Dr Nassif Mansour and colleagues discuss preventing seizures, the use of sodium valproate and postnatal care for pregnant women who have epilepsy
Approximately one woman in 200 presenting for maternity care has epilepsy and is taking anti-epileptic drugs (AEDs). Many remain free of seizures throughout their pregnancies and have a straightforward journey.
However, 15-30% of pregnant women with epilepsy have an increase in seizure frequency, commonly in the first or third trimester. Possible triggers include hormone changes, stress, decreasing blood levels of AEDs or poor compliance.
Seizures during pregnancy have serious consequences including increased risk of miscarriage, preterm delivery, pre-eclampsia, placental abruption and gestational hypertension. Women with epilepsy have an increased chance of emergency caesarean section during delivery.
Increased risk of harm to the mother during pregnancy include trauma from falls and sudden unexpected death in epilepsy (SUDEP), though this is extremely rare.
Preconception counselling
To reduce the risks to mother and baby in pregnancy, the aim is to be as seizure free as possible.1 The benefit of preventing a seizure during pregnancy outweighs the side-effects of the medication.
However, AEDs carry a risk of teratogenicity, which is likely to be a concern to the mother. These risks include neural tube defects, congenital heart defects and cleft palate.
It is important to remind women who are considering pregnancy to start folic acid 5mg daily at least three months before conception and continue until 12 weeks’ gestation, to reduce the risk of neural tube defects.
However, sodium valproate must not be used in women of childbearing age unless there is a pregnancy prevention programme in place. Women taking sodium valproate should be reviewed regularly to ensure they are aware of the risks.
Sodium valproate has the highest risk of birth defects. Folic acid is unlikely to reduce the risk of birth defects from sodium valproate.
GPs should check what AEDs the patient is taking and must consider referring women to a preconception clinic if they:
- Take more than one AED.
- Take sodium valproate.
- Have not been seizure free for the past two years.2
Who should always be referred
Urgent referral to the local maternity unit is essential if women with epilepsy present in early pregnancy for assessment and counselling.
Although pregnancy does not cause epilepsy, seizure frequency increases for up to 30% of pregnant women with epilepsy, as stated earlier.
It is important to urgently refer women with epilepsy who are pregnant or planning on becoming pregnant to an epilepsy specialist to discuss ongoing AED treatment.
Eclampsia can cause seizures. Immediate referral to maternity units is essential to any pregnant woman who has a seizure.
The GP role during pregnancy
Although most care is provided by the specialised maternity units, the GP’s role during pregnancy remains important as they provide a holistic approach. GPs can signpost patients to appropriate specialists including a midwife, obstetrician, neurologist and epilepsy nurse specialist.
While women should be monitored by specialists, it is important for the GP to be aware of the increased risks and monitor adherence with epilepsy medication.
Some people are at increased risk of seizures when tired, so the GP can provide support to aid this and monitor the patient’s physical and mental wellbeing.
Management in the immediate postnatal period
The risk of accidental injuries occurring during a seizure in the postnatal period can put the mother’s and baby’s safety at risk.
Maternity units and midwives will continue monitoring high-risk women but GPs should be aware of these risks and stay involved in monitoring compliance with medications, addressing women’s concerns and ongoing long-term postnatal care.
Many women worry about seizures in the postnatal period. The chance of having a seizure during and immediately after labour is higher than in the antenatal period, and so they should continue their AED.
They should also take measures like laying the baby down when they have an aura, nursing from the floor, avoiding known triggers, asking for support from family and friends and not bathing the baby alone.
Ongoing postnatal care
- Once the mother’s long term treatment plan has been arranged and they have been discharged to your care, arrange to see her and her baby at six to eight weeks postnatal.
- Mothers should be supported to ensure seizure triggers such as alcohol consumption, lack of sleep and stress are minimised.
- AEDs are thought to be safe while breastfeeding for most women, but may be passed on to the child through breast milk. Generally most women will choose to breastfeed as the benefits outweigh risks, but it is important to ensure they are reviewed by their specialist and have an agreed plan for their AEDs and feeding.
- GPs should refer the mother and baby to the specialist who oversaw their pregnancy care if they do not have an agreed plan for AEDs and feeding. Check the baby for signs of AED toxicity such as excessive sleep, poor feeding or irritability and especially if the mother is on phenobarbital, primidone, or benzodiazepines.
Dr Nassif Mansour is a GPwER in neurology in Surbiton, Surrey. Charlotte Casteleyn and Ziad Mansour are fifth-year medical students at University College, University of London
References
- Razaz N, Tomson T, Wikström A et al. Association between pregnancy and perinatal outcomes among women with epilepsy. JAMA Neurology 2017;74:983. Link
- Ward L, Parisaei M. Preconception Guidelines-Epilepsy. NHS; 2021. Link
- Epilepsy Action 2023. Pregnancy and epilepsy. Link
- Royal College of Obstetricians and Gynaecologists. Epilepsy in Pregnancy. Green Top Guideline 68, June 2016. Link
- Mayo Clinic. Epilepsy in Pregnancy: what you need to know. August 2022. Link
- NICE. Epilepsy in adults. 2013. Quality standard [QS26]. Link
- Epilepsy Foundation. 2014. After the baby is born. Link
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