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In response to questions concerning epilepsy in pregnancy, the Professional Advisory Board of the Epilepsy Foundation of America has developed the following answers:
QUESTION: Can a woman with epilepsy become pregnant?
ANSWER: Women with epilepsy are no different from others in this respect. They certainly can become pregnant and have perfectly normal babies.
QUESTION: Should a woman with epilepsy become pregnant?
ANSWER: This is a decision that each woman will have to make, but it should ideally be discussed with a physician before pregnancy. Epilepsy can affect pregnancy, and pregnancy can affect epilepsy. Both epilepsy and the medications given for its control may have adverse effects on the baby.
QUESTION: How will pregnancy affect seizures?
ANSWER: For some women pregnancy causes a decrease in their seizures; for others it causes an increase; for others there is no change in their seizure activity. The hormonal changes in pregnancy can affect the way antiepileptic medications are absorbed and how they are handled in the body. Therefore, a woman's physician may want to check blood levels of anticonvulsants more frequently during pregnancy. There are also major changes in blood level just after delivery, so this is a time when doses might be readjusted.
QUESTION: Does epilepsy, or do drugs taken during pregnancy, affect the baby?
ANSWER: Women with epilepsy taking anticonvulsant medication have a 2-3 times greater risk of having infants with congenital malformations than do those women who do not have epilepsy. Part of this is due to the medication, but women who have epilepsy and are no longer taking medication have a 1-2 times greater risk than the general population of having an infant with congenital malformations. The cause of the increased risk is not completely known. There may be genes common for epilepsy and congenital malformation, or it may be a specific effect of the drugs, or a predisposition to the effects of the drugs. Researchers are working to find ways to identify those who may be more susceptible to the effects of the drugs. The most common malformations are cleft lip, cleft palate, and congenital heart disease.
It is important to remember that women with epilepsy have a greater than 90% chance of having a normal child.
QUESTION: What about specific drugs?
ANSWER: Phenytoin (Dilantin) slightly increases the risk of cleft palate and heart disease. It also causes what is referred to as the "Fetal Hydantoin Syndrome." This incudes growth deficiency, abnormalities of the nails and fingers, small head size, and a number of other minor malformations. Most of these infants develop with normal intelligence.
Phenobarbital also may cause problems although they may be less frequent than with phenytoin.
Women taking valproic acid (Depakene) during the first several months of their pregnancy may have an increased risk of having a child with spina bifida (open spine). This risk may be as high as 1-2 per hundred. A woman who becomes pregnant while on valproic acid should consult with her obstetrician about prenatal testing for a neural tube defect (spina bifida).
Certain drugs seem more likely to cause problems: Trimethadione (Tridione) and paramethadione (Paradione) are more likely to cause severe congenital malformation. While on these drugs, a woman should probably avoid pregnancy, or discuss changing to another medication prior to pregnancy.
There is insufficient information about most other anticonvulsants to make definite statements, but the increased frequency of malformation over the usual occurrence appears to be small.
QUESTION: Should a woman stop taking anticonvulsants if she plans to try to become pregnant?
ANSWER: This decision should be made in conjunction with the physician. If a woman has not had seizures for many years, it may be possible for her and her physician to decide to slowly discontinue the medication before she attempts to become pregnant. Pregnancy without anticonvulsants may lessen the risk to the child. However, if anticonvulsant medication is needed to control the epilepsy, it is usually best for it to be continued. Although the risk of problems to the baby is greater than without medication, there is still a high probability (more than 90 percent) of having a normal child.
QUESTION: If a woman is already pregnant, should she stop medication?
ANSWER: Since most malformations develop during the first three months, there is probably little reason to stop the medication after the first three months.
QUESTION: Is it advisable to change to another anticonvulsant?
ANSWER: Since the risk with phenobarbital and phenytoin (Dilantin) is low, there would appear to be little reason to switch to other anticonvulsants about which less is known.
QUESTION: What about breast feeding?
ANSWER: Medications are carried in the breast milk and do get into the baby, but insuch low doses that it probably makes little difference to the baby. Women taking more than 90 mgs. of phenobarbital may occasionally find that their babies are sleepy. Other sedative drugs such as Valium may also cause sleepiness in the child. If this is the case, it should be discussed with the physician.
SUMMARY
The Epilepsy Foundation of America agrees that:
When possible, a woman who has been seizure free for many years should be withdrawn from her medication prior to pregnancy.
When a woman has epilepsy and requires medication, she should be advised that she has at least a 90 percent chance of having a normal child, but that the risk of congenital malformations and mental retardation is 2-3 times greater than average - either because of her condition, the medication, or a predisposition to the effects of the medication. For this reason, it is important to maintain a close dialogue with the physician in regard to the epilepsy and the antiepileptic medications.
Women who seek advice after becoming pregnant should continue the drug therapy because if major anatomical malformations have occurred, it would most likely be past the time for it to occur.
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