Learning outcomes

After reading this article, pharmacists should be able to:

• Describe the risks epilepsy and ASM pose to both mother and baby during pregnancy;
• Identify strategies to reduce risk before and during pregnancy, including appropriate medication choice and folic acid use; and
• Apply practical pharmacy-based interventions to support women with epilepsy during pregnancy and in the postnatal period.

Epilepsy is one of the most common serious neurological conditions worldwide, affecting an estimated 15 million women of reproductive age. In Ireland, approximately 25 per cent of people diagnosed with epilepsy are women of child-bearing potential, representing almost 10,000 individuals. These women often require carefully managed treatment plans and need to consider the impact of both epilepsy and anti-seizure medications (ASM) on menstruation, contraception, fertility, pregnancy, infant care, and menopause. Pharmacists, therefore, play a critical role in helping women and their families understand risk–benefit balances, supporting adherence, and reinforcing specialist advice.

Epilepsy and pregnancy: risks for the mother

Most women with epilepsy will experience a normal pregnancy and childbirth. However, several important risks should be considered:

1. Increased maternal mortality: Epilepsy in pregnancy is associated with a significantly increased risk of maternal death, estimated to be up to ten-fold higher than in the general population. Sudden Unexpected Death in Epilepsy (SUDEP) is the leading cause, followed by status epilepticus. Epilepsy Ireland provides valuable resources on recognising and reducing SUDEP risk, as well as guidance on the emergency management of prolonged seizures (see ie);
2. Higher rates of obstetric complications: Women with epilepsy are more likely to experience complications such as pre-eclampsia, haemorrhage, premature delivery, foetal growth restriction and stillbirth, compared with the general population; and
3. Increase in seizure frequency: Approximately one third of women may experience an increase in seizure frequency during pregnancy. This can be due to:

• Increased exposure to seizure triggers such as sleep deprivation, stress, pain, infection, dehydration, nausea, and vomiting;
• Reduced adherence to ASMs, including missed doses due to severe nausea or vomiting;
• Hormonal changes; and/or
• Pharmacokinetic changes in pregnancy leading to reduced absorption or lower serum levels of some ASMs.

Epilepsy and pregnancy: risks for the baby

Some anti-seizure medications used in pregnancy carry teratogenic potential. Although the majority of babies born to women with epilepsy are healthy, the following risks are increased compared with the general population:

1. Major congenital malformations (MCMs): There is a two- to three-fold increased risk of MCMs, including neural tube defects (for example spina bifida), orofacial clefts, congenital heart defects, urogenital and skeletal abnormalities. These conditions often require medical or surgical intervention and may not be fully correctable;
2. Minor congenital malformations: Minor malformations occur approximately twice as often. These are usually physical variations that have no medical consequences, such as clinodactyly (curved fingers or toes), mild syndactyly (webbed fingers or toes), low-set ears, wide-set eyes, or a low nasal bridge;
3. Neurodevelopmental disorders: There is an increased risk of neurodevelopmental disorders, including attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder (notably with valproate and topiramate), and intellectual disability. These conditions may not become apparent until school age and can affect learning, communication, behaviour, and social functioning; and
4. Foetal anticonvulsant syndromes: In some cases, multiple risks may occur in the same child. Foetal anticonvulsant syndromes describe a pattern of major and minor malformations with or without neurodevelopmental delay. Foetal Valproate Spectrum Disorder (FVSD) is a well-known example.

Uncontrolled seizures are not proven to cause congenital malformations; however, they are associated with increased foetal and maternal mortality. Therefore, it is essential that as pharmacists, we support adherence to ASMs.

Minimising risks of epilepsy in pregnancy

Effective seizure control remains the primary goal throughout pregnancy, as most risks increase when seizures are poorly controlled. Women should be clearly advised never to stop or adjust their ASM without specialist input, even if pregnancy is confirmed unexpectedly.

Pregnancy planning is one of the most effective risk-reduction strategies. Some ASMs are enzyme inducers and can reduce the effectiveness of hormonal contraception. Women with epilepsy should therefore receive counselling on effective contraception and pregnancy considerations from menarche onwards.

Community pharmacists should encourage women with epilepsy wishing to conceive, to seek pre-conception counselling. The aims are to:

• Achieve seizure freedom (where possible);
• Use the lowest effective dose of the most pregnancy-compatible ASM; and
• Avoid polytherapy where feasible.

