Epilepsy and Pregnancy -- Postpartum Issues

Women with epilepsy experience the same physical and emotional adjustments as other postpartum women. Additionally, some of those factors, such as sleep deprivation and stress, may affect seizure frequency. Good seizure control and careful assessment of anti-epileptic drug (AED) levels are important to optimize well-being during the postpartum period.

Anti-epileptic Medications

During pregnancy, serum concentrations of AEDs may decrease secondary to decreased protein binding of AEDs, increased drug clearance, and increased maternal plasma volume. Increased AED dosages may be necessary for optimal seizure control.

In the postpartum period, as maternal metabolism returns to the pre-pregnancy state, AED serum concentrations may rise, resulting in medication toxicity. Plasma levels of unbound AEDs should be monitored closely for at least eight weeks following delivery, with dosage adjustments as indicated.

Breast-Feeding

For most women with epilepsy, breast-feeding is a safe option. All AEDs appear in breast milk inversely to the degree of maternal plasma protein binding. This results in a relatively low concentration of most AEDs in breast milk. Term infants have had nine months of AED exposure and most can metabolize the medication effectively.

However, infants of women with epilepsy who take phenobarbital or primidone may occasionally be irritable or sedated. If sedation or irritability becomes a problem, discontinuation of breast-feeding should be considered.

Contact the American Academy of Pediatrics and the U.S. Food and Drug Administration for more information on recommended breast-feeding practices.

Adverse Outcomes in the Neonate

There is an increased risk (<7 percent) of a unique hemorrhagic disorder in the neonate which occurs within the first 24 hours of life. It has been associated with exposure to AEDs in utero (phenobarbital, primidone, phenytoin, and perhaps others). The risk seems more pronounced with polypharmacy and can be reduced by maternal supplementation with oral vitamin K (at a dose of 10 mg. per day) during the last month of pregnancy.

There is a higher rate of prenatal, neonatal, and infant mortality in the children of wpmen with epilepsy. Risk factors are not well understood, but poor maternal seizure control seems implicated.

Newborn and Infant Care

Women with epilepsy need to develop a child care plan based on seizure type and frequency and the availability of support from family members or friends. If appropriate support is not readily available, assistance from a home health agency may be helpful.

Postpartum issues of stress, fatigue and hormonal changes that may affect seizure control and overall function should be discussed. If necessary, assist the family in assessment of environmental safety factors for the mother and the newborn infant.

See also Parenting Issues for women with epilepsy.

CONTACT

For additional information, contact the Women and Epilepsy Initiative of the Epilepsy Foundation at (800) 332-4050.

REFERENCES

Foldvary N. Treatment of epilepsy during pregnancy. In: Wyllie E, ed. The Treatment of Epilepsy, 3rd ed. Baltimore: Williams & Wilkins; 2001:775-786.

Yerby M. Contraception, pregnancy and lactation in women with epilepsy. Baillieres Clinical Neurology. 1996;5:887-908.

Practice parameter: management issues for women with epilepsy (summary statement). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 1998;51:944-8.