Unplanned Pregnancy & Epilepsy
It is ideal for patients with epilepsy to consult with their care team as much as 12 months before trying for pregnancy. Unfortunately, that ideal isn’t always obtainable.
Some studies found that up to 65% of women with epilepsy reported at least one unplanned pregnancy. While each patient situation is unique and will require an individualized approach to counseling and plan formation, common steps should include the following:
Supplementation
Put your patient on prenatal vitamins as soon as possible, including at least 400-1000 mcg of folic acid daily, which can be prescription. You may also want to consider B12 and Vitamin D supplementation. You can find more information on folic acid, B12, and Vitamin D on our Folic Acid & Supplements page.
Anti-seizure Medication (ASM) Level Checks
If your patient is on an anti-seizure medication (ASM), get a baseline blood level (if there isn’t one already available), and extrapolate back to figure out a good ASM level (see ASM Level Checks). Continue monthly level checks from this point forward.
Medication Changes
Despite the varied risk profiles of different ASMs (see Anti-seizure Medications and Pregnancy Suitability), medication switching should ideally be attempted well in advance of pregnancy, not once a patient is already pregnant, as this exposes the fetus to more than one medication and may increase the patient’s risk for seizures. However, you may need to consider early-pregnancy ASM changes for patients taking valproic acid.
Strategies for Handling Valproic Acid
Due to known fetal risks, if the patient is already in the first trimester of pregnancy and is taking valproic acid, consider whether the dose can be lowered or the medication can be removed from the patient’s regimen.
Deciding to remove or lower valproic acid requires careful consideration of the patient’s epilepsy, seizure types, and medication trials. Trained specialists should do this in consultation with the patient. The patient’s healthcare providers may need to collaborate to schedule an appointment quickly.
If quickly removing valproic acid (likely switching to levetiracetam), consider in-patient admission and consult a neurologist/epilepsy specialist for electroencephalogram (EEG) monitoring to ensure no excessive seizure activity is seen, then titrate dose accordingly.
Risk of major congenital malformations that exposure to valproic acid may impact is generally complete by 13 weeks of pregnancy. If it is not possible to lower or remove valproic acid from a pregnant patient’s medication regimen before this point, it is not urgent to do so after. However, stopping continued exposure to valproic acid is likely to reduce the fetus’s risk of adverse neurodevelopmental outcomes. It’s vital to consider reducing or removing valproic acid regardless of how far along the patient’s pregnancy is. If a taper plan is not in place prior to delivery, there is no need for concern from clinician or patient, as the first dosage decrease is not until more than 48 hours after delivery.
NOTE: Lamotrigine is difficult to titrate once a patient is pregnant, given increased metabolism in pregnancy, and rarely should be started during pregnancy.
Guide Your Patients
Do not make the patient feel guilty or that they have done anything wrong. Your job is to help the patient make good decisions going forward and make the best of the situation.
Counsel your patient on the risks of pregnancy as you would any other patient but take their medication into account (see Anti-seizure Medications & Pregnancy Suitability).
Once blood levels are taken for baselining, ASM changes are made (if the patient takes valproic acid), and folic acid starts, the pregnancy can follow approaches similar to those outlined on the Pregnancy Planning page.
Reviewed by: Laura Kirkpatrick, MD, August 2023