Epilepsy Pregnancy — United States (Pregnancy population)
When treating people with epilepsy of childbearing potential (PWECP)
Clinicians should recommend ASMs and doses that optimize both seizure control and fetal outcomes should pregnancy occur, at the earliest possible opportunity preconceptionally (e.g., at the time of starting an ASM in a person post-menarche).
For PWECP
Clinicians should engage in joint decision-making, taking individual preferences into account when selecting ASMs and monitoring their dosing.
During pregnancy in PWECP
Clinicians must minimize the occurrence of convulsive seizures (generalized tonic-clonic seizures and focal-to-bilateral tonic-clonic seizures) to minimize potential risks to the birth parent (e.g., seizure-related mortality) and to the fetus.
Once a PWECP is already pregnant
Clinicians should exercise caution in attempting to remove or replace an ASM that is effective in controlling generalized tonic-clonic or focal-to-bilateral tonic-clonic seizures, even if it is not an optimal choice with regards to the risk to the fetus (e.g., valproic acid).
Throughout pregnancy
Clinicians should monitor ASM levels as guided by individual ASM pharmacokinetics and patient clinical presentation.
In response to decreasing serum ASM levels or worsening seizure control
Clinicians should adjust the dose of ASMs at their clinical discretion.
When treating PWECP
Clinicians must consider using lamotrigine, levetiracetam, or oxcarbazepine when appropriate based on the patient's epilepsy syndrome, likelihood of achieving seizure control, and comorbidities, to minimize the risk of major congenital malformations (MCMs).
Clinicians must avoid the use of valproic acid to minimize the risk of MCMs (composite outcome) or neural tube defects (NTDs), if clinically feasible.
To reduce the risk of cardiac malformations
Clinicians must avoid the use of phenobarbital in PWECP, if clinically feasible.
To reduce the risk of oral clefts
Clinicians should avoid the use of phenobarbital and topiramate in PWECP, if clinically feasible.
To reduce the risk of urogenital and renal malformations
Clinicians should avoid the use of valproic acid in PWECP, if clinically feasible.
To minimize the risk of offspring being born small for gestational age (SGA)
Clinicians should avoid the use of valproic acid or topiramate in PWECP, if clinically feasible.
To reduce the risk of poor neurodevelopmental outcomes, including autism spectrum disorder (ASD) and lower IQ, in children born to PWECP
Clinicians must avoid the use of valproic acid in PWECP, if clinically feasible.
To decrease the risk of neural tube defects (NTDs) in the offspring
Clinicians should prescribe at least 0.4 mg of folic acid supplementation daily preconceptionally and during pregnancy to any PWECP treated with an ASM.
To possibly improve neurodevelopmental outcomes such as ASD and global IQ in the offspring
Clinicians must prescribe at least 0.4 mg of folic acid supplementation daily preconceptionally and during pregnancy to any PWECP treated with an ASM.
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