Managing Epilepsy During Pregnancy

Pre-Pregnancy Planning

Women with epilepsy who are pregnant or planning pregnancy should continue antiepileptic drug (AED) therapy, as uncontrolled seizures pose greater risks to both mother and fetus than most AED exposures, according to the American Academy of Neurology 1, 2
The most important intervention occurs before conception: reviewing and optimizing AED selection based on teratogenic risk profiles, as recommended by the American College of Obstetricians and Gynecologists 3
Identifying high-risk AEDs, particularly valproate, which carries substantially higher risks of major congenital malformations and neurodevelopmental impairment compared to other AEDs, is crucial, as stated by the National Institute of Neurological Disorders and Stroke 3
Switching from valproate to lower-risk alternatives before conception if the seizure type permits is advised, according to the American Epilepsy Society 3
Women on valproate require special attention due to reproductive endocrine complications, including polycystic ovary syndrome (PCOS), which affects 60-64% of women on valproate monotherapy, as reported by the Endocrine Society 4
Obese patients or those with significant weight gain on AEDs need evaluation for reproductive endocrine disorders before pregnancy, as recommended by the American College of Obstetricians and Gynecologists 3

Never discontinue AEDs during pregnancy due to concerns about fetal effects—breakthrough seizures carry catastrophic risks that outweigh medication risks, according to the American Academy of Neurology 1, 2
Seizure control is paramount for reducing maternal and fetal morbidity and mortality, as stated by the National Institute of Child Health and Human Development 1, 2
Changing medications during pregnancy introduces unnecessary risks if seizures are already controlled, as advised by the American Epilepsy Society 1
If seizure control worsens, increasing AED doses rather than switching medications is recommended, according to the American Academy of Neurology 1

Seizures during labor constitute a medical emergency requiring immediate EMS activation, as stated by the American College of Obstetricians and Gynecologists 2
Metabolic disturbances during labor can precipitate seizures, according to the National Institute of Neurological Disorders and Stroke 2
Planning for specialized care during labor with continuous supervision and emergency protocols is essential, as recommended by the American Academy of Neurology 2
Seizures lasting >5 minutes require immediate anticonvulsant intervention, as advised by the American Heart Association 2

Radiopharmaceuticals for nuclear medicine imaging (PET/SPECT) are generally contraindicated in pregnancy, according to the European Association of Nuclear Medicine 5, 6
If clinically necessary, decisions require multidisciplinary team analysis of benefits versus fetal risks, as stated by the Society of Nuclear Medicine and Molecular Imaging 5, 6
Otherwise, imaging should be postponed until after pregnancy, as recommended by the American College of Radiology 5, 6

For nuclear medicine procedures: no interruption needed for [18F]FDG; 12-hour pause recommended for other 18F-labeled compounds, as advised by the European Association of Nuclear Medicine 5, 6

Assuming all AEDs carry equal pregnancy risks—valproate is distinctly more teratogenic, as stated by the National Institute of Neurological Disorders and Stroke 3
Attempting to taper or discontinue AEDs during pregnancy when seizures are controlled, as advised against by the American Academy of Neurology 1
Making medication changes during pregnancy rather than before conception, as recommended against by the American Epilepsy Society 3, 1