Ask the Expert: Pregnancy & Epilepsy

Dr. Mark Yerby is back! Once again, Dr. Yerby is participating in the "Ask the Expert" series on Pregnancy and Epilepsy.

Introduction

Women with epilepsy may wonder what their chances are of having a healthy baby. They can relax with the knowledge that their chances of having a normal, healthy child are greater than 90 percent. However, there are some increased risks for women with epilepsy that they should consider before getting pregnant, if possible. Both the neurologist and the gynecologist/obstetrician need to be involved in reviewing medication and 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 and pay attention to nutrition before and during pregnancy. A regular schedule with adequate exercise and appropriate rest will keep a pregnant woman physically fit and may help manage stress. It is important to 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 very early in pregnancy, it is wise to 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 women with epilepsy who become pregnant will have increased seizures during their pregnancy despite continued use of anti-epileptic medication. During pregnancy, concentrations of seizure medication in the bloodstream may change or decrease, putting a woman at greater risk for seizures. The physician may need to check blood levels of medication more often, and may need to adjust the dose.

Women may wonder if it's true that medication taken for seizures may affect their children. Yes, there may be some increased risk to children of women with epilepsy who are 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 anti-epileptic drug at the lowest dose that provides seizure control. It is important to work with the health care team to make the best decisions about medications during pregnancy. Remember, women should never stop taking their anti-epileptic 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 to deliver their babies 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 blessed arrival.

I am 37 weeks pregnant and I'm not sure if I want pain medicine when I go into labor because I'm not sure if it's okay to have any of them. The medicine I take for seizures is Lamictal, 100mg morning and 150 mg night. I was just wondering if there are any medicines I can not have? So far I haven't had any problems with my pregnancy except one grand mal seizure and some partial seizures. Thanks for you help.

Some women do practice "natural" childbirth and refrain from using analgesics (pain medication). There is nothing inherently wrong with this. There are many different responses to the pain of labor. Some women tolerate it well and others do not.

Properly managed there should be no problem with using analgesics during labor. High doses of narcotics after delivery may reduce the seizure threshold and result in seizures in the post partum period. Your doctor should recognize this and dose you carefully.

I would add that you state that you have had only one grand mal and several partial seizures. I would consider this a significant problem. You should speak to your neurologist about improving seizure control.

I have epilepsy and have three little girls. All three where born early. My first was 6 weeks early. They are all straight A students and I was taking depokate, Neurontin, Klonopin and Dilatin. During delivery, I had all of my children with no pain medications. What happened? My husband and I want to try for a boy, do you have any suggestions? Right now, I'm on Depokote and Klonopin, do you have any suggestions on what best to take because everything except for febatol has worked but it makes me sick as a dog to where I literally can't walk across the floor.

I am happy your previous pregnancies were successful. However, you are playing the odds and I strongly suggest trying to use a single medication (monotherapy) instead of two. All the evidence about the safety of AEDs in pregnancy has demonstrated adverse pregnancy outcomes with polytherapy (more than one AED). Review your medication use with your neurologist.

Lamotrigine has a similar spectrum of effectiveness as Depakote (valproic acid). It appears to have less risk of adverse outcomes than valproic acid and might be worth a try. Just because the first three pregnancies went well does not guarantee that a fourth will. You still have only a 50 percent chance of having a boy. With a history of multiple prematuries your risk of another preterm birth with all the potential problems is high.

I am planning to try to have a baby in the next year or so and I have a seizure disorder. I currently take carbamazepine. I need to know who I need to see first, my neurologist or OB-GYN? I know I need to change my medication because it is a class D so it wouldn't be safe for me to become pregnant right now so that's the first step I need to take I suppose isn't it? Please help! What do I do first? Thanks so much for your time.

Speak with your neurologist and seek more information from the Epilepsy Foundation about pregnancy and epilepsy. You do not necessarily have to change your medication. In fact, if well controlled on monotherapy with no medication side effects I would argue against a change. One cannot be certain that a "new" medication will work as well. There is no drug that is absolutely safe.

I suggest asking your neurologist if you require continued treatment or if you are in long term remission, or possibly a candidate for temporal lobectomy. If carbamazepine is required be certain that you are taking the most effective dose. Start taking a multivitamin with at least 400mg of folic acid before you become pregnant. Then speak to your obstetrician about planning a pregnancy. Remember most women with epilepsy have healthy babies. Good luck.

Hello! My wife has epilepsy and she is 27 years old. Right now she is 6 weeks pregnant taking Folvite folic acid 5gm and Lamotrigine 300/300 and Lamatec 50mg. Should she have an abortion? Will the baby be normal or not? Will she face any problems during the pregnancy? Will she be safe during the delivery? Thanks.

