First Steps for Pregnancy Management Planning
Maintaining seizure control is always important for patients with epilepsy but is a crucial component of pregnancy care. The Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs (MONEAD) study showed that when a patient receives appropriate epilepsy care, there is no indication of increased seizure rates in pregnant patients versus those who were not pregnant.
However, pregnant patients will likely need more frequent medication adjustments than non-pregnant patients, underscoring the importance of frequent and proactive care appointments. Establish care with patients and inform the patient’s other providers (OB-GYNs, neurologists, etc.) as soon as pregnancy is confirmed.
If they are not already taking them, the patient should start on folic acid and prenatal vitamins as soon as possible. They should continue folic acid supplementation throughout their childbearing years, including during pregnancy, while breastfeeding, and between babies.
Topics covered on this page include:
Folic Acid & Pregnancy
All patients with epilepsy and childbearing potential should take at least 400-1000 mcg of folic acid daily (can be prescription, offered in the United States as tablets).
ASM Level Checks and Adjustments
Because clearance of several ASMs increases during gestation, therapeutic drug monitoring has an important role in controlling seizures during pregnancy. The degree to which ASM clearance changes varies from patient to patient.
If a pre-pregnancy ASM level is not available, obtain a level as soon as possible when pregnancy is suspected/confirmed. Target level should be at this level or slightly above (depending on the known pharmacokinetics in pregnancy). Level checks should then be obtained at four-week intervals. See ASM Level Checks for more information on performing level checks and resulting dosage adjustments.
Ideally, switching to an ASM with a lower risk of structural teratogenesis should not be attempted once a patient is already pregnant. This exposes the fetus to more than one medication and may increase the risk for seizures. See Switching ASMs for more information.
Timing of ASM Blood Levels
Given that OB visits are every four weeks (until increased frequency later in pregnancy), the OB clinic visit can often be a good time to coordinate care to get ASM blood levels. Ensure patients know that level checks need to occur at the same time of day each time and that these four-week blood checks are critical to their seizure control.
If a neurologist is involved in the patient’s care, the neurology practice is usually in charge of ordering and following ASM levels and increasing doses. However, all providers should be aware of the need for level monitoring.
Establishing Seizure Control
The MONEAD study demonstrated that seizure frequency was no more likely to increase in pregnant versus non-pregnant patients receiving appropriate care (e.g., ASM dosage adjustments during pregnancy). Pregnant patients with epilepsy had much more frequent medication adjustments than non-pregnant patients with epilepsy and these adjustments ensure seizure control.
At each prenatal visit, the OB clinicians should assess if the patient is having any increase in seizures, including:
NOTE: An increase in milder seizure types can often serve as a warning for the increased likelihood of convulsive seizures, which are important to avoid. The goal is to balance maternal seizure stability while avoiding over-exposing the developing fetus to higher levels of ASMs than necessary. See Seizure Control for more information on this topic.
Key Appointments and Ultrasounds
Every 4 Weeks
ASM blood level checks performed at a time and location that allows consistency for the patient.
At 18-20 Weeks
At this stage, a complex and comprehensive evaluation of fetal anatomy ultrasound emphasizing cardiac views should be performed. (This is sometimes known as ‘anatomy scan’ or ‘level II’ ultrasound.) Smaller clinics might need to refer out to access this ultrasound.
A fetal echo is likely unnecessary unless the fetal anatomy ultrasound raises a concern. However, some OB-GYNs may recommend a fetal echocardiogram if the patient takes an ASM with a higher risk for cardiac malformations (e.g., phenobarbital).
One or more surveillance growth ultrasounds in the third trimester should be considered for all patients with epilepsy. There is a potentially increased risk for intrauterine growth restriction with some ASMs (notably topiramate and zonisamide, to a lesser extent).
Between 34-36 weeks, consider a consultation with obstetrical anesthesia where available.
A plan for delivery logistics needs to be created and shared with all members of the care team and the patient’s support system. A controlled environment is important, so a hospital setting is the safest birth location.
The delivery plan should address the following:
- Preparation for potential seizure.
- Preparation for C-section (NOTE: Epilepsy alone is not an indication for C-section. C-section preparation is a standard obstetrical indication.)
- 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 (hospitals may not have extended-release formulations, for example).
- Postpartum tapering plan (determined several weeks before delivery and given to the patient and the obstetrician – waiting until after delivery is not practical and risks toxicity in some cases). See Anti-seizure Medication Tapering Schedule Tool.
Women with Epilepsy can Deliver Vaginally
Epilepsy alone is not an indication for a C-section. Vaginal deliveries account for two-thirds of deliveries in the United States, and unless there are obstetric indications for a C-section, pregnant patients with epilepsy can deliver vaginally.
Postpartum Care Plan
Formulate the postpartum care plan with the patient and the patient’s support system during a pregnancy visit. The plan should include:
- 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 opt for breastfeeding, formula feeding, or a combination of both.
- 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.
See Postpartum Care page for more information on this topic.
Guide Your Patients
Pregnancy can be a trying time under the best circumstances. Offer your patients a calming voice of reassurance.
The scheduling of appointments and checkups with ASM level checks and other important milestones needs to be well-documented and presented in a way that feels doable and not overwhelming.
Provide clear lines of communication for when potential issues arise so there’s no confusion.
Reviewed by: Laura Kirkpatrick, MD, August 2023