II. Risks of congenital defect

  1. Major malformations (4-8% risk; 2.0 Relative Risk)
    1. Cleft Lip and Palate
    2. Ventricular Septal Defect
    3. Neural Tube Defect
      1. Associated more with Valproate and Carbamazepine
  2. Minor malformation (7-15% risk; 2.0 Relative Risk)
    1. Hypertelorism
    2. Epicanthal folds
    3. Broad Nasal Bridge
    4. Elongated philtrum
    5. Hypoplasia of distal digit (include nail bed)

III. Diagnostics

  1. Monitor free fraction of antiepileptic medication
    1. Measure free drug level each trimester
    2. Measure free drug level before delivery
    3. Measure free drug level 4 and 8 weeks post-delivery
  2. Congenital defect screening
    1. Obtain serum Alpha-fetoprotein at 15-20 weeks
    2. Obtain Fetal SurveyUltrasound at 16 to 18 weeks

IV. Pregnancy Guidelines

  1. Recommended prophylactic medications
    1. Folic Acid 1 mg or more qd starting before conception
    2. Vitamin K 10 mg PO qd after 36 weeks
  2. Avoid Valproate and Carbamazepine if possible
    1. Older agents have higher risk of Neural Tube Defects
    2. Avoid these agents especially if NTD Family History
  3. Minimize medication exposure
    1. Use lowest possible dose
    2. Use most effective drug as monotherapy
    3. Adjust dosing based on free drug level (see above)

V. Lactation Guidelines

  1. See Medications in Lactation
  2. AAP recommends Breastfeeding despite Epilepsy
    1. Benefits of Lactation outweigh risk of drug exposure
  3. Monitor infant for adverse medication effects
    1. Irritability
    2. Altered sleep
    3. Poor weight gain

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