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Pregnancy

Approximately 1,000,000 women of childbearing age in the United States suffer from epilepsy. Complications arise during conception and pregnancy that involve the choice and use of medication, dosing schedules, and seizure management. These complications have social as well as medical ramifications for pregnant women and their families.

During pregnancy, factors such as antiepileptic drug (AED) treatment, hormonal changes, and vitamin deficiency can influence seizure patterns, even for women who have had excellent seizure control in the past.

These complications combined with genetic factors also lead to a greater risk for major and minor birth defects for babies born to epileptic mothers. Although this risk is not typically significant enough for neurologists and epileptologists (epilepsy specialists) to advise their patients against pregnancy, health care specialists advocate a conscientious and careful pregnancy for all prospective mothers who suffer, or have suffered, from epilepsy.

Incidence
For most epileptic women, seizure frequency remains unchanged during pregnancy. However, approximately 20% will experience an increase in seizure frequency during pregnancy. And some women experience seizures only during birth.

The physiological changes that may play a role in the increased incidence of seizures for some women include changes in hormone production, metabolism, stress, and alteration in sleeping patterns.

Hormones such as estrogen and progesterone increase naturally and steadily during normal pregnancy. Estrogen has been shown to be epileptogenic (increases seizure activity) for epileptics, while progesterone is thought to have an antiseizure effect. Fluctuations in the levels of these hormones can make it more difficult for epileptic mothers to predict and control their seizures.

Generally, sleep deprivation influences seizure frequency for those who suffer from epilepsy. A significant increase in seizure occurrence may result during pregnancy when sleep patterns change. Stress, and the associated changes in eating and sleeping habits, may also contribute to an increase in seizures in some cases.

AEDs like phenobarbital, valporate (Depakene®), and carbamazepine (Tegretol®) are used to treat epilepsy. In most cases, the level of AEDs in the blood decreases during pregnancy, despite adherence to the proper dosage. For many women, this does not translate into an increased seizure frequency. However, in most cases, where seizures are seen to increase, the levels of AED in the blood are found to be lower than the recommended therapeutic range. It is therefore very important to monitor levels closely during pregnancy and to adhere to a physician-prescribed treatment.

Should I Continue AED Medication While Pregnant?
Many women are concerned about the effects of AED therapy on the health of their developing fetus. Although many medications, including antiepileptic drugs, have teratogenetic potential (causing abnormal embryo development), most women continue to need treatment to prevent seizures during this period of time. In order to maintain optimum seizure control and minimize risk to the fetus, women should educate themselves about medication and pregnancy prior to conception.

It is necessary for women who are treated with AEDs to continue medication when they learn they are pregnant. A physician may decide to discontinue drug therapy if a patient has not experienced seizures for several months. But this decision should be made at the discretion of the physician only. Often, patients who are not having seizures wrongly decide on their own to minimize dosage or to discontinue taking their medication entirely. This is unsafe because seizures can adversely affect a developing baby by decreasing vital oxygen or blood supply to the womb. Changes in treatment can immediately alter the balance of medication in the body, which could lead to sudden changes in condition, especially when pregnancy is involved.

For example, a period known as status epilepticus may occur, during which a series of seizures can result in intermittent consciousness or an indefinite period of unconsciousness. Considering that epilepsy symptoms can include collapse during loss of consciousness, the risk to a mother and a developing baby is high. So negligent discontinuation of medication is perhaps less safe than continuing medication until counseling and re-evaluation can begin. The reality is that epileptic women find themselves in a double bind concerning pregnancy. On one hand, it is broadly known that taking various medications while pregnant poses certain risks to the fetus. However, for women with epilepsy, it is usually necessary to take this otherwise avoidable risk, because discontinuing medication might result in uncontrollable symptoms and permanent damage to both mother and child.

In fact, while it is generally understood that medication is necessary for epileptics to function safely in life, complications that can affect fetal development deter many epileptic mothers from conceiving.

Risks for Mother and Child

It is generally thought that women with epilepsy have at least a 90% chance of having a normal, healthy baby. All women have roughly a 2% to 3% chance of giving birth to a baby with some type of malformation. Although the exact causes for an increased incidence of abnormality are not fully known, a number of factors are thought to increase congenital malformations in the children of women with epilepsy.

These factors include genetic predisposition, seizures that occur during pregnancy, and the effects of AEDs. It is estimated that mothers with epilepsy have approximately twice the risk of having a baby born with a malformation than women in the general population, an approximately 4% to 6% risk.

The most common malformations include neural tube defects such as spinal bifida (characterized by the protrusion of spinal cord membranes through abnormal gaps between vertebrae), cleft palate, cleft lip, and congenital defects that affect the heart.

Some minor abnormalities, including developmental delay, speech abnormalities, widened eye set, flattened nasal bridge, small fingernails, and other structural features have also been described in association with AED treatment. These minor abnormalities have no long-term medical ramifications. Also, fertility rates (giving birth to live offspring) are lower in persons with epilepsy. This may be related partially to hormonal changes and menstrual irregularities associated with the disease.

