3
Treatment
General
1A. Clinicians should engage in joint decision-making with PWECP,
taking individual preferences into account when selecting ASMs and
monitoring their dosing (Level B).
1B. When treating 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) (Level B).
2A. Clinicians must minimize the occurrence of convulsive seizures
(generalized tonic-clonic seizures and focal to bilateral tonic-clonic
seizures) in PWECP during pregnancy to minimize potential risks to the
birth parent (e.g., seizure-related mortality) and to the fetus (Level A).
2B. 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) (Level B).
2C. Clinicians should monitor ASM levels in PWECP throughout pregnancy
as guided by individual ASM pharmacokinetics and patient clinical
presentation (Level B).
2D. Clinicians should adjust the dose of ASMs at their clinical discretion
during the pregnancy in response to 1) decreasing serum ASM levels,
or 2) worsening seizure control (observed or anticipated based on
the clinician's judgment and known pharmacokinetics of ASMs in the
pregnant state) (Level B).
2E. Clinicians treating PWECP using acetazolamide, eslicarbazepine,
ethosuximide, lacosamide, nitrazepam, perampanel, piracetam,
pregabalin, rufinamide, stiripentol, tiagabine, or vigabatrin should
counsel their patients that there are limited data on pregnancy-related
outcomes for these drugs (Level B).
Major Congenital Malformations
3A. Clinicians must counsel their patients with epilepsy that the birth
prevalence of any MCM in the general population is approximately
2.4%–2.9%, providing a comparison framework for their individual risk
(Level A).
3B. Clinicians must consider using lamotrigine, levetiracetam, or
oxcarbazepine in PWECP when appropriate based on the patient's
epilepsy syndrome, likelihood of achieving seizure control, and
comorbidities, to minimize the risk of MCMs (Level A).
