Epilepsy And Pregnancy: How To Manage The Risks

There are approximately 1.1 million women of childbearing age living with epilepsy in the United States. If you fall into this demographic or have a partner or daughter who does, it is important to understand how epilepsy might influence pregnancy and how pregnancy might affect epilepsy.¹

The importance of the right contraception

Before we look at the risks of epilepsy during pregnancy, let’s talk about contraception. Not all pregnancies are planned. In fact, over half the pregnancies in women with epilepsy in the US are unplanned.

Not all anti-epileptic drugs are safe to use during pregnancy. When an unplanned pregnancy occurs, it’s possible that certain anti-epileptic drugs can harm a fetus before a woman discovers she is pregnant.

Ideally, before falling pregnant, you should:

• Be taking anti-epileptic drugs with the lowest teratogenic risk (drugs with the lowest risk of causing developmental malformations in your baby)

• Have optimized seizure control for at least a year

• Be taking a folate supplement

Anti-epileptic drugs can also interact with hormonal contraception, specifically oral contraception, making it less effective.

It is for this reason that the World Health Organization has recommended that women with epilepsy intrauterine contraceptive devices instead of oral contraception as these have proved to be the most reliable.²

Pregnancy and seizures

Pregnancy involves physiological, hormonal, and psychological changes that can increase seizures.

For example, physiological changes during pregnancy can alter the pharmacokinetics (how your body absorbs, distributes, and excretes drugs) of some anti-epileptic medications, potentially changing their efficacy.

Hormonal changes, sleep deprivation, and stress can also play a role in lowering the seizure threshold. Complications from pregnancy, such as having bad morning sickness, can also affect the swallowing of anti-epileptic medication, so the timing of medications may need to be adjusted.

Seizure frequency

Research suggests that seizure frequency one year before pregnancy is a good indicator of seizure frequency during pregnancy. Women who experienced seizures during the year before becoming pregnant are three to four times more likely to experience seizures during pregnancy than those women whose seizures were fully controlled in the year leading up to the pregnancy.³

The type of seizures you experience also seems to affect seizure frequency. The seizure freedom rate in pregnancy is higher in women with generalized seizures (all parts of the brain are affected) than in those with focal epilepsy (certain parts of the brain are affected).

Impact of seizures

Seizures can pose a risk to both the mother and her fetus. Many types of seizures (particularly those that involve a loss of consciousness) can result in accidents that cause trauma, increasing the risk of infection, early labor, and placental tearing.

Tonic-clonic seizures (involving both stiffening and jerking of muscles) have been shown to slow the fetal heart rate for more than 20 minutes, and repetitive tonic-clonic seizures can trigger maternal and fetal oxygen starvation, miscarriages, and stillbirths.

Risks related to anti-epileptic drugs

As is the case with all medications, anti-epileptic drugs come with risks and potential side effects. Fetal exposure to certain anti-epileptic drugs can increase the risk of major birth defects such as microcephaly (a condition in which the baby’s brain doesn’t develop as normal, resulting in a much smaller head), growth retardation, and lumbosacral spina bifida.

However, not all anti-epileptic drugs carry the same risks.

Based on existing research:⁴

• Levetiracetam and lamotrigine appear to carry the lowest risk of major birth defects and have the safest profile with regard to neonatal and neurodevelopmental outcomes.

• Valproate, which has been associated with high rates of major birth defects, a detrimental impact on neurodevelopment, and an increased risk of autism, should be avoided during pregnancy if possible.

• Topiramate should be used cautiously as it has also been associated with an increased risk for major birth defects and fetal growth restriction.

Is folic acid supplementation helpful?

In the general population, folate deficiencies have been associated with fetal neural tube defects, which affect the development of the brain and spinal cord, so all pregnant women are advised to take a folic acid supplement.

A recent study found an association between preconception folate supplementation and higher intelligence quotient at the ages of three and six for children of women with epilepsy.

While it is not yet clear if women with epilepsy should take higher doses of folic acid than women in the general population, and if so, the exact dose that should be taken, current guidelines recommend higher folic acid supplementation for the preconception phase and pregnancy in all women.

Risks related to childbirth

If you are already pregnant, you might worry about the extra risks women with epilepsy face during childbirth. What if a seizure happens while you’re in labor?

This is a common concern, and some obstetricians favor a planned cesarean section to reduce this risk. Women with epilepsy are more likely than women without epilepsy to have a cesarean section.

Women with epilepsy — particularly those taking anti-epileptic drugs — are at higher risk of delivery complications and, as such, should be monitored carefully during childbirth.

Taking anti-epileptic drugs also increases the risk that your newborn baby will experience perinatal complications and might need to be admitted to the neonatal care unit. It is important to be mentally prepared for this possibility and to ensure that the facility where you give birth has a good neonatal care unit.

Epilepsy and breastfeeding

For women without epilepsy, exclusive breastfeeding for the first six months of life is encouraged globally because of the benefits for both the mother and child. Breastfeeding lowers the risk of infections, decreases infant mortality, and has neurodevelopmental advantages.

Some women with epilepsy choose not to breastfeed their babies because of concerns about the presence of anti-epileptic drugs in maternal milk and the adverse effects these drugs might have on their babies.

However, the benefits of breastfeeding need to be weighed against the risk of adverse effects. A study in Norway found that infants exposed to antiepileptic drugs during pregnancy and via breastfeeding had better neurodevelopmental outcomes at 18 months than the infants of women with epilepsy who were not breastfed.

Another concern regarding breastfeeding in women with epilepsy is that it interrupts maternal sleep. Lack of adequate sleep increases the risk of seizures. For this reason, some women with epilepsy choose to supplement breastfeeding with one or two bottles of formula (given to the infant by another caregiver) to allow for more sustained sleep.

The lowdown 

When you live with epilepsy, discovering that you are pregnant or contemplating starting a family can be scary. Women with epilepsy face more risks when pregnant, and anti-epileptic drugs can adversely affect your baby's development.

However, it is important to remember that these risks can be managed. With the right planning and a good medical team, you can have a happy and healthy pregnancy!