Recent guidance from leading medical organizations aims to assist clinicians in navigating the complexities of epilepsy treatment during pregnancy. Released jointly by the American Academy of Neurology, the American Epilepsy Society, and the Society for Maternal-Fetal Medicine, the new practice guideline provides recommendations on the use of antiseizure medications (ASMs) and folic acid supplementation before and during pregnancy.
Dr. Alison M. Pack, the lead author of the guidelines and a professor of neurology at Columbia University, emphasized the importance of balancing seizure control with minimizing potential risks to both the mother and the fetus. The guideline, published online in Neurology, serves as a significant update to the 2009 guidance, incorporating new data on the differential effects of various ASMs on pregnancy outcomes.
The comprehensive review addresses the nuanced considerations surrounding ASM use during pregnancy. Notably, the guideline emphasizes shared decision-making between patients and clinicians to ensure informed choices aligned with individual preferences and values. Key recommendations include optimizing seizure control and fetal outcomes through ASM selection, monitoring ASM levels throughout pregnancy, and adjusting doses as necessary based on clinical response and pharmacokinetics.
Of paramount importance is the cautionary approach recommended regarding valproic acid use due to its association with a higher risk of major congenital malformations and neurodevelopmental issues in offspring. Instead, the guideline advocates for considering alternative ASMs such as lamotrigine, levetiracetam, or oxcarbazepine when feasible.
While acknowledging the limitations in available data, particularly regarding certain ASMs’ effects on pregnancy outcomes, the guideline underscores the importance of ongoing monitoring and fetal screenings to detect any potential complications early.
Dr. Pack emphasized the critical need for further research to better define optimal folic acid supplementation dosages and to address remaining uncertainties surrounding ASM use during pregnancy.
Commenting on the guidelines, Dr. Kimford Meador from Stanford University acknowledged the progress made since 2009 and deemed the recommendations reasonable given the available evidence.
As epilepsy affects a significant portion of individuals of childbearing potential, understanding the implications of ASM use during pregnancy is essential for healthcare providers managing these patients. The new guidelines provide valuable insights to support informed decision-making and optimize outcomes for both mothers and their offspring.
