April 2024

NEUROSCIENCES

Q&A WITH ELIZABETH GERARD, MD: GUIDING YOUR PATIENTS WITH EPILEPSY THROUGH PREGNANCY

Featuring: Elizabeth Gerard, MD, and ​Alexa King, MD

​Elizabeth Gerard, MD, associate professor of Epilepsy and Clinical Neurophysiology at Northwestern Medicine, Neurology, is a supporting clinical expert of the Epilepsy & Pregnancy Medical Consortium (EPMC). Dr. Gerard, with support from Alexa King, MD, leads the Women With Epilepsy Program at Northwestern Medicine. In this Q&A, Dr. Gerard addresses questions about caring for pregnant patients with epilepsy.

Is it safe for your patients with epilepsy to get pregnant?

Women with epilepsy can have safe, healthy pregnancies. However, proper planning and care is essential. The goal of planning is to minimize the risk of congenital malformations or adverse neurocognitive outcomes for the fetus while maintaining seizure control for the patient.

What are your recommendations for managing ASMs when your patient is planning for pregnancy?

When switching or adjusting the dosages of ASMs, physicians should aim to identify the lowest effective ASM dosage that will pose the least risk to the fetus while maintaining the patient’s seizure control. 

I recommend switching medications well before the patient becomes pregnant to establish the efficacy of the ASM regimen at the lowest dose possible for them. The risks of exposing a fetus to ASMs may increase at higher doses of many ASMs. Advanced planning helps avoid fetal exposure to multiple medications and helps reduce the risk of seizures.

For unplanned pregnancies, I typically do not change a patients’ medications at the beginning of pregnancy. This may expose the pregnancy to additional risks including seizures. In exceptional cases, changing to a higher risk medication such as valproic acid can be considered. 

What risks are associated with ASMs for pregnant epilepsy patients?  ​

Risks associated with ASMs vary for pregnant epilepsy patients.
  • Lamotrigine exposure appears to carry a relatively low risk of fetal structural abnormalities and adverse neurodevelopmental outcomes.
  • Levetiracetam also carries a low risk of fetal structural abnormalities and adverse neurodevelopmental outcomes.
  • The data on valproic acid suggests highly elevated risk for fetal structural abnormalities and adverse neurodevelopmental outcomes.
  • Topiramate exposure is associated with an increased risk for small for gestation age (SGA).  
 
Click here for the latest guidelines on the risks related to various seizure medications in pregnancy.
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​Is there a higher risk of having seizures during pregnancy?

If appropriate care is in place, the patient’s seizure frequency should not increase during pregnancy. There is no indication of higher seizure rates in pregnant patients when compared to patients who aren’t pregnant, according to the Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs (MONEAD) study. In this study, however, pregnant patients with epilepsy had much more frequent medication adjustments than non-pregnant patients with epilepsy. These adjustments help ensure seizure control.

Physicians should establish care with the patient and inform the other members of the patient’s care team (such as OB-GYNs and neurologists) as soon as pregnancy is confirmed.

What are key appointments and ultrasounds for pregnant epilepsy patients?
​
  • Every four weeks: Perform ASM blood level checks at a time and location that allows consistency for the patient. 
  • At 18 to 20 weeks:  Perform a complex and comprehensive evaluation of fetal anatomy ultrasound that emphasizes cardiac views. Smaller clinics may need to refer out so the patient can access this ultrasound. 
  • Fetal echo:  Some experts may recommend a fetal echo if the patient takes an ASM with a higher risk for cardiac malformations (for example, phenobarbital).
  • Third trimester: Consider one or more surveillance growth ultrasounds in the third trimester for all patients with epilepsy. There is a potentially higher risk for intrauterine growth restriction with some ASMs (notably topiramate and zonisamide, to a lesser extent).
  • Developing a postpartum ASM tapering plan: Most ASMs may require higher doses during pregnancy due to changes in drug clearance. However, patients should reduce these increased doses in the first few weeks after giving birth to prevent potential toxicity as the metabolism of these medications returns to normal. For most ASMs, the initial step is to hold at the delivery dose for 48 hours. After this period, a gradual tapering process should be implemented over the appropriate interval for the specific ASM, typically lasting three weeks. 
  • Developing a feeding plan: After delivery, the patient and the baby require care and support to ensure their health and safety. When establishing a feeding plan, patients should consider whether to breastfeed, formula feed or a combination of both. 
  • Developing a sleep plan: Sleep is important to maintaining seizure control. Work with your patient to establish a plan that includes at-home sleeping arrangements and shifts with other caregivers. 

How can you help your epilepsy patients plan for labor and delivery?
​
In patients whose epilepsy is well-managed, the risk of obstetric complications is no different from that of the general population. Physicians should create and share a plan for delivery logistics with all members of the care team and the patient’s loved ones. A controlled environment is important, so a hospital setting is the safest birth location for patients with epilepsy.

The delivery plan should address:
  • Preparation for:
    • Potential seizure (consult with neurology, have rescue medication at the bedside.)
    • C-section (Note: Epilepsy alone is not an indication for C-section. Unless there are obstetric indications for a C-section, pregnant patients with epilepsy can deliver vaginally.)
  • Prioritizing “sleep as medicine.” Epidurals can help the patient get enough sleep during labor.
  • Patients should bring their home medications to the hospital in the original medication bottles since hospitals may not have extended-release formulations (for example).
  • Postpartum tapering plan. Determine this during the second trimester and give it to the patient and the obstetrician. Do not wait until after delivery; it is not practical and risks toxicity in some cases.

What special considerations are there for postpartum care?

For patients on ASMs that were increased during pregnancy, reduce their dose in the first few weeks to avoid toxicity. To ensure a smooth transition, establish a postpartum tapering plan in the second trimester and share it with the patient and their obstetrician. 

What should your epilepsy patients know about breastfeeding?

There are clear benefits to breastfeeding for both mother and infant. Research supports that breastfeeding is safe for patients who take ASM medications while they breastfeed. For most seizure medications, infants’ blood levels while breastfeeding are much lower than that of their mothers. Studies have shown that infants exposed to seizure medications through breastmilk have normal cognitive outcomes. ​

Tools and Resources

Epilepsy and Pregnancy Appointment Calendar
Anti-seizure Medication Tapering Schedule
Anti-seizure Medications and Birth Control Effectiveness
​Teratogenesis, Perinatal, and Neurodevelopmental Outcomes After In Utero Exposure to Antiseizure Medication: Practice Guideline From the AAN, AES, and SMFM
​​
Elizabeth E. Gerard, MD, Associate Professor of Epilepsy and Clinical Neurophysiology at Northwestern Medicine
Alexa M. King, MD, Assistant Professor of Epilepsy and Clinical Neurophysiology at Northwestern Medicine

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