Pregnant Women With Epilepsy Should Avoid Valproate

New guidelines stress that, with good planning, most moms-to-be will do fine

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By Serena Gordon
HealthDay Reporter

MONDAY, April 27 (HealthDay News) -- Despite recent concerns about fetal malformations linked to the anti-seizure medication valproate, most women with epilepsy can expect to have a relatively uneventful pregnancy with careful planning and preparation, say new guidelines from the American Academy of Neurology.

Whenever possible, women should avoid taking valproate (Depakote) while pregnant, the guidelines state, because its use has been associated with fetal malformations and a decline in cognitive abilities in children whose mothers took the drug during pregnancy.

However, "women with well-controlled epilepsy can safely have children," stressed the lead author of the new guidelines, Dr. Cynthia Harden, director of the epilepsy division at the University of Miami Miller School of Medicine.

"There have been a lot of myths circulating about epilepsy and pregnancy, and even some doctors have told women they can't have children if they have epilepsy," she said. "By using a rigorous, scientific approach to come up with these guidelines, we're dispelling a lot of those myths."

For example, the guideline authors found that women with epilepsy don't have a significantly increased risk of having a cesarean section, late pregnancy bleeding, premature labor or premature delivery.

The new guidelines are scheduled to be presented at the American Academy of Neurology's annual meeting in Seattle on Monday and will be published online in the journal Neurology.

There are about half a million women with epilepsy in the United States, according to the guidelines. Out of every 1,000 births, there are between 3 and 5 infants born to women with epilepsy.

Harden said that women who are seizure-free for at least nine months prior to pregnancy will likely go through their whole pregnancy seizure-free as well. But, the guideline authors did recommend that medication levels be checked periodically throughout the pregnancy, because pregnancy can cause levels of seizure medications in the blood to drop.

Pre-pregnancy planning is key, according to the guidelines. The ideal is to be on one anti-seizure medication and to be on the lowest dose possible during pregnancy. And the time to experiment with different medications is before you get pregnant.

While it's best to avoid certain drugs, such as valproate and also phenytoin and phenobarbital, according to the guidelines, it's not always possible to do so. Some women must use these medications to control their seizures. And, having seizures during pregnancy is dangerous for both mother and baby.

"There are women who need to take valproate," said Harden, who added that these women should talk to their doctors to assess the risks before pregnancy. "The risk of malformations is higher, but 90 percent of babies born to women on valproate will not have major malformations," she said.

A study in the April 16 issue of the New England Journal of Medicine found that valproate could cause lasting cognitive impairment in children exposed in-utero to the drug. And the study's lead author recommended that valproate shouldn't be a first-line medication for women of childbearing age, because so many pregnancies are unplanned.

Dr. Orrin Devinsky, director of the Epilepsy Center at New York University's Langone Medical Center, said he agreed with that recommendation. However, if a woman must be on valproate during pregnancy, she should try and get to the lowest levels possible and be aware of the risks. "Pregnancy is a risk/benefit decision for each woman," he noted.

As in women without epilepsy, smoking can increase the risk of premature labor and delivery in women with epilepsy, the experts added.

The guidelines also recommend that women with epilepsy follow the standard recommendation to take 400 international units of folic acid daily to help prevent birth defects.

"Before a woman with epilepsy gets pregnant, she should consult a doctor who's knowledgeable about epilepsy and pregnancy, reduce medications if possible, and start taking folic acid," said Devinsky, adding that "women who are well-controlled going into pregnancy tend to do well in pregnancy."