[Guideline summary] Evidence-based recommendations for management of women with epilepsy during the reproductive cycle

Special attention is needed for women with epilepsy throughout the reproductive cycle. Promising advancement in antiepileptic drug (AED) development has been noted since the publication of the Hong Kong Epilepsy Guideline in 2019. This article aims to update the Guideline with a focus on epilepsy management among the female population. The below summarizes some key points from preconception to lactation:
 

Preconception counselling and teratogenicity of AEDs

• ALL women with epilepsy should receive information about epilepsy and the related treatment specific to the reproductive cycle
• 5 mg of folic acid can be offered daily to ALL women with epilepsy of childbearing age
• Risk of epilepsy in offspring of women with epilepsy is related to the inheritance pattern of individual epilepsy syndrome
  • There may be a ~3-fold increase in overall risk versus the general population
• AEDs can be teratogenic
  • It is advised to perform early ultrasound during pregnancy and other prenatal screenings for key congenital malformations
• Valproate is correlated with lower cognitive function in offspring with in-utero exposure and the risk may be dose-related. Risks and benefits of its use should be discussed with patients and/or families in details for a joint decision
   

Pregnancy

• Majority of women with epilepsy have uneventful pregnant
  • But, adverse health outcomes for both mothers and fetus happens relatively more frequently in pregnant women with epilepsy
• Ultrasound scan are advised to identify major fetal malformations
• Monitoring levels of AEDs (e.g. lamotrigine) throughout gestation may help to guide adjustment of dosage
• For mothers taking enzyme-inducing AEDs,
  • Oral vitamin K1 (10-20 mg/day) may be prescribed in the last month of gestation
     

Labour

• In most women with epilepsy, spontaneous vaginal delivery is considered to be safe
• If seizures are frequent, elective caesarean section may be appropriate
• Continue AEDs orally or intravenously
• Vitamin K1 (1 mg) may be given to newborns of mothers with epilepsy taking enzyme-inducing AEDs parenterally at delivery
   

Breastfeeding

• Counselling on the pros and cons of breastfeeding is needed for women with epilepsy
• Significant penetration into human milk probably occurs:
  • Primidone, levetiracetam, barbiturates, benzodiazepines, lamotrigine, gabapentin, topiramate, ethosuximide, and zonisamide

Link to publication: https://www.hkmj.org/system/files/hkmj198367.pdf

Reference

Chang RSK et al. Update to the Hong Kong Epilepsy Guideline: evidence-based recommendations for clinical management of women with epilepsy throughout the reproductive cycle. Hong Kong Med J. 2020;26(5):421-431. 

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[Guideline summary] Summary of German practical recommendations for women before and during pregnancy
 

WYE-EM-296-DEC-20