Folic acid supplementation should be promoted for all women of child-bearing potential. It is recommended for at least three months prior to conception and during the first trimester, with some evidence supporting continuation throughout pregnancy. Folic acid reduces the risk of neural tube defects and has been associated with improved cognitive outcomes in children.

Women should be encouraged to engage regularly with neurology services during pregnancy, ideally at least once per trimester. Serum levels of ASMs such as lamotrigine and levetiracetam may fall during pregnancy, necessitating dose increases. Pharmacists should explain dose changes clearly, as patients may have been stable on the same dose for many years and may overlook dispensing label changes.

Encouraging patients to keep an up-to-date medicines list is good practice. The HSE’s My Medicines List can be printed from the HSE website, or patients may keep a digital list on their phone.

Comparative safety of ASMs in pregnancy

The risks associated with ASMs vary significantly between agents and are often dose-dependent. In general, lower doses are safer than higher doses, and monotherapy is preferred to polytherapy.

Large pregnancy registries have provided valuable safety data and have informed the introduction of the sodium valproate and topiramate Pregnancy Prevention Programmes. Sodium valproate and topiramate are considered higher-risk ASMs and are therefore contraindicated in pregnancy. Drugs such as lamotrigine and levetiracetam are associated with a lower known teratogenic risk. For newer ASMs, like cenobamate, pregnancy safety data remain limited.

Folic acid dosing

The standard folic acid dose for women of child-bearing age in the general population is 400 mcg daily. A higher dose of 5 mg daily is recommended for women at increased risk of neural tube defects in offspring and has traditionally been advised for women with epilepsy, as some ASMs have anti-folate effects.

Recent studies have suggested a possible association between higher doses of folic acid (>1 mg daily) and cancer risk, leading to some uncertainty. At present, there is no national consensus regarding optimal dosing for women with epilepsy. Community pharmacists should reinforce individualised specialist advice, which may vary between services.

Practical advice for community pharmacists

Community pharmacists can make a significant impact through routine practice:

• Strictly follow sodium valproate and topiramate Pregnancy Prevention Programmes and the valproate guide for male patients, reporting any pregnancy exposure to the HPRA;
• Reinforce adherence to ASMs at every opportunity; consider blister packing or medication reminders;
• Educate patients about seizure triggers and promote healthy lifestyle measures (for example, diet, hydration, regular sleep, avoid alcohol, and illicit drugs use);
• Raise awareness of SUDEP within the community;
• Encourage attendance at neurology services pre-conceptually, during pregnancy, and postnatally;
• Be alert to interacting medicines or drugs that lower the seizure threshold (for example, tramadol, certain anti-emetics);
• Ensure women with tonic-clonic seizures have access to buccal midazolam and that their significant others know how to administer it; and
• Advise urgent medical review if seizures worsen or if ASMs cannot be taken due to vomiting

Postnatally, community pharmacists can support patients by offering breastfeeding advice, reinforcing medication adherence, and providing practical safety guidance. This includes advising mothers on strategies to reduce risk during infant care, such as avoiding bathing the baby alone and taking baths by herself, avoiding baby slings, and avoiding co-sleeping. Where possible, mothers should be encouraged to sleep with another adult in the room for up to one year postpartum to reduce the risk of SUDEP and should feed and change the baby at a low level (for example, on the floor), ideally surrounded by cushions.

Case study

Aoife, a 29-year-old woman with epilepsy, presents to the pharmacy to collect her repeat prescription for lamotrigine. She mentions that she has recently discovered she is pregnant and is worried about harming her baby.

Pharmacist considerations:

• Reassure Aoife that maintaining seizure control is essential for both her and her baby;
• Explain that lamotrigine is among the ASMs associated with a lower known teratogenic risk;
• Emphasise that she should continue her medication and not stop abruptly;
• Encourage prompt contact with her neurologist or epilepsy specialist nurse; and
• Confirm current folic acid use and reinforce specialist guidance.

This interaction demonstrates how community pharmacists can reduce anxiety, prevent unsafe discontinuation of ASMs, and promote timely specialist review.

Conclusion

Managing epilepsy during pregnancy requires careful balancing of maternal and foetal risks. While some ASMs carry teratogenic and neurodevelopmental risks, uncontrolled seizures can be life-threatening. Community pharmacists play a vital role in safeguarding women with epilepsy through providing accurate information, consistent counselling, and close collaboration with specialist services. By remaining informed and proactive, pharmacists can contribute to safer pregnancies and improved outcomes for both mother and baby.