Seizure Control During Pregnancy
Maintaining seizure stability 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, pregnant patients are no more likely to experience an increase in seizure rates than non-pregnant patients.
Epilepsy care teams should include monthly anti-seizure medication (ASM) blood levels and anti-seizure medication dosage adjustments in their patient’s overarching pregnancy plan to maintain the individual’s target ASM blood level. Assure your patients that ASM dosage changes are normal during pregnancy, as pregnant patients with epilepsy almost always require more frequent medication adjustments than non-pregnant patients. Emphasize that increased ASM dosage does not mean they or the fetus are seeing higher levels of their medication, but the same levels they saw before pregnancy.
Seizure control before pregnancy is a good indicator of seizure control during pregnancy. Understanding and managing your patients’ seizures through careful ASM monitoring and adjustment before they become pregnant is a critical way to support their well-being throughout the pregnancy.
This page includes guidance on how you and your patients with epilepsy can maintain the best control possible of their seizures while pregnant.
Topics covered on this page include:
Impacts of Seizures
Maintaining seizure control is crucial throughout the pregnancy of a person with epilepsy, including during labor and delivery.
Tonic-clonic seizures or any type of seizure with impaired awareness can result in falls or car accidents, leading to multiple complications in obstetric patients, including:
- Placental abruption
- Internal hemorrhage
- Direct fetal injury
- Rupture of fetal membranes
- Fetal death
Any type of convulsive seizure resulting in trauma could cause fetal heart rate changes and lactic acid build-up.
NOTE: The patient’s care teams should monitor the patient throughout their pregnancy for all seizure activity, regardless of severity. An uptick in mild seizures often signals an increased likelihood of convulsive seizures.
Minimizing Seizures During Pregnancy
Avoiding convulsive seizures, when possible, or preventing an increase in seizure frequency and intensity is crucial to help ensure the safety of your patient with epilepsy and their fetus during pregnancy.
Seizure Monitoring by the Pregnancy Care Team
Throughout the pregnancy, the patient’s OB or other pregnancy care providers should assess the patient for an increase in all types of seizures, including:
NOTE: The care team should also monitor milder seizure activity. An uptick in these seizures often signals an increased likelihood of convulsive seizures.
The patient may see their pregnancy care providers before their epilepsy care providers, so it’s important that the patient’s entire care team regularly communicates information about the patient’s seizure activity with each other.
Seizure Monitoring by the Patient
Pregnant patients with epilepsy should also be urged to keep track of their seizure activity and report all breakthrough seizures, regardless of severity, to their pregnancy care team.
Sleep Deprivation & Increased Seizures
Sleep deprivation is expected during the third trimester of pregnancy and the postpartum period. Sleep deprivation is also a common seizure trigger (particularly for frontal lobe and idiopathic generalized epilepsy seizures). During your pregnant patient’s second trimester, collaborate with them to develop a comprehensive sleep plan that may include their family, their employer, or other support system.
Once the baby is delivered, this plan should include arrangements for night care, such as family assistance. In rare instances, a family may decide to obtain additional assistance by hiring a night nurse, if necessary and affordable. Their plan should include 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.
Determine Lowest Effective Dose of ASMs
Ensure that patients with epilepsy are prescribed the lowest effective dose of ASM(s) at the onset of pregnancy, and they maintain that individualized target concentration throughout pregnancy. The risks associated with exposure to some ASMs in-utero may increase at higher levels of fetal exposure.
There is no particular type or dose of ASM that provides seizure control for all patients, but consider the following when determining the correct ASM dose for your patient considering pregnancy:
- Get a baseline for the type(s) and frequency of seizures a patient has prior to becoming pregnant in order to compare it to seizure activity during the pregnancy.
- Especially for patients with drug-resistant epilepsy (DRE), the goal is not to stop ALL seizures but to prevent seizures from worsening in frequency or severity compared to the baseline and to minimize convulsive seizures.
- Some patients with epilepsy may maintain seizure freedom at levels lower than lab-published “therapeutic levels.”
- When planning seizure control for a pregnant patient with epilepsy, determine what motivated the last increase in their ASM dose. Consider decreasing the dose if it was increased in response to provoked seizures.
