Therapeutic strategies for treating epilepsy during pregnancy

ABSTRACT

Introduction: Counseling for women with epilepsy of childbearing potential surrounding pregnancy issues is of the utmost importance and should be done when antiepileptic medications are prescribed and reviewed regularly at clinic visits. Physicians must be familiar with risks associated with antiepileptic medication, and endeavor to minimize risks to a fetus while selecting best medications for epilepsy type.

Areas covered: The authors discuss the role of folic acid, updated evidence relating to the occurrence of major congenital malformations and neurocognitive risks associated with antiepileptic medication. They also examine the rationale for monitoring drug levels, optimum delivery strategies, and evidence for the safety of breastfeeding while taking antiepileptic medication.

Expert opinion: Valproate carries the highest known teratogenic risk in pregnancy and should only be prescribed to women of child-bearing potential in a specialist setting. There is a need for the ongoing register collection of risks associated with newer AEDs which lack substantial (major) data. Choosing these newer medications can create a dilemma for physicians, particularly when seizures are not well controlled or where treatment options are limited. The authors advocate a multidisciplinary team approach to managing women with epilepsy so that pregnancies in such women can be well managed in an optimum and individualized fashion.

KEYWORDS:

• Antiepileptic medication
• epilepsy
• major congenital malformation
• pregnancy
• therapeutic drug monitoring

Article highlights

• Preconceptual planning for is important in WWE, with folic acid supplementation advised in current guidelines.

• We present the MCM risk data in relation to various AEDs, with particularly increased risk related to valproate therapy, which should be avoided where possible.

• Neurocognitive risks have been associated with valproate therapy, with increased risk of learning difficulties and autism spectrum disorders in children who had been exposed in utero.

• There is a need for therapeutic drug monitoring with certain AEDs whose metabolism is significantly altered in pregnancy – these should be anticipated with close supervision and monitoring of serum levels.

• Planning labor and postpartum care in WWE is important, and breastfeeding ought to be encouraged, despite AED therapy.

This box summarizes key points contained in the article.

Declaration of interest

N Delanty has served on an advisory board for Sanofi in the past. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

One referee declares having received grant funding from GW Pharmaceuticals.