Pregnancy and Epilepsy Medications
Studies which are being conducted in the area of pregnancy and epilepsy have helped to establish some guidelines for women with epilepsy. Many questions remain unanswered, however, and this is why continued research is so important.
Generally speaking, having epilepsy should not prevent a woman from planning a family but planning ahead is important. Over 90 percent of the babies born to women with epilepsy are normal and healthy. This percentage is even higher if the pregnancy is planned in advance with the consultation of a neurologist, any necessary adjustments are made to the anticonvulsants and supplemental folic acid is begun prior to conception, and the woman receives early and ongoing prenatal care.
American women who take anticonvulsant medications face difficult choices between their medical need for treatment and the potential risks associated with the drugs during pregnancy. In the vast majority of cases, the risk of seizures outweighs the risks of the medications. Most women do not have the luxury of stopping medications during pregnancy without seizure recurrence. A recent rigorous review of the literature, outlined in the AAN Updated Practice Parameter Statements on Pregnancy in Women with Epilepsy, is very encouraging that the risks can be minimized, especially by considering recent findings of differential risks between medications. There are several relatively safe options for anticonvulsant medications during pregnancy, and more is known about how to adjust them during pregnancy for the healthiest outcome for both the mother and the newborn.
Anticonvulsant drugs were originally developed to treat epilepsy but are now used for many other medical conditions. More than a million American women with epilepsy take anticonvulsant drugs to prevent seizures. Millions more may at some point take them to treat chronic medical problems affecting the central nervous system, including migraine, severe pain caused by damaged nerves (neuropathic pain), and bipolar and associated mood disorders.
While the vast majority of women who become pregnant while taking these medications deliver healthy babies, new research is showing that some anticonvulsants increase the risk of major malformations (including heart, spinal cord and cleft lip/cleft palate abnormalities) and cognitive problems in children exposed to them during the mother's pregnancy.
In general, studies of these medications have focused on the 'older' drugs (that is, those approved prior to 1980) such as carbamazepine, phenobarbital, phenytoin, primidone and valproate, and we now have good information on one of the "newer" drugs, lamotrigine. A convergence of data from multiple recent studies demonstrate an increased risk for valproate to the unborn child and suggest that valproate is not the best first choice for women of childbearing age; however, when no other anticonvulsants work to control an individual's seizures or other neuropsychiatric illness, then the risk may be reduced by limiting the dose during pregnancy. Guidelines just developed by the American Academy of Neurology and the American Epilepsy Society recommend that women with epilepsy avoid taking valproate during pregnancy and avoid taking more than one epilepsy drug at a time (polytherapy) during pregnancy if possible. Valproate use, and to a lesser extent polytherapy use, have been linked to an increased risk for birth defects and an increased risk for developmental delay in the children after exposure during pregnancy. However, it is extremely important that women taking any antiepilepsy drug should not discontinue the drug on their own, but should consult with their doctor if they are, or may become, pregnant.
Very little is known about the long term or pregnancy-related effects of most of the anticonvulsants approved within the past 15 years. The Epilepsy Foundation is calling for more research on pregnancy and long term effects of all the newer drugs. In addition to its recommendation that women who take anticonvulsants and become pregnant enroll in the North American Pregnancy Registry, the Epilepsy Foundation is urging women to increase their chances of a successful pregnancy and long term health by taking the following actions
- Work with doctors on the best choice of medication before you become pregnant
- Review anticonvulsant risks and benefits with your health care providers
- Discuss medicine changes before pregnancy begins
- Take folic acid and vitamin supplementation before and during pregnancy
- Have your medication levels monitored during pregnancy
- Avoid stopping an anticonvulsant abruptly
- Explore ways of preventing other negative effects on quality of life
- Keep current on emerging research