Epilepsy and pregnancy: What should you know before conception?

How do you plan for pregnancy if you have epilepsy?

The most important step in preparing for a pregnancy with epilepsy is preconception counselling. Before trying to conceive, schedule an appointment with both your neurologist (preferably an epileptologist) and your obstetrician/gynaecologist (Ob/Gyn). Your neurologist will evaluate how well-controlled your seizures are, review your medication, and make any necessary changes. Some women may also be referred to a maternal-fetal medicine specialist for additional care during pregnancy.

Some key aspects of preconception planning include:

• Medication adjustments: Your doctor may switch you to a safer anti-seizure medication (ASM) or adjust your current dosage to minimize risks to your baby while maintaining seizure control.
• Folic acid supplementation: Women with epilepsy are advised to take higher doses of folic acid (up to 4 mg daily) at least two to three months before conception. Folic acid helps prevent neural tube defects like spina bifida, especially in women taking ASMs that can lower folate levels.
• Healthy lifestyle choices: As with any pregnancy, it’s important to avoid smoking, alcohol, and drugs, and to maintain a balanced diet, exercise regularly, and get enough sleep.

With proper preconception care, you can improve your chances of a healthy pregnancy and ensure that both you and your baby are well-prepared.

Can epilepsy medication be continued during pregnancy?

High-risk medications like valproate and phenobarbital can increase the risk of neural tube defects and cognitive issues in the child. If you are taking these medications, your doctor may recommend switching to safer alternatives like lamotrigine or levetiracetam before you conceive.

If you're also taking more than one ASM, the risk to your baby may increase. Your doctor might simplify your medication regimen to reduce this risk while keeping your seizures under control.

Throughout your pregnancy, your ASM levels will need to be monitored frequently. Due to changes in blood volume, kidney function, and metabolism, ASM levels may drop, especially for medications like lamotrigine and levetiracetam. Regular blood tests will help adjust your dosage to maintain seizure control and minimize risks to the baby.

Never stop or adjust your medication without consulting your doctor. Stopping ASMs suddenly can lead to seizures, which can be more dangerous for both you and your baby.

How does pregnancy affect epilepsy?

Pregnancy impacts each woman differently, but for many, seizure frequency remains the same or decreases. This is because pregnancy hormones like progesterone can have anti-convulsive effects, reducing the likelihood of seizures. However, some women may experience an increase in seizures during pregnancy due to changes in medication levels, sleep deprivation, or nausea and vomiting that interfere with medication absorption.

Seizures during pregnancy can pose risks to both mother and baby, especially generalized tonic-clonic (grand mal) seizures. These can cause falls, oxygen deprivation to the baby, or preterm labour. Focal seizures, which affect only part of the brain, tend to pose less risk unless they lead to injury.

To protect both yourself and your baby, it’s crucial to maintain good seizure control throughout your pregnancy. Monitor your seizure frequency and report any changes to your healthcare provider immediately, as medication adjustments may be needed.

What risks and complications should you be aware of?

While most women with epilepsy can have healthy pregnancies, there is a slightly higher risk of complications compared to the general population.

Some potential risks for the baby are:

• Birth defects: Women with epilepsy have a 4-6% risk of giving birth to a baby with a birth defect, compared to 2-3% in the general population. The risk is higher if you are taking certain ASMs, especially at high doses.
• Developmental delays: Some medications, particularly valproate, are linked to developmental issues such as cognitive delays or language impairments. Your doctor may suggest regular ultrasounds and monitoring throughout your pregnancy to check for abnormalities, especially during the 20-week scan, which can detect neural tube defects.
• Seizure-related risks: Generalized tonic-clonic seizures can pose significant risks to the baby, including oxygen deprivation or premature labour. Falls or injuries to the mother during a seizure can also affect the baby’s health. For this reason, maintaining seizure control is essential.

The healthcare team will closely monitor the baby’s growth and development through prenatal care, including regular ultrasounds and checkups to track fetal well-being.

Can epilepsy affect mental health during pregnancy?

According to studies, women with epilepsy are at a higher risk for depression and anxiety during pregnancy and the post-partum period. Factors such as a history of mood disorders, unplanned pregnancy, or multiple seizures can increase this risk. While most women do not experience major depression during pregnancy, it is essential to watch for signs of anxiety or depression, such as:

• Excessive crying
• Difficulty bonding with your baby
• Loss of interest in favourite activities
• Thoughts of harming self or the baby

Safe treatments for depression and anxiety during pregnancy, such as certain medications and therapy, are available. If you experience any symptoms, speak with your healthcare provider to find the right support.

What should you expect in terms of post-partum care?

After giving birth, your ASM levels will gradually return to pre-pregnancy levels. Your doctor may need to adjust your medication dosage to prevent side effects or toxicity. In the early post-partum period, sleep deprivation is a common seizure trigger, so it’s important to get enough rest and ask for help when needed.

Can you breastfeed if you’re taking ASMs?

In most cases, breastfeeding is safe for women with epilepsy. While small amounts of medication may pass into breast milk, research has shown that this exposure is minimal compared to what the baby was exposed to in the womb. Medications like lamotrigine, levetiracetam, and carbamazepine are generally considered safe during breastfeeding.

However, if you're taking medications like phenobarbital or primidone, your doctor may recommend monitoring the baby for signs of excessive sleepiness or feeding difficulties.

The benefits of breastfeeding often outweigh the risks, and it's encouraged by major health organizations such as the American Academy of Pediatrics.

Will the baby develop epilepsy?

The risk of passing epilepsy to your child is relatively low. If only one parent has epilepsy, the risk of the child developing the condition is about 5%, slightly higher than the 1% risk in the general population. The risk increases slightly if both parents have epilepsy or if your epilepsy is genetic.

If you're concerned, genetic counselling can provide more personalized information based on your family history.

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