Epilepsy

Question 1

What are the key principles of epilepsy management in pregnancy?

Answer 1

Pre-conception counselling is essential (ideally before stopping contraception)
Continue anti-epileptic drugs (AEDs) — uncontrolled seizures are more dangerous than medication
Monotherapy at lowest effective dose preferred
Sodium valproate CONTRAINDICATED unless no alternative (Pregnancy Prevention Programme required)
Safest AEDs: Lamotrigine, Levetiracetam
High-dose folic acid 5mg pre-conception → 12 weeks
Drug levels may change in pregnancy (particularly lamotrigine — levels fall due to increased clearance → may need dose increase)
Vitamin K for baby at birth (IM vitamin K offered to all neonates routinely; some enzyme-inducing AEDs increase risk of haemorrhagic disease)
If on enzyme-inducing AEDs (carbamazepine, phenytoin, phenobarbital): oral vitamin K 10mg daily from 36 weeks to mother (some guidelines)
Breastfeeding: Generally safe with most AEDs (some sedation with phenobarbital/benzodiazepines)
Avoid sleep deprivation postnatally (seizure trigger) — safety advice: don’t bathe baby alone, change nappies on floor
Status epilepticus in pregnancy: IV lorazepam → IV phenytoin → consider delivery if prolonged

Question 2

Rank the teratogenicity of common AEDs.

Answer 2

1. Sodium valproate - 10%
2. Carbamazepine - 2-3%
3. Phenytoin - 3-4%
4. Phenobarbital - 5-6%
5. Topiramate 4%
6. Lamotrigine - 2%
7. Levetiracetam - 2% (Relatively reassuring data)