II. Risks of congenital defect
- Major malformations (4-8% risk; 2.0 Relative Risk)
- Cleft Lip and Palate
- Ventricular Septal Defect
- Neural Tube Defect
- Associated more with Valproate and Carbamazepine
- Minor malformation (7-15% risk; 2.0 Relative Risk)
- Hypertelorism
- Epicanthal folds
- Broad Nasal Bridge
- Elongated philtrum
- Hypoplasia of distal digit (include nail bed)
III. Diagnostics
- Monitor free fraction of antiepileptic medication
- Measure free drug level each trimester
- Measure free drug level before delivery
- Measure free drug level 4 and 8 weeks post-delivery
- Congenital defect screening
- Obtain serum Alpha-fetoprotein at 15-20 weeks
- Obtain Fetal SurveyUltrasound at 16 to 18 weeks
IV. Pregnancy Guidelines
- Recommended prophylactic medications
- Folic Acid 1 mg or more qd starting before conception
- Vitamin K 10 mg PO qd after 36 weeks
- Avoid Valproate and Carbamazepine if possible
- Older agents have higher risk of Neural Tube Defects
- Avoid these agents especially if NTD Family History
- Minimize medication exposure
- Use lowest possible dose
- Use most effective drug as monotherapy
- Adjust dosing based on free drug level (see above)
V. Lactation Guidelines
- See Medications in Lactation
- AAP recommends Breastfeeding despite Epilepsy
- Benefits of Lactation outweigh risk of drug exposure
- Monitor infant for adverse medication effects
- Irritability
- Altered sleep
- Poor weight gain