| Timeline | Preconception | Pregnancy first trimester | Pregnancy second trimester | Pregnancy third trimester | Postpartum (approximately 6 weeks) |
| Clinic visits with the neurologist, with discussion topics | - Review the history, imaging and EEG findings to confirm diagnosis and ascertain the epilepsy syndrome
- Balance seizure risks against AED risks, by type of AED and dose of AED (eg, major congenital malformation, adverse neonatal outcomes, adverse neurodevelopment).
- Valproate should be avoided whenever possible. If on valproate, consider whether all other appropriate options have been tried.
- Consider whether the patient could be on monotherapy with lower dosage. Consider AED withdrawal if appropriate (epilepsy in remission and high likelihood of successful withdrawal).
- Seizure control before pregnancy is important if possible. Counsel the patient about risks of increased seizure rates or severity during a pregnancy, especially if AEDs are stopped abruptly (eg, blunt trauma with risk of foetal loss, injury, or abruptio placentae, decreased foetal oxygenation, increased foetal distress, maternal SUDEP).
- Given the incidence of unplanned pregnancies, women with childbearing potential taking AEDs should also be on supplementary folic acid prior to pregnancy and continue throughout pregnancy.
| - Reinforce AED clearance changes and begin AED level monitoring immediately*, if on an AED with substantial clearance changes.
- AED dose adjustments for increased seizures or side effects and to maintain baseline, non-pregnant AED level(s)*.
- Re-dose AEDs if emesis occurs shortly after AED intake.
- Screening for depression and anxiety.
| - Continue to monitor changes in AED levels at least monthly*.
- AED dose adjustments to maintain baseline level(s)*, and for seizures or side effects.
- Review results from prenatal screening tests.
- History and neurological examination for signs of increased medication side effects.
- Screening for depression and anxiety.
| - Possible increased risk of seizure worsening peripartum.
- Birth plan recommendations from neurology perspective.
- Desire to breastfeed with data to support that benefits outweigh theoretical risks.
- Strategies to breastfeed but allow some sleep for the mother.
- Postpartum AED taper plan (usually determined after an AED level at 34 to 37 weeks gestational age).
- Newborn safety and signs for adequate hydration and nutrition if breastfeeding.
- History and neurological examination for signs of increased medication side effects.
- Screening for depression and anxiety.
| - Review history of postpartum seizures and/or medication side effects.
- Assess for postpartum depression and anxiety.
- Assess sleep hygiene and strategies to increase if needed.
- History of infant feeding, growth and development.
- Neurological examination for signs of medication side effects.
|
| Blood workup for AED levels, if on an AED with clearance changes during pregnancy* | Determine optimal individualized baseline pre-pregnancy AED level*. | Monthly AED blood levels*. | Monthly AED blood levels*. | Monthly AED blood levels*. | AED blood level if clinically indicated*. |
| Communication with the patient about AED dosing | | Adjustment of AED dosing for seizures or side effects and to maintain baseline, non-pregnant AED levels. | Adjustment of AED dosing for seizures or side effects and to maintain baseline, non-pregnant AED levels. | Adjustment of AED dosing for seizures or side effects and to maintain baseline, non-pregnant AED levels. | Review if postpartum AED taper was followed and adjust further as needed clinically. |
| Communication between the neurologist and obstetrician | - Decision on contraception choice/initiation/discontinuation.
- Further adjustment of AED regimen regarding type of AED and dose of AED with lowest foetal risk without compromising seizure control.
| - Obtain AED levels* (blood can be drawn at more frequent obstetric appointments).
| - Obtain AED levels*.
- Results from screening tests (blood and ultrasound) reviewed and communicated to patient.
| - Obtain AED levels*.
- Coordinate labour and delivery hospital care plan with the obstetrician, neurologist, and patient. Include neonatologist for clinical concerns based on prenatal testing.
| Neurologist and obstetrician together: - Develop short-term and long-term plan for contraception.
- Discuss future pregnancy plans and preferred timing.
|
