Epilepsy in pregnancy

Epilepsy is the most common neurologic disorder that requires continuous treatment during pregnancy, and AEDs are one of the most frequent chronic teratogen exposures. Approximately one-half million women with epilepsy are of childbearing age in the United States, and 3 to 5 births per1000 will be to women with epilepsy . However, it is estimated that the total number of children in the United States exposed in utero to AEDs is substantially greater with the emergence of AED use for other illnesses including headache, chronic pain, and mood disorders. Women with epilepsy were once counseled to avoid pregnancy, but epilepsy is no longer considered a contraindication to pregnancy. While over 90 percent of women with epilepsy will have good outcomes, they are at increased risk for a range of perinatal complications compared with the general population, including preeclampsia, hemorrhage, fetal growth restriction, stillbirth, and maternal mortality . With a few exceptions, the approach to the diagnosis and management of a first seizure in pregnancy is the same as in a nonpregnant individual. During pregnancy and the intrapartum period, women are more likely to be exposed to potential seizure triggers and may have an increase in seizure occurrence. Common triggers include sleep deprivation and increased emotional stress, as well as nausea and vomiting affecting medication levels. If seizures occur for the first time during the last 20 weeks of pregnancy, eclampsia needs to be excluded. Treatment with AEDs should be optimized before conception, with the objective to use monotherapy at the lowest effective dosage. Select the AED that is most likely to control seizures (i.e. the appropriate first-line drug for seizure type and epilepsy syndrome). Status epilepticus occurs in less than 1% of all pregnancies of women with epilepsy and does not seem to occur more frequently during pregnancy than in other periods of life. Lamotrigine has a reasonable documentation concerning pregnancy outcomes, but the pronounced pharmacokinetic alterations during pregnancy can result in breakthrough seizures. Levetiracetam appears slightly less problematic in this respect . There is an increased risk of major congenital malformations in fetuses exposed to AEDs. The reported risk of major congenital malformations with maternal AED use is 4 to 6 percent, compared with a population estimate of 2 to 3 percent .Across all pregnancy registries, valproate monotherapy is associated with the highest rates of major malformations. Phenytoin and phenobarbital have also been associated with relatively high baseline rates of major malformations.