Epilepsy is a serious neurological condition characterized by seizures that can range in severity from mere headaches to fainting and convulsions. Epilepsy presents many challenges for the estimated 1 percent of Americans (about 2 million people) who suffer from it—and epilepsy and pregnancy together can be an especially difficult journey to navigate.
The good news is that women with epilepsy account for only about 0.5 percent of all pregnancies, and more than 95 percent of epileptic pregnant women deliver healthy babies. In this article we will explore the risks and possible complications associated with epilepsy and pregnancy.
Epilepsy and Conception
The effect of epilepsy on women who are attempting to conceive is mixed: on one hand, many of the medications used to treat and control epilepsy can contribute to fertility problems. On the other hand, many of those same medications can sometimes reduce the effectiveness of hormonal birth control methods. If you are attempting to become pregnant, you should make sure your ob-gyn and any fertility specialists you may be seeing are aware that you are taking anti-epileptic drugs (AEDs).
Epilepsy itself can cause problems for women who are attempting to conceive—the condition can lead to occasional sexual dysfunction or abnormal menstrual cycles.
Prior to Becoming Pregnant
Folic acid supplementation (0.4 to 0.8 mg daily) is recommended for all women of child bearing potential to minimize the risk of neural tube defects. Published clinical guidelines regarding the dose of folate supplementation in women with epilepsy vary and are not definitive. The American College of Obstetricians and Gynecologists recommends 4.0 mg (4 mg not 0.4) of folic acid daily for women at risk of having offspring with neural tube defects, including women taking AEDs. The higher dose of folic acid has not been associated with adverse effects.
If you are planning to become pregnant, your choice of seizure-control medication is extremely important. If possible, valproate should be avoided during pregnancy due to an increased risk of birth defects such as spina bifida and autism (see below).
The Effect of Pregnancy on Epilepsy
Every case of epilepsy and pregnancy is different because the effect of pregnancy on epilepsy varies from one woman to the next. Some women see no change in their conditions, and others will see a decrease in the frequency of seizures. However, 25 to 40 percent of epileptic women have more frequent seizures during pregnancy, especially if they already tend to have frequent seizures. One possible reason for this is that a pregnant woman’s body responds differently to many of the medications used to treat epilepsy, and some medications may not be absorbed as well or may be less effective. Morning sickness can also play a role by causing a woman to vomit up her medication before it has taken effect.
Problems associated with epilepsy and pregnancy are often hormone-related. Estrogen, in particular, increases electrical activity in the brain, and progesterone has the opposite effect.
Risks of Epilepsy and Pregnancy
One important risk of epilepsy and pregnancy is that the expectant mother may have a seizure and injure herself and/or the baby. Other risks are specific to either the mother or the baby:
- For the Mother
While many epileptic women would say their greatest fear is that they might have a seizure while in labor, only about 2 percent of pregnant women with epilepsy have seizures during labor or delivery, although seizures are somewhat more likely to occur within the days following childbirth due to hormonal changes and sleep deprivation.
- For the Baby
There is in some cases a small risk that a seizure suffered by the mother can result in oxygen deprivation that can harm the baby. This is rare, however; most risks to the baby stem from anticonvulsive drugs the mother may be taking to manage her condition.
The risks to the baby posed by anti-epileptic drugs (AEDs) during pregnancy must be weighed against the risks associated with epileptic seizures during pregnancy (especially grand mal seizures). These risks include possible slowing of the fetal heart rate, placental abruption (this is when the placenta separates from the uterus), low birth weight, pregnancy-induced hypertension (high blood pressure), miscarriage, premature birth, and stillbirth.
While epileptic seizures during pregnancy are undesirable, there are risks associated with certain AEDs as well; these risks include autism and cognitive difficulties. The children of women who took the AED known as sodium valproate (Depakote) while pregnant were three times more likely to suffer from autism, and 30–40 percent of women taking sodium valproate give birth to babies who suffer some form of cognitive impairment or intellectual disability. Furthermore, 11 percent of babies born to women using sodium valproate had physiological deformities.
Fetal anti-convulsant syndrome (FACS) can sometimes occur in a child if the mother takes AEDs during pregnancy. This condition is characterized by slower development of speech and language skills, and by difficulty with attention and memory.