The question of whether or not to have an abortion is an intensely personal one. Since most women with epilepsy have healthy babies, and since by 16 weeks of gestation an anatomic ultrasound can identify over 95 percent of all birth defects, I would wait. I would continue the multivitamins and AEDs and obtain an anatomic ultrasound at 12 and again at 16 weeks. If there are no defects then in all probability your child will be healthy. If serious malformations are found then discussions with your obstetrician about the potential impact of the abnormalities on the fetus and if they would seriously impair function then one might consider abortion.

My wife is 7 months pregnant and recently was tested for gestational diabetes. The doctor informed her that her sugar levels were 142. She will now have to take the longer glucose test. My question involves her epilepsy. She is taking Lamictal at 200MG twice per day. She had an aura seizure around two hours before the test. I read that seizures may cause glucose levels to spike. Do you think this could be the reason her levels were so high? It couldn't be the Lamictal, could it? I just want to reassure her before her next test. Thank you.

I do not believe that the aura or lamotrigine have any effect on glucose. Many otherwise healthy women have elevated glucose concentrations during pregnancy. I suggest getting the additional test and following the obstetrican's recommendations.

Dr. Yerby, I am currently 16 weeks pregnant and have a couple of quick questions to ask of you. I was taking folic acid and a prenatal vitamin prior to pregnancy and am on Lamictal, so I think that I have done everything right so far! I was just wondering if there is a specific birth defect related to Lamictal and what it/they are. Also, why does my medicine level decrease during pregnancy so dramatically? I have already had to raise my dosage. Thank you for your help.

I know of no specific birth defect associated with Lamictal (lamotrigine). The Lamotrigine pregnancy registry reports a fairly low rate of malformations. Most AED concentrations fall in pregnancy. This is due to the changes in maternal metabolism, alterations in plasma protein binding, increased clearance of the unbound medication and increased maternal plasma volume in the third trimester. Raising the dose to maintain an adequate plasma concentration is appropriate. It does not expose the fetus to more medication but rather maintains the mother's concentrations protecting her from seizures.

Do AEDs affect a woman's chance of getting pregnant, and if so, how much?

It is not entirely clear if AEDs themselves affect fertility. Some researchers feel that some specific AEDs may do so. Most observations however, support an effect of seizures or interictal (abnormal electric brain discharges not strong enough to express themselves as a seizure) discharges on the reproductive system causing less ovulation and thus reduced fertility. Women with epilepsy have only one quarter to one third of the number of expected live births. Thus one would expect a woman with epilepsy to have one quarter to one third the chance of pregnancy as a woman without epilepsy.

I have been seizure-free for eight years, and just a few months ago my neurologist took me off of my medication. (I was on Trileptal 600 mg/day). Two weeks ago, I found out I was pregnant (unplanned, and I have three other children that were born before my seizure disorder started.) A few days ago I woke up in the middle of the night to my husband telling me I just had a grand mal. I called the doctor and he said it would be best to start taking my Trileptal again, at the same dosage. Is this the best medicine I could be on during pregnancy? He said it was okay since I wasn't taking a high dosage. What else can I do to ensure I don't have any problems? I haven't seen my OB/GYN yet, I have an appointment in two weeks. Thanks for your help. I just started taking 800 mcg of folic acid daily and am also taking an over-the-counter prenatal vitamin that has 800 mcg of folic acid in it.

A generalized tonic-clonic seizure increases the risk of miscarriage and developmental delay in the fetus. It is therefore a good idea to take a medication to prevent seizures. Since Trileptal (oxcarbazepine), has worked for you in the past it is a sensible medication to try now. Having already conceived and in the first trimester (the period in which the fetus is vulnerable to malformations) the horse is all ready out of the barn.

AEDs increase the risk but do not necessarily cause birth defects. Most children exposed to these medications in utero are normal. It would have been better to have started the folic acid before conception. This is why the national Centers for Disease Control and Prevention recommend that all women of childbearing age take at least 0.4 mg. of folic acid a day. You should take AED at the proper dose to prevent seizures and medication side effects. You should also take folic acid and should gain an appropriate amount of weight.

Consult with your neurologist and gynecologist. Obtain an anatomic ultrasound at 12 and 16 weeks of gestation. Good luck!

I am pregnant and taking Lamictal. My question is can I breast feed while on this medication?

Yes, you can breast feed. A term infant has been exposed to the AED for 9 months and can metabolize the medication as well as an adult, and there is generally less medication in the breast milk than in the mother's plasma.