Comprehensive Epilepsy Center
Women's Health - Pregnancy 

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Fact of the day: Both seizures and medicines used to control seizures increase the risk of birth defects. Women with epilepsy reduce the risk by taking the lowest dose of seizure medicine that controls their seizures.

Seizures, especially convulsions (tonic-clonic seizures) during pregnancy can harm the fetus-directly by causing abdominal trauma and also by causing changes in the fetal heart rate, oxygen levels and blood supply. Complex partial seizures may also change the fetal heart rate.

Exposure to epilepsy drugs during pregnancy is associated with an increased risk of birth defects. The major birth defects include heart defects, cleft lip or palate, skeletal malformations (clubfoot), open spine defects (neural tube defects), and small head size. The risk of birth defects in healthy women in the U.S. is two to three out of every 100 babies. The risk for women with epilepsy is increased two times, so that four to six babies out of 100 are affected. Over 90% of women with epilepsy have routine pregnancies and deliver healthy babies.

All of the seizure medications are associated with birth defects. There is no “ideal” drug for pregnancy. The FDA gives a rating to all medicines concerning their risk in pregnancy. All of the seizure medicines are category C except Depakote and Tegretol, which are category D. Category C means that human studies are lacking. Category D means that there is a known risk in humans. If Depakote or Tegretol control your seizures best, you should take it during pregnancy.

Specific antiepileptic drugs and fetal malformations:

• Phenytoin (Dilantin): In addition to the major birth defects noted above there is also a described “fetal hydantoin syndrome” which consists of numerous minor problems including lazy eye, eyelid drop, nail and finger changes, hyperextensible joints, hernia, and abnormal dermatoglyphic (finger print) patterns.
• Phenobarbital: In addition to the major and minor anomalies listed above, exposed infants can have barbiturate depression at birth or drug withdrawal.
• Carbamazepine (Tegretol): It is associated with spina bifida (open spine defect). In the general population, one out of every 1,000 American babies is born with spina bifida. The overall risk for neural tube defect (NTD) in infants exposed to carbamazepine is estimated at 1 in 100. This represents a ten-fold increase compared to the general population. Since the neural tube closes between 22 and 29 days after conception, exposure after the fifth week of pregnancy does not produce this defect.
• Valproic acid (Depakote): This drug may also cause a neural tube defect with an estimated risk of 1-2 out of 100. This occurs independently of mom’s family history of NTD or with type of epilepsy. Patients with higher serum levels may be at greatest risk because most cases occur in infants exposed to >1,000 mg/day.
• Lamitrigine (Lamictal): So far, 362 pregnancies have been registered with the company prospectively from 13 different countries. Of these pregnancies, 42% involved Lamictal monotherapy and 58% involved polypharmacy (multiple drugs). The risk of birth defects on Lamictal monotherapy is 1.5%, similar to the risk in the general population. There appears to be a high risk of birth defects when Lamictal is taken with Depakote (28%).
• Keppra, Topamax, Gabitril, and Zonegran: There is little to no information concerning these drugs. There is special concern for Topamax and Zonegran due to their effects on metabolism.

There is a national pregnancy registry, which is sponsored by six drug companies. The purpose is to record pregnancy outcome for all women with epilepsy. This will allow everyone to better determine the specific risks of birth defects for all the drugs. All women with epilepsy that become pregnant should be reported to the toll-free AED Pregnancy Registry. All information is kept confidential. Any women may call 1-888-233-2334. Enrolled women are asked to report the health status of their infants.

TIPS for a healthy pregnancy:

1. Plan your pregnancy and speak with your doctor. You may be able to reduce the number of medication you are taking or lower the dose.
2. Begin taking a vitamin supplement and folic acid.
3. Stop smoking.
4. No alcohol.
5. Eat a balanced diet.
6. Report seizures promptly to your doctor.
7. Have blood levels checked regularly.
8. Find a high-risk obstetrician.