastfeeding is considered the ideal method of nourishing young infants. Most women choose to and are encouraged to do so. Anticonvulsant medications are secreted in maternal breast milk. Nursing women with epilepsy therefore transmit anticonvulsant medication to their children. It appears that all anticonvulsants are excreted in breast milk. The more highly protein-bound the AED the less is transferred from plasma to milk. With the exception of carbamazepine and ethosuximide, the elimination half-life of anticonvulsants tends to be prolonged in neonates.

At the present time we do not know how much AED is transmitted to breast milk and for how long. Furthermore, we do not know whether or not it adversely effects infant development. Since a term infant has been exposed to an anticonvulsant for nine months, their hepatic microsomal enzyme systems are all ready induced, the volumes of breast milk ingested are small it seems reasonable to have them breast feed and thus actually reduce their risk of medication withdrawal. The kinetics of AED in breast milk are listed in the table below.

AED Kinetics in Plasma and Breast Milk

Question: I had my first seizure during the 3rd trimester of pregnancy and was put on Dilantin. My son (now 10 weeks old) is fine. I was weaning off of the medication after delivery and had another seizure so am now back up to 300mg/day. (It seems I have partial complex lobe epilepsy.)

I am breastfeeding him and have heard conflicting opinions as to whether or not I should continue. Two neurologists, a pharmacist and all the sources I've found online say it's okay. My current neurologist and pediatrician say it's not, based on the Physicians Desk Reference. My baby has a rash on his face that seems to get worse when I feed him. Is there a connection? Is it safe? Should he be tested to see how much he's getting?

Answer: It seems unlikely that one would get a drug rash only on the face. See the answer to the question above.

Question: What are the known effects of Trileptal medication on the fetus?

Answer: There are two reports. One is a retrospective study from Finland (Isojarvi et al 2003) of 133 women, 101 on monotherapy with no malformations and 32 on polytherapy and two malformations both in combination with oxcarbazepine and valproic acid. The other from Argentina (Rabinowicz 2002) 42 women 25 using monotherapy with no malformation, 17 on polytherapy with one malformation that child was also exposed to phenobarbital.

Question: I am 15 weeks pregnant and taking 250mg valproic acid 3x daily. I am also taking 5mg folic acid and a prenatal vitamin. I have been seizure free since starting the valproic acid a few years ago. I am allergic to every other type of medication I have tried, so changing meds wasn't a choice for me. As far as I know I am doing everything possible to have a healthy baby - eating properly, getting adequate rest. I am still concerned about birth defects caused by the drug. I had an ultrasound at 12 weeks, and everything is fine so far. I am having an AFP blood test next week, another ultrasound at 18 weeks, an EKG on the baby's heart at 21 weeks, and am having my medication levels checked once a month. Do you have any other suggestions of things I can do to ensure my baby has the best chance possible?

Answer: Be certain that you have an anatomic ultrasound at 16 weeks of gestational age.

Question: I had a seizure while in labor with my son, five months ago. I just recently had another seizure. I have just been diagnosed with "seizures" and told to start taking Keppra. I was also told that I would have to stop nursing my son. I'm not ready to do that. What's the harm in delaying medication for a few more months or is there a medication I can take and still breastfeed?

Answer: Seizures are potentially dangerous to you. They can cause serious injury, memory loss and rarely death. If you really do have seizures you deserve to be treated. The amount of medication in breast milk is smaller than the amount in your blood stream so the baby's exposure is relatively small. All medication will be excreted in the breast milk so there is no medication you can take that will not eventually be in the breast milk. There is no way to honestly tell you what the effect of this may be on your child. I believe it is probably small, but I would not risk your health and thus your child's but not taking medication to prevent seizures.

Question: I have tried to do research on the chance for a woman to breastfeed. I am in my eighth month of pregnancy. In most of my research, I found that breastfeeding was okay for most women with epilepsy. However, at my last doctor's appointment, my gynecologist said it wasn't recommended. I am currently taking the drug Trileptal and was wondering if you have any information on this topic.

Answer: See previous answer on breastfeeding.

Question: I've had petite mal seizures since childhood, but they were not diagnosed until I had a grand mal seizure in 1987 (the one and only of that type). During the last 10 months my seizures have become more severe, though not more frequent. I may go one to two months with nothing, then have five or six in one day. The funny part is that my blood levels are always normal when I go to the doctor or hospital, even on the day of the seizures. I currently have a son who is almost 5 years old. I was taking 300mg Dilantin a day when expecting him, and he is completely normal. I want to have one more child. Others often discourage me. I now take 330mg Dilantin and 200mg Topamax daily. Am I wrong?"

Answer: You do not have a precise diagnosis of your seizures. One would not generally use Dilantin for "petit mal" seizures. Your best chance of a successful pregnancy outcome is to have your seizures well controlled prior to conception preferably with a single medication. Dilantin is clearly not effective in controlling your seizures and the addition of Topamax does not seem to have been effective either. It does seem as though more work is necessary to improve seizure control and try to do so with one medication before attempting pregnancy. Also are you taking folic acid? Good Luck!