| Practical Guide for Woman
with Epilepsy of Childbearing age |
| Post pubertal woman
with epilepsy |
 | Select the most appropriate Antiepileptic
drug (AED) for seizure type. |
| AED therapy should be optimized before conception if possible. |
| Monotherapy should be the aim of treatment. |
| Discuss the potential for decrease in effectiveness of hormonal
contraception when taking enzyme-inducing AEDs. |
| Folic acid > 0.4 mg qd instituted. |
| Contraceptions:
 | If hormonal contraception is used in a woman taking enzyme-inducing AEDs,
a formulation that includes > 50 µg of ethinyl estradiol or mestranol should be used. |
|
| Prepregnancy counseling
| Folic acid supplementation |
| Teratogenic potential of AEDs, risk levels of
major and minor birth defects |
| Options for considering AED discontinuation before
pregnancy |
| Possibility for change in seizure frequency during
pregnancy |
| Importance of medication compliance during
pregnancy |
| Need for regular follow-up during pregnancy |
| Inheritance risks for seizures |
| Advantages and disadvantages of breast-feeding |
| Over 90% have uneventful pregnancy and normal
infants. |
| Additional information: EFA at 1-800-EFA-1000 or www.efa.org |
|
|
| Withdrawal of
AED |
| If AED withdrawal is planned, this should be completed at least 6 months
before conception. |
| Risk for seizure recurrence is cumulative but greatest in the first 6
months after discontinuation of AED. |
| Discontinuation of AEDs may be considered in a patient who has been
| Seizure free for 2 to 5 years |
| Single type of sezure |
| Normal neurological exam and IQ |
| EEG that has normalized with treatment |
|
|
| Pregnant patient |
| Change to an alternate AED should NOT be undertaken during pregnancy for
the sole purpose of reducing teratogenic risk. |
| WWE, especially those treated with carbamazepine, divalproex sodium, or
valproic acid, should be offered
| Alpha-fetoprotein levels at 14 to
16 weeks gestation |
| Level II (structural) ultrasound at 16 to 20 weeks'
gestation |
| If appropriate, amniocentesis for amniotic fluid alpha-fetoprotein and
acetylcholinesterase levels. |
|
| Consider monitoring non-protein-bound AED levels during pregnancy. |
| For the stable patient, levels should be ascertained before conception,
at the beginning of each trimester, and in the last month of pregnancy. |
| Additional levels should be done when clinically indicated (seizure
occurrence, side effects, suspected noncompliance). |
| Vitamin K, 10 mg per day, should be prescribed in the last month
if taking enzyme-inducing AEDs.
| If this has not been done, parenteral vitamin K1 should be
administered to WWE as soon as possible after the onset of labor. |
| Administration of 1 mg IM or IV vitamin K1 to the neonate. |
|
|
| Post partum
management |
| AED levels should be monitored through the eighth postpartum week. If AED
dosage increases have been necessary during pregnancy, subsequent reductions to the
prepregnancy dosage will usually be possible and may be necessary to avoid toxicity. |
| Rediscuss Advantages and disadvantages of breast-feeding |
| Discuss infant care risk |
|
| Other comments |
| Hereditary, socioeconomic status and other determinants of maternal
health all play a role in the production of adverse pregnancy outcomes in WWE. |
| A specific syndrome referable to one drug is less likely than previously
suggested. |
| Risk for neural tube defects may be greatest for:
| Valproic aced - 1% |
| Carbamazepine - 0.5% |
|
| Children of woman taking multiple AEDs appear to be at high risk for
congenital malformations and development delay. |
| Teratogenic potential for the newer AEDs - Felbamate, Gabapentin,
Lamotrigine, Tiagabine, Topiramate and Vigabatrin is unknown at this time. |
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| Further
Reading |
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