Despite the risks associated with AEDs, epilepsy, and pregnancy, you should never reduce the dosage of your medication without your doctor’s express orders, and you absolutely must not stop taking your medication suddenly. Your doctor (or doctors) will tell you what steps must be taken regarding your medications. These steps may involve changing your dosage or switching to a different medication, but only your doctor is qualified to decide what should be done.
Finally, if you have epilepsy and are planning to become pregnant, you should be aware of the role genetics plays in this condition. Epilepsy is sometimes caused by brain injury, but it is sometimes genetic, and can be inherited. The risk that you might pass your condition on to your offspring is small, however—the incidence of epilepsy in the general population is less than 2 percent. Even if you have epilepsy but the father does not, the risk is still less than 5 percent, and it is only slightly higher if you both have epilepsy.
Managing Epilepsy and Pregnancy
Better management of epilepsy before pregnancy can improve the experience of pregnancy: a 2006 study by the International Registry of Antiepileptic Drugs and Pregnancy (EURAP) found that women who had gone more than twelve months without a seizure enjoyed a 50–70 percent reduction in seizure risk while pregnant. You should also keep in mind that your primary doctor and your neurologist are more familiar with the specifics of your particular condition than the obstetrician who is monitoring your pregnancy, so make sure all your doctors are in communication with one another.
Anticonvulsants can affect the levels of folic acid and vitamin K in your body, so your doctor may advise you to take prenatal vitamins. AEDs also affect the manner in which your body uses folic acid. Folic acid is extremely important during pregnancy, and a lack of it can cause such problems as neural tube defects and spinal bifida. Babies whose mothers take AEDs during pregnancy have a 4–6 percent chance of birth defects, compared to the 2–3 percent risk for the population as a whole. In addition to those listed elsewhere in this article, birth defects that can result from AEDs include cleft lip and various heart abnormalities. The risk is higher if the mother takes multiple forms of AED. Again, although these risks may sound frightening, consult your doctor before making any changes in your medication regimen.
Your doctor may advise you to take at least 5 mg of folic acid per day, but you should consult him or her before beginning to take any over-the-counter supplements, as folic acid can interact with certain anticonvulsant medications, hampering their effectiveness and increasing the chances that you will have a seizure.
Vitamin K is important for blood clotting, and AEDs affect the levels of vitamin K in your body. Deficiencies in vitamin K can lead to hemorrhagic (bleeding) disease in the baby. Most physicians recommend oral administration of Vitamin K1 (10 to 20 mg/day) during the last month of pregnancy to women treated with AEDs to protect the child against severe postnatal bleeding due to a deficiency in vitamin K-dependent clotting factors.
Don’t forget to continue taking your medication as directed after the baby is born. Your sleep-deprived “new mom” brain may make it difficult for you to remember, so enlist your spouse or another family member to help you with this. In order to reduce the risk of accident-related injury, change your baby’s diapers on the floor, not on a table, and have someone help you bathe the child.
Epilepsy and Breastfeeding
Surprisingly, breastfeeding is highly recommended for new mothers who have epilepsy. For one thing, the benefits generally outweigh whatever risks there may be. Also, your baby will have been exposed in utero to any medication you’ve been taking, so breastfeeding may be a good way to wean your baby from these drugs and minimize possible withdrawal symptoms. Again, always follow your doctor’s advice; it may be better for mothers who take levetiracetam or lamotrigine not to breastfeed.
Labor and Epilepsy
As noted above, seizures during childbirth are rare. If you do suffer a seizure during labor or childbirth, your doctor may decide to deliver the baby via C-section. All the same methods of pain control that would be used on any other patient are perfectly safe for you, although some doctors may recommend epidural.
Individuals with epilepsy have an increased prevalence of depression compared with individuals without epilepsy, and this appears to be true during pregnancy and the postpartum period as well. In one study of 706 pregnancies in women with epilepsy, peripartum depression affected 27 percent of women with epilepsy compared with 19 percent of the non-epilepsy population. Risk factors for depression included high seizure frequency, antiepileptic drug use, and pre-pregnancy depression or anxiety.
The Antiepileptic Drug Pregnancy Registry (Toll-free: 888-233-2334; online at https://www.aedpregnancyregistry.org/) is a North American registry for pregnant women who are taking any AED. The registry’s purpose is to collect data to assess the fetal risk from AEDs and to provide information about pregnancy issues to patients with epilepsy and their physicians.