April 2024

NEUROSCIENCES

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

Featuring: Elizabeth Gerard, 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). 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.
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There do not appear to be any differences in pregnancy rates, time to conceive, or pregnancy outcomes in people with epilepsy compared to the general population. However, proper planning and care is key, as it can take three to 12 months to switch or adjust anti-seizure medication (ASM) if the patient is taking a medication with a higher level of teratogenic or neurodevelopmental risk.

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, don’t try to switch your patient’s medication unless they’re taking a high-risk medication during pregnancy, such as valproic acid.

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 adverse neurodevelopmental outcomes. 
  • Levetiracetam also carries a low risk.
  • The data on carbamazepine are mixed but generally suggest a low risk.
  • Topiramate should be avoided due to small for gestation age (SGA) risk.  
  • The data on valproic acid suggests highly elevated risk, especially for neurodevelopmental issues.

​Is there a higher risk of having seizures during pregnancy?

When a patient has regular epilepsy care and medication checks, 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 addition, if regular care is in place, the patient’s seizure frequency should not increase during pregnancy.

Pregnant patients with epilepsy had much more frequent medication adjustments than non-pregnant patients with epilepsy. These adjustments help ensure seizure control. However, after delivery, the patient will need to be placed on an ASM tapering plan.

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: A fetal echo is likely unnecessary unless the fetal anatomy ultrasound raises a concern. However, some OB-GYNs 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). Between 34 and 36 weeks, consider a consultation with obstetrical anesthesia where available.
  • 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. 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: Work with your patient to establish a plan that includes at-home sleeping arrangements and shifts with other caregivers. The goal is to ensure the patient receives at least one uninterrupted four-hour stretch of sleep at night and an additional two hours of naps during the day to reduce the risk of seizures.
How can you help your epilepsy patients plan for labor and delivery?
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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. 

After delivery, patients should soon resume their contraception to prevent unintended pregnancies. It is important to discuss the significance of planning for pregnancy with your patient during their childbearing years. The use of enzyme-inducing ASMs is associated with a higher risk of unplanned pregnancies as they can reduce the effectiveness of hormonal contraception methods (for example, pill, vaginal ring, Depo-Provera injection, etonogestral/progesterone implant and patch).

What should your epilepsy patients know about breastfeeding?

Research supports that breastfeeding is safe for patients who take ASM medications while they breastfeed as long as they taper their ASMs accordingly after delivery. Parents with epilepsy may feel nervous about breastfeeding while taking ASMs. However, infants are exposed to only a fraction of medication during breastfeeding than they are in utero, and there is little evidence to suggest that ASM exposure from breastmilk has clinical effects on

Tools and Resources

Epilepsy and Pregnancy Appointment Calendar
Anti-seizure Medication Tapering Schedule
Anti-seizure Medications and Birth Control Effectiveness
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Elizabeth E. Gerard, MD, Associate Professor of Epilepsy and Clinical Neurophysiology
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