For many years, researchers of epilepsy have hypothesized that a main mechanism of abnormal fetal development is an AED-based folate disturbance. Folate (folic acid, a B vitamin) is an important component in many chemical reactions in the body. It is necessary in the transfer of carbon, which is used to make the amino acids that form proteins in the body. Many AEDs can decrease the level of folate in the blood, which might lead to metabolic dysfunction, abnormal fetal developmental, and malformations.

More Medications, More Risk Involved
Other evidence also suggests that the risk of giving birth to a child with major malformations increases with the number of medications used simultaneously to treat seizure disorders, including epilepsy. The extent to which AED combination influences such a risk is not specifically known at this time. Epilepsy patients, whether pregnant or not, are usually treated with as few medications as possible. Combinations of Tridione® and Paradione®, as well as those drugs mentioned above, are thought to cause more frequent and extensive congenital birth defects.

Some of these drugs are being prescribed less and less by physicians because of their association with such defects. Also, AED use is restricted for patients who have a family history of neural tube defects. Again, pregnant women should consult with their physician prior to adjusting dosage of any or all AEDs.

Management
In addition to the traditional means of promoting healthy pregnancy, such as proper nutrition, exercise, good sleep, and substance avoidance, there is a disease-specific regimen often prescribed to mothers afflicted with epilepsy.

Early planning, management, and education is especially essential for all women of childbearing age who suffer from epilepsy. It is best if prior to conception, when pregnancy is being planned, that a woman see her physician, and that a full evaluation is performed. A thorough neurological exam is necessary to teach women all the major issues of potential concern. Women might consider involving an epileptologist or a neurologist who has experience treating issues and complications surrounding pregnancy, as well as an obstetrician. Ultimately, an epileptic woman must have the right to make an educated decision regarding conception. Indeed, the risks often deter couples from having children. However, should an epileptic woman decide to conceive a child, she can utilize several management strategies to reduce the risk of abnormal pregnancy and birth.

For example, a major component to healthy pregnancy for sufferers of epilepsy is multivitamin therapy with folate (folic acid). Research has indicated that the use of folate can help minimize the risk of some of the major congenital malformations, specifically those involving the spinal cord.

Even women with a seizure disorder who are not using AEDs (which diminish folic acid levels) during pregnancy should take daily folate supplements. In fact, it is suggested that women should begin folic acid supplementation before conception. Specialists recommend that a minimal dose of 2 mg a day is sufficient to maintain proper folate balance before and during pregnancy.

Compliance with medication is essential. Many clinicians also believe that even before becoming pregnant, if at all possible, women should switch to monotherapy (treatment with just one AED). Doing so, and using the lowest possible dose, can help minimize risks. Again, seizures can potentially affect a developing baby by decreasing oxygen or blood supply to the womb. So the decision to reduce dosage should only be made at the discretion of a physician who understands the biological and physiological patterns of epilepsy.

Many clinicians suggest a thorough ultrasonography examination at 16-18 weeks of gestation. This exam, which produces internal sonographic photos of the fetus, can help rule out spina bifida, limb abnormalities, and heart abnormalities. Amniocentesis, with testing for alpha-fetoprotein (a protein that is elevated in spina bifida), is often suggested for epileptic mothers.

Furthermore, an increase in vaginal hemorrhaging, early labor, and eclampsia (toxemia of pregnancy with postpartum convulsions) has been reported in epilepsy-related pregnancies.

Postpartum Management, Effects, and Incidence
Treatment for epileptic mothers does not stop after birth. Careful monitoring of AED levels should be performed throughout pregnancy and after delivery postpartum. The risk of seizure while attending to a newborn is significant enough for most epileptic parents to create alternative ways of care. For example, parents are often advised to change and feed their babies while sitting in secure, protective areas. Continued medication after pregnancy is especially important, as the effects of proper care now influence a baby who requires it.

Also, there is a chance that a baby born to a woman who has been treated with AEDs will be affected by the medication. Sometimes, newborns experience sedation as well as withdrawal symptoms for the first few weeks of life. Although alarming, these symptoms are usually temporary. They pose no significant medical problem, unless they prohibit the baby from eating properly.

Does AED Treatment Affect Breastfeeding?
Antiepileptic drugs do show up in fairly low levels in breast milk, some higher than others, but pose no serious health threat to a nursing baby. However, physicians often advise caution for mothers who have been treated with certain AEDs that tend to remain at higher levels in breast milk. Generally, mothers with epilepsy can expect to breastfeed their babies without complication, though counseling with an obstetrician is advised.

What Are the Chances that My Baby Will Have Epilepsy?
Because the causes for most types of seizure disorder are varied, the occurrence of epilepsy in children born to epileptic parents varies. Children whose mothers have epilepsy have about a 3% chance of getting the disease. If just the father is affected by epilepsy, the risk is the same as it is for anyone in the general public. If both parents are epileptic, the risk rises to approximately 5%.

Often, those who suffer from epilepsy gain an advanced knowledge of their disease as a result of planning a pregnancy. Certainly, preconception planning is just as important as the 9 months that follow. With the assistance of a physician, women with epilepsy can experience a healthy pregnancy and childbirth.

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