Management issues for women with epilepsy--focus on pregnancy (an evidence-based review): III. Vitamin K, folic acid, blood levels, and breast-feeding: Report of the Quality Standards Subcommittee and Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology and the American Epilepsy Society.

A committee assembled by the American Academy of Neurology (AAN) reassessed the evidence related to the care of women with epilepsy (WWE) during pregnancy, including preconceptional folic acid and prenatal vitamin K use and the clinical implications of placental and breast-milk transfer of antiepileptic drugs (AEDs). The committee evaluated the available evidence based on a structured literature review and classification of relevant articles. Preconceptional folic acid supplementation is possibly effective in preventing major congenital malformations in the newborns of WWE taking AEDs. There is inadequate evidence to determine if the newborns of WWE taking AEDs have a substantially increased risk of hemorrhagic complications. Primidone and levetiracetam probably transfer into breast milk in clinically important amounts. Valproate, phenobarbital, phenytoin, and carbamazepine probably are not transferred into breast milk in clinically important amounts. Pregnancy probably causes an increase in the clearance and a decrease in the concentrations of lamotrigine, phenytoin, and, to a lesser extent carbamazepine, and possibly decreases the level of levetiracetam and the active oxcarbazepine metabolite, the monohydroxy derivative (MHD). Supplementing WWE with at least 0.4 mg of folic acid before pregnancy may be considered. Monitoring of lamotrigine, carbamazepine, and phenytoin levels during pregnancy should be considered, and monitoring of levetiracetam and oxcarbazepine (as MHD) levels may be considered. A paucity of evidence limited the strength of many recommendations.

Management of epilepsy and pregnancy: an obstetrical perspective.

Women with epilepsy who take antiseizure medicines have successful and unremarkable pregnancies the majority of the time. Achieving seizure freedom is important for successful pregnancies, and it is also highly predictive of seizure freedom during pregnancy. From data derived from the general population, vitamin supplementation is important to prevent birth defects, and women with epilepsy of child-bearing potential should be encouraged to take folic acid supplements daily. Pregnant women with epilepsy should have their pregnancies screened for neural tube defects with a maternal serum alpha-feto-protein level at 15-16 weeks of gestational age and an anatomical survey by ultrasound at 18-22 weeks of gestation. Pregnant women with epilepsy do face a higher risk of both non-proteinuric hypertension and induction of labor than do then general population, as well as an approximately twofold risk of cesarean section. However, the indication for cesarean section is unclear and appears not to be related to fetal distress and may in part be influenced by caution at the time of delivery for such patients. Collaboration between the patient, neurologist, and obstetrician is important for managing this dynamic and complex clinical situation.