- In rare circumstances, if the onset of epilepsy occurred prior to adolescence, and the patient has experienced long-term freedom from seizures, it may be possible to wean them off ASMs.
- Similarly, if the patient has been seizure free for two years or longer, consider weaning them off ASMs after discussing the risks and benefits of doing so with them. Have this discussion in the context of evaluating the many other factors that determine the individual’s prognosis to be able to discontinue all ASMs and remain seizure free.
- Lamotrigine, oxcarbazepine, and valproic acid doses can often be lowered when a patient prescribed one of these ASMs stops taking estrogen-containing birth control. Take the following steps to determine if the dose can be lowered:
- Obtain an ASM level before the patient stops the estrogen.
- If appropriate, lower the ASM dose.
- At least one week after lowering the dose, repeat the ASM level test.
- If appropriate, adjust the dose again.
NOTE: Use Ambulatory EEGs to guide medication weaning in patients with generalized epilepsy syndromes.
Checking ASM Levels to Maintain Seizure Control
Pregnancy can increase ASM clearance, and the extent of clearance changes will vary from patient to patient, so frequent monitoring of ASM levels and adjusting medication doses can help maintain optimal seizure control. Keeping track monthly of a patient’s ASM levels throughout their pregnancy will help you manage any ASM dosage changes to maintain seizure control while avoiding exposing the developing fetus to higher-than-necessary levels of ASMs.
Prescribing Rescue Medicine
Consider prescribing a rescue medicine for your pregnant patients with epilepsy. These medications have a short-term effect and lower the chance of breakthrough seizures. As long as the rescue medicine is not taken on a regular and frequent basis, the patient could use the rescue medicine when:
- They have had a seizure and need to prevent additional seizures. This is especially important in people who tend to have seizure clusters.
- They are in a particularly stressful situation.
- They are concerned about having a seizure.
- They’ve missed a dose of their regular ASM. Additionally, if a dose is missed, the person should be advised to take the missed dose at the time it is recognized.
Seizure rescue medications come in several forms. The most commonly available are:
- Pills, which tend to be less expensive and easy to use.
- Nasal sprays, which are often costly and which insurance plans sometimes don’t cover.
Addressing New-Onset Seizures During Pregnancy
It is important to note that not all new-onset seizures are due to epilepsy. If a patient is experiencing seizures for the first time while pregnant, standard workup and treatment for new-onset seizures should not be compromised:
- Administer lorazepam as the first line of treatment.
- Administer levetiracetam as the second line of treatment.
- Diagnostic considerations should include pregnancy-associated conditions, such as eclampsia and cerebral venous thrombosis.
- Eclampsia will be accompanied by HTN and proteinuria, although these signs may present before or after the seizure.
- Image using MRI without IV contrast. If MRI is not available, use a CT scan.
Prescribing ASMs for New-Onset Epilepsy During Pregnancy
Use the following guidelines when prescribing ASMs for patients experiencing new-onset epilepsy while pregnant:
- Clinicians usually favor starting pregnant patients on levetiracetam.
- For patients with focal epilepsy, clinicians can also consider prescribing carbamazepine, especially after the 1st trimester.
- Oxcarbazepine is another medication option for treating focal epilepsy, but data is more sparse about neurodevelopmental effects of in utero oxcarbazepine exposure.
- Avoid prescribing valproic acid or lamotrigine as maintenance therapies.
- Lamotrigine is not good to begin during pregnancy due to it requiring slow titration and because pregnancy tends to increase metabolism rates.
- Valproate is not good to begin during pregnancy because it is associated with the highest risk of malformations and adverse neurodevelopmental outcomes for the fetus
Guide Your Patients
Your patients with epilepsy may have significant concerns about experiencing seizures while pregnant. Emphasize that their seizures are not likely to increase as long as their ASM levels are checked regularly, and their medication dosages are adjusted accordingly.
Emphasize how important it is for patients to track all seizure activity while pregnant and report it to their pregnancy and epilepsy care teams. An increase in mild seizure activity might be a predictor of convulsive seizures.
If warranted, consider prescribing a rescue medication to provide greater peace of mind for your pregnant patients with epilepsy.
Reviewed by: Page Pennell, MD FAES, August 2023