By: Aaliyah Ellison-McPeters
Growing and carrying a healthy baby to term can be a nerve-wracking and overwhelming experience for the average mother, even more so for the mother with epilepsy. However, with the proper knowledge and health care providers, becoming a mother with epilepsy can be a safe and beautiful event in a woman’s life.
On average, 24,000 infants are born to women with epilepsy annually, with a standard birthrate of 3 to 5 babies per 1,000 childbirths. Although most women with epilepsy have the same likelihood of conceiving and similar birth outcomes as mothers without epilepsy, it is highly recommended that any plans for conceiving are brought up to your obstetrician, support team, and especially your neurologist. This way, the chances for a healthy pregnancy and successful birth increase.
AEDs and Pregnancy
The concern many health care providers will have for a pregnant woman with epilepsy is ensuring the pregnancy was planned so that the use of pharmacotherapy can be administered to lower the risk of fetal anomalies and control the frequency of seizures throughout pregnancy. If a pregnant woman were to seize during pregnancy, it could slow the fetus’s heart rate, decrease oxygen, and cause low birth weight and preterm birth (Mayo Clinic, 2020). Additional risks to a developing fetus include the teratogenic effect, development of malformations, caused by anti-epileptic drugs. Teratogenicity can cause congenital abnormalities and dysmorphia, typically occurring during the first trimester of pregnancy. It was found that the risk of babies of epileptic mothers not using AEDs developing congenital abnormalities ranged from 1.1-1.3%, similar to non-epileptic mothers. The risk increases to 4-9% with the use of AEDs and even more so with valproic acid and polytherapy.
Studies have shown that supplementing with 5 mg of folic acid daily can prevent fetal deformity in fetuses of epileptic women taking AEDs by reducing the frequency of seizures. (Dohery 2021). However, high doses of more than 5 mg/day of folic acid are not recommended (Asadi-Paoya, Ali A, 2015)
Stages of Labor
Most epileptic women have similar birth outcomes as non-epileptic women; however, it’s beneficial to understand the stages of labor and how they may affect a woman with epilepsy. There are four stages of labor:
- The first stage is responsible for the dilation of the cervix.
- The second stage is when the birth of the baby takes place.
- The third stage is when the afterbirth, or the delivery of the placenta, occurs.
- The fourth stage is recovery.
In the first stage of labor, labor starts with the dilation of the cervix and ends once the mouth of the uterus reaches 10 centimeters. This stage of labor typically begins spontaneously through the combination of the pressure of the baby against the cervix and the hormone oxytocin. The stimulation of your baby pressing up against your cervix and the tissue of your pelvic floor sends impulses to the brain that stimulate the pituitary gland to deliver oxytocin into your bloodstream. In stimulating uterine contractions, the production of prostaglandins increases, increasing the frequency of contractions. Labor can also be induced by manually opening the cervix, breaking of waters, or through medication. In the second stage of labor, the cervix is completely open, thin, and soft, which means you’re ready for childbirth. This stage can last anywhere from 30 minutes to a few hours. In the third stage, the maternal placenta is delivered, the cord is cut, and the placenta is separated from the uterine wall and passes through the birth canal. This is the natural end of childbirth. In the last stage of recovery, rest should be prioritized, and skin-to-skin and breastfeeding can be established.
On average, 1-2% of women with epilepsy experience seizures during childbirth. Labor itself can create stress that can induce seizures, though no evidence shows that the use of AEDs harms the process of birth or immediate postpartum. The risk of having seizures during childbirth may decrease if AED levels are maintained during the last trimester of pregnancy, and the use of AEDs should not be stopped during pregnancy as it could have adverse effects on both fetal and maternal parties (Gedzelman, E., & Meador, K. J., 2012).
Antenatal Complications and Immediate Postpartum
Epileptic women have an increased risk of developing mild preeclampsia, gestational hypertension, bleeding during pregnancy, and excessive bleeding postpartum during or immediately after pregnancy. Though it is unclear if the increased risk of pregnancy-related complications stems from the condition itself, the use of anti-epileptic drugs, or both, current research points to the use of medications and the dosage during gestation (Borthen, I., & Gilhus, N. E., 2012). For women with epilepsy, the postpartum period can be a vulnerable time concerning any medication changes, stress, sleep deprivation, and any challenges with breastfeeding. In addition, the adjustment of AEDs during postpartum can create difficulty in controlling the frequency of seizures and increase the risk of developing postpartum mood disorders. It is essential that new mothers have a strong support system to facilitate proper healing and bonding with their new baby. New mothers should eat balanced meals, sleep adequately, and receive appropriate care from their healthcare providers regarding their physical, emotional, and mental state. Adequately caring for women during immediate postpartum promotes the overall health and well-being of new mothers and may increase the recovery rate.
Asadi-Pooya, A. A. (2015). High dose folic acid supplementation in women with epilepsy: are we sure it is safe? Seizure, 27, 51-53.
Beraki, G.G., Tesfamariam, E.H., Gebremichael, A. et al. Knowledge on postnatal care among postpartum mothers during discharge in maternity hospitals in Asmara: a cross-sectional study. BMC Pregnancy Childbirth 20, 17 (2020). https://doi.org/10.1186/s12884-019-2694-8
Borthen, I. (2015). Obstetrical complications in women with epilepsy. Seizure, 28, 32-34.
Borthen, I., & Gilhus, N. E. (2012). Pregnancy complications in patients with epilepsy. Current opinion in obstetrics & gynecology, 24(2), 78–83. https://doi.org/10.1097/GCO.0b013e32834feb6a
Danielsson, K. C., Borthen, I., Morken, N. H., & Gilhus, N. E. (2018). Hypertensive pregnancy complications in women with epilepsy and anti-epileptic drugs: a population-based cohort study of first pregnancies in Norway. BMJ open, 8(4), e020998.
Gedzelman, E., & Meador, K. J. (2012). Anti-epileptic drugs in women with epilepsy during pregnancy. Therapeutic advances in drug safety, 3(2), 71–87. https://doi.org/10.1177/2042098611433192
Hiilesmaa, V. K., Bardy, A., & Teramo, K. (1985). Obstetric outcome in women with epilepsy. American journal of obstetrics and gynecology, 152(5), 499-504.
Jędrzejczak, J., Bomba-Opoń, D., Jakiel, G., Kwaśniewska, A., & Mirowska-Guzel, D. (2017). Managing epilepsy in women of childbearing age—Polish Society of Epileptology and Polish Gynecological Society Guidelines. Ginekologia Polska, 88(5), 278-284.
Katz, J. M., & Devinsky, O. (2003). Primary generalized epilepsy: a risk factor for seizures in labor and delivery? Seizure, 12(4), 217–219. https://doi.org/10.1016/s1059-1311(02)00288-1
Klein A. (2012). The postpartum period in women with epilepsy. Neurologic clinics, 30(3), 867–875. https://doi.org/10.1016/j.ncl.2012.06.001
Lascar, E. M., Warner, N. M., & Doherty, M. J. (2021). Pregnancy outcomes in women with epilepsy and MTHFR mutations supplemented with methylated folate and methylcobalamin (methylated B12). Epilepsy & Behavior Reports, 15, 100419.
Leach, J. P., Smith, P. E., Craig, J., Bagary, M., Cavanagh, D., Duncan, S., … & Reuber, M. (2017). Epilepsy and pregnancy: for healthy pregnancies and happy outcomes. suggestions for service improvements from the Multispecialty UK epilepsy mortality group. Seizure, 50, 67-72.
MacDonald, S. C., Bateman, B. T., McElrath, T. F., & Hernández-Díaz, S. (2015). Mortality and morbidity during delivery hospitalization among pregnant women with epilepsy in the United States. JAMA neurology, 72(9), 981-988.
Mayo Clinic. 2020. Epilepsy and pregnancy: What you need to know. [online] Available at: https://www.mayoclinic.org/healthy-lifestyle/pregnancy-week-by-week/in-depth/pregnancy/art-20048417
Nie, Q., Su, B., & Wei, J. (2016). Neurological teratogenic effects of anti-epileptic drugs during pregnancy. Experimental and therapeutic medicine, 12(4), 2400-2404.
Pilo, C., Wide, K., & Winbladh, B. (2006). Pregnancy, delivery, and neonatal complications after treatment with anti-epileptic drugs. Acta obstetricia et gynecologica Scandinavica, 85(6), 643-646.
Vajda, F. J. (2014). Effect of anti-epileptic drug therapy on the unborn child. Journal of Clinical Neuroscience, 21(5), 716-721.
Veroniki, A. A., Cogo, E., Rios, P., Straus, S. E., Finkelstein, Y., Kealey, R., … & Tricco, A. C. (2017). Comparative safety of anti-epileptic drugs during pregnancy: a systematic review and network meta-analysis of congenital malformations and prenatal outcomes. BMC medicine, 15(1), 1-20.
Yerby M. S. (1992). Risks of pregnancy in women with epilepsy. Epilepsia, 33 Suppl 1, S23–S27. https://doi.org/10.1111/j.1528-1157.1992.tb05897.x