New guidelines for women with epilepsy have been issued by the American Academy of Neurology (AAN). A summary statement of the practice parameter was published in the October 1998 issue of Neurology. It is accompanied by a review of the literature referable to the management of women with epilepsy. The recommendations in the practice parameter are intended to help women with epilepsy make decisions about contraception, pregnancy and breast feeding while effectively managing the disease.
The development of this parameter was undertaken by members of the AAN Quality Standards Subcommittee in conjunction with the American Epilepsy Society, the Epilepsy Foundation and the Child Neurology Society (CNS). Parameter drafts were reviewed by selected experts in epilepsy and of the American College of Obstetrics and Gynecology, the American Academy of Pediatrics and the CNS.
According to the guidelines, there are potentially over 1 million women with epilepsy of childbearing age in the United States. The authors of the guidelines emphasize that the issues for these women are complex and multi-faceted, and many women with epilepsy and their health care professionals need more information about these issues. The issues covered in the guidelines include the risk of birth defects in children born to women taking antiepileptic drugs, contraception, seizures and hormonal fluctuations, management during pregnancy, counseling, breast feeding and adjustment of medication after pregnancy (see table).
The following are the guidelines that have been proposed by the AAN:
Because antiepileptic medications can increase the risk of birth defects, using only one antiepileptic drug should be the goal in women of childbearing age. The drug selected for use should be the most appropriate for the woman's seizure type. Drug therapy should be optimized before conception, if possible. If drug withdrawal is planned, withdrawal should be completed at least six months before conception. A change in medications should not be undertaken solely for the purpose of reducing teratogenic risk.
As is recommended for the general female population, all women with epilepsy should take folic acid supplementation of no less than 0.4 mg per day.
Because some antiepileptic drugs can decrease the effectiveness of oral contraceptives, women with epilepsy should be counseled concerning the preferred method of birth control.
During pregnancy, women with epilepsy, especially those treated with carbamazepine, divalproex sodium or valproic acid, should be offered prenatal testing with alpha-fetoprotein levels at 14 to 16 weeks of gestation, level II ultrasound at 16 to 20 weeks of gestation, and, if needed, amniocentesis for amniotic fluid alpha-fetoprotein and acetylcholinesterase levels.
Breast feeding can be recommended as an option for infants of women with epilepsy. According to the AAN, there are no absolute contraindications to breast feeding in these infants. However, these infants should be closely monitored.
The practice parameter also lists practice options that include counseling for the possibility of seizure frequency changes during pregnancy, importance of medication compliance, the need for regular follow-up during pregnancy and inheritance risks of seizures. Additional information for patients may be obtained from the Epilepsy Foundation at 800-EFA-1000. The Web site is http://www.efa.org.
The report calls for more research in several areas. These include well-designed studies of pregnancy outcomes for women with epilepsy, especially in women taking the new antiepileptic drugs; studies on the efficacy of hormonal contraception in women with epilepsy; studies of issues concerning seizure frequency changes through the stages of reproductive life; and the promotion of pregnancy registries to monitor the teratogenesis of antiepileptic drugs. The AAN also recommends physician education regarding management issues for women with epilepsy at all levels of training and practice.