Ask the Expert: Women and Pregnancy

Introduction

Women with epilepsy may wonder if they can have a healthy baby. They can relax, because there is a greater than 90 percent chance that their newborn will be normal and healthy. However, there are some increased risks these women should consider before getting pregnant, if possible. Both their neurologist and gynecologist/obstetrician must be involved in reviewing medications and determining any potential changes prior to the beginning of a pregnancy.

What should a woman with epilepsy do to get ready for a pregnancy? She should be in good general health. She should pay attention to nutrition before and during pregnancy. A regular schedule of adequate exercise and appropriate rest will keep a pregnant woman physically fit and help manage stress. Take vitamins with folic acid prior to and throughout pregnancy to reduce the risk of certain kinds of birth defects. Since many of these problems occur early in pregnancy, start taking folic acid before becoming pregnant.

How can pregnancy affect seizures? Most women will see no change in their seizures. One-quarter to one-third of pregnant women with epilepsy will have increased seizures despite continued use of antiepileptic medication. During pregnancy, concentrations of seizure medication in the bloodstream may change or decrease, putting a woman at greater seizure risk. The physician may need to check medication blood levels more often, and may need to adjust the dose.

Women may wonder if it's true that seizure medication may affect their children. Yes, there may be some increased risk to children of women with epilepsy taking seizure medications. In the general population there is a 2 to 3 percent chance that a child will have a birth defect (also called a congenital malformation). In women with epilepsy, this risk is increased to 4 to 8 percent. In general, there seems to be higher risk if a woman is taking more than one seizure medication, particularly at high doses.

But there are other risks, to both mother and developing child, from uncontrolled seizures. Most women with epilepsy should continue their seizure medication, and whenever possible, take a single antiepileptic drug at the lowest dose that provides seizure control. Work with the health care team to make the best decisions about medications during pregnancy. Remember, women should never stop taking their antiepileptic drugs or change the doses without the advice and the supervision of the doctor.

Other problems to consider are that women with epilepsy are more likely to have morning sickness and vaginal bleeding during pregnancy. There is an increased risk for early labor and delivery. Sometimes labor does not progress normally and more women with epilepsy need to have cesarean sections than other women. There is a small risk that the baby will develop a bleeding problem in the first 24 hours after birth. Women with epilepsy are often given oral vitamin K supplements during the last month of pregnancy to lessen the chances of this happening to their babies.

In summary, just like any other pregnancy, good pre-natal care and good communication with the medical team can increase the chances of a happy, healthy arrival.

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?

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.

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

Three percent and 1 percent respectively.

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?

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.

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.

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.

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?

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.

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?

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

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.

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

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

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.

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?

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

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?

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.

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?

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!

This event was posted in July 2004.