Epilepsy
Contraception and Pregnancy Issues

Contraception

Some anti-epilepsy medicines have a side-effect of increasing the speed in which some contraceptive pills and injections are processed by the liver. (These medicines are known as liver enzyme inducers as they speed up certain processes in the liver cells.) For example, the following anti-epilepsy medicines are liver enzyme inducers: carbamazepine, oxcarbazepine, phenobarbital, phenytoin, primidone, and topiramate. Other anti-epilepsy medicines such as sodium valproate, lamotrigine (but see below), and ethosuximide are not liver enzyme inducers.

In general, women with epilepsy who require contraception are usually treated with medicines that are not liver enzyme inducers. Contraceptive choices, doses, etc, are then usually the same as for any other women (but see below about lamotrigine). See leaflet called 'Contraceptive Choices' for details of the options. However, in some situations, an anti-epilepsy medicine that is a liver enzyme inducer is required for treatment. If you take an anti-epilepsy medicine that is a liver enzyme inducer, then:

• If you take the combined oral contraceptive pill - the dose of the oestrogen part needs to be at least 50 micrograms. This is more than the usual dose. Also, many doctors recommend that:
  • You should take three packs together (tricycling). This means taking one pack after each other without a break between the three packs. Then have a 'pill free break' after the third pack.
  • When you do have a 'pill free break', only have four days break rather than the usual seven.
  • If you get breakthrough bleeding whilst taking the pill, the dose of oestrogen should be increased to 75-100 micrograms per day.
  Even with these extra precautions, the reliabilty of the pill is reduced compared to women who do not take medicines that are liver enzyme inducers. Therefore, some doctors advise that you use condoms in addtion to the pill for extra contraceptive protection.
• If you use the progestogen injection called Depo-provera for contraception - then you need an injection every 10 weeks. (This is more often than usual which is every 12 weeks.)
• The progestogen-only pill is not recommended.
• Progestogen implants are not recommended.
• The combined transdermal contraceptive patch is not recommended.
• If you use emergency contraception tablets - the initial dose of levonorgestrel should be increased to 1.5 mg followed by 750 micrograms 12 hours later.

Special consideration - lamotrigine and the pill
There is some evidence that the combined oral contraceptive pill may interact with lamotrigine (Lamictal) in some women. Lamotrigine is an anti-epilepsy medicine. It is not a liver enzyme inducer but may interact with the pill in another way. The interaction may work 'both ways'. That is, the lamatrigine may make the pill less efective. But also, the pill may make the lamotrigine less effective and increase your risk of seizures. Therefore, the doses of both may need to be adjusted.

The 'take home message'
For reliable contraception, it is best to seek advice from a doctor or nurse. They will be able to tell you if your epilepsy treatment affects a method of contraception.

Pregnancy

Most pregnant women with epilepsy have a normal pregnancy and childbirth. Being pregnant does not usually make epilepsy any better or worse. However, for women with epilepsy, the risk of complications during pregnancy and labour is higher than for women without epilepsy. The small increase in risk is due to the small risk of harm coming to a baby if you have a serious seizure whilst pregnant, and the small risk of harm to an unborn baby from anti-epilepsy medicines (discussed further below).

Therefore, before becoming pregnant, it is best to seek advice from a doctor, epilepsy nurse, or counsellor. The potential risks can be discussed. Some of the points are briefly mentioned below.

Before becoming pregnant
Most of the advice is the same as for any other woman. (This is discussed in a separate leaflet called 'Planning to Become Pregnant?'. For example, advice on diet, smoking, alcohol, avoiding infection, etc.) The additional issues that relate to women with epilepsy include:

• You may wish to discuss the relative benefits and risks of adjusting medication.
• If you have not had any seizures for some time, you may wish to consider stopping anti-epilepsy medication before becoming pregnant. Deciding to come off anti-epilepsy medication can be a difficult decision. Factors such as the type of epilepsy that you have can be important. For example, if you have the type of epilepsy that causes severe tonic-clonic seizures, there is a risk that you could have a severe seizure when you are pregnant if you stop your medication.
• All women taking anti-epilepsy medication are recommended to take 5 mg per day of folic acid before becoming pregnant, and continued until 12 weeks of pregnancy. Folic acid is recommended for all women who are pregnant, but the dose for women taking anti-epilepsy medicines is higher than usual. If you take folic acid tablets in early pregnancy you reduce the risk of having a baby born with a spinal cord problem such as spina bifida.
• You may wish to discuss the question 'what are the risks that my child will also have epilepsy?'. In general, the probability is low that a child born to a parent with epilepsy will also have epilepsy. However, it can partly depend on your family history as some types of epilepsy run in families. Therefore, genetic counselling may be an option to consider if one partner has epilepsy, particularly if the partner has idiopathic epilepsy (epilepsy of unknown cause) and a family history of epilepsy.
• If you do become pregnant, you will be encouraged to notify your pregnancy to the UK Epilepsy and Pregnancy Register (see www.epilepsyandpregnancy.co.uk for details). This is a major ongoing research study that collects information about the safety of anti-epilepsy medicines in pregnancy.

Risk from seizures occurring during pregnancy
The risk of having a seizure is much the same during pregnancy as when you are not pregnant.

• If you have generalized tonic-clonic seizures, there is a small risk that a severe or prolonged seizure may harm the unborn baby. However, the risk is small, and the baby is not affected during most seizures. The risk of a tonic-clonic seizure during childbirth is low. However, to play safe, childbirth should take place in hospital with facilities for mother and baby resuscitation.
• If you have partial seizures, absence seizures, or myoclonic seizures, a seizure is not likely to cause harm to a baby (unless you fall and badly injure yourself).

Risk from anti-epilepsy medicines
If you take anti-epilepsy medication when you are pregnant, you have a small increased risk of having a baby with a birth defect. The most common birth defects that occur are neural tube defects (such as spina bifida), facial defects, congenital heart defects, and hypospadias (a defect of the penis).

• Overall, about 4 in 100 pregnant women who take one anti-epilepsy medicine have a baby with a birth defect. The risk rises to about 6-7 in 100 when taking two anti-epilepsy medicines.
• However, the risks from different medicines can vary. For example, the risk for sodium valproate is about 7 in 100 whereas the risk for carbamazepine is about 2 in 100 and the risk for lamotrigine is about 3 in 100. Therefore, if possible, sodium valproate is not prescribed to women who may become pregnant.
• