Women with Epilepsy

Practice Tool for Women with Epilepsy
This Practice Tool offers discussion points for the care of women with epilepsy.  Points are highlighted for females during their reproductive years, women who are planning pregnancy, women during pregnancy, and those who are beyond childbearing years.

For all Women, Adolescents, and Pre-teens during Reproductive Years

  • Relationship between hormones and epilepsy (overview)
  • Possible menstrual cycle-related influence on seizure susceptibility (catamenial epilepsy)
  • Impact of epilepsy on sexual and reproductive issues
  • No clear relationship between epilepsy and infertility                 
    • Consult infertility specialist if there is a sign of difficulty conceiving, test for PCOS
  • Relation of some AEDs to libido and sexual dysfunction
  • Women with epilepsy CAN become pregnant whether they are on AEDs or not
    • Importance of pregnancy planning including folate supplementation
    • Need for effective and consistent contraception to avoid unplanned pregnancy
  • Effective contraception choices should consider:
    • Interactions between hormonal contraception and certain AEDs
    • Possible contraceptive failure, need to consider more effective methods
    • Forms of long-acting reversible contraception (LARC) ideal if on an enzyme-inducing AED (IUD, Depo-Provera, progestin implant)
  • Enzyme-inducing effects of estrogen hormones on some AEDs 
  • Need to inform neurologist if contraception is discontinued
  • Optimize bone health
    • Need for vitamin D screening (25 hydroxyvitamin D concentrations) and vitamin D supplementation (at least RDA of 400 IU, higher dose with enzyme inducing AEDs)
    • Ensure RDA of calcium with food and supplements
    • Monitor bone health with DXA screening for those at risk. 
  • Optimal seizure control and AED type and dose should be achieved before attempting to conceive
    • Folic acid supplementation recommendation for all women with childbearing potential.  The optimal dose of folate is not known but at least 0.4 mg/day up to 4 mg/day

Women Planning to Conceive

  • Confirm the diagnosis of epilepsy and seizure type. In all discussions, emphasize the balance of all risks and the goal of controlling seizures.
  • Optimal seizure control and AED choices should be achieved before attempting to conceive
  • Need for folate supplementation in all women of with child bearing potential.  The optimal dose of folate is not known but at least 0.4  mg/day up to 4 mg/day.
  • Healthy pregnancies and healthy babies are the goal
  • Assess all risks (women not taking AEDs also have risks)
  • Risks to the baby from AEDs must be balanced with risk of seizures to baby and mother
  • Ways to reduce risks to mother and baby (AED choice, folate supplementation)
  • Appropriate AED medication and dosing
    • Optimize before pregnancy
    • Compliance counseling
    • Neurology consultation before any AED changes
  • Identify an obstetrician comfortable treating a woman with epilepsy
  • How pregnancy can affect seizure frequency and severity
  • Fertility treatments and possible effects on AED levels and seizure susceptibility

Pregnant Women 

  • Confirm the diagnosis of epilepsy and seizure type. In all discussions, emphasize the balance of all risks and the goal of controlling seizures.
  • Consultation with patient’s obstetrician ________________(date) 

For patients who never received pre-pregnancy planning or counseling:

  • Discuss impact of AEDs and multiple AEDs on outcome, risks of AEDs vs. seizures, timing of major malformations to first trimester, but neurodevelopment occurs throughout all 3 trimesters.
  •  Possible teratogenic effects compared to people not taking an AED
  • Possible change in AED therapy (only in consultation with neurologist) 

Review of pregnancy management by trimester:
First Trimester

  • Establish care with obstetrician
  • Continue folic acid
  • Changes in serum AED concentration in pregnancy and need for close monitoring of blood levels, serum levels once per month recommended during pregnancy
  •  AED management with severe emesis 

Second Trimester

  •  Continue folic acid
  • Changes in serum AED concentration in pregnancy and need for close monitoring of blood levels, serum levels once per month recommended during pregnancy 
  • High resolution, structural ultrasound approximately 16-20 weeks gestational age

Third Trimester

  • Possible Vitamin K use with certain AEDs beginning at 36 weeks GA
  • Changes in serum AED concentration in pregnancy and need for close monitoring of blood levels, serum levels of once per month recommended during pregnancy 

Labor and Delivery

  •  Need to bring AEDs to the hospital during labor and to take regular doses 
  • Consider need for IV formulations of AEDs during prolonged labor and delivery or if complications present
  • Consider need for rescue AED treatment for seizures during labor and delivery

Post-partum

  •  AED dose adjustment following delivery and post-partum follow-up
  • Breast feeding: discussion of risks from AEDs balanced against known benefits of breast feeding, including improved neurodevelopment
  • Parenting safety to maximize safety:
    • Maintaining adequate sleep for mother to prevent seizure exacerbation
    • Home safety preparation
    • Safety for the newborn (changing on floor or bed, bathing, carrying up stairs)
    • Safety for the mother with enhanced seizure precautions during immediate postpartum phase (bathing, driving)

Women Beyond Childbearing Years

  • Bone health and need for vitamin D screening and supplementation, calcium or other treatments for bone health as needed; bone density monitoring.
  • Maximize seizure control to prevent falls
  • Peri-menopause effects on seizures/AEDs
  • Menopause/hormone replacement issues; enzyme-inducing effects of hormones on AEDs 

 

Adapted with permission from Checklist for Discussions with Your Doctor, epilepsy.com.

Approved:        AES Practice Committee, September 2007

Revised:           Patricia O. Shafer RN, MN Page Pennell MD, Allison Pack MD, Barbara Dworetzy, MD

October 6, 2013

Disclaimer: AES is providing this document without representations or warranties of any kind and for information only, and it is not intended to suggest how a specific patient should receive medical treatment. Determination of whether and/or how to use all or any portion of this document is to be made in your sole and absolute discretion. No part of this document constitutes medical advice. As a clinician, your knowledge of the individual patient and judgment about what is appropriate and helpful to them should be used in making clinical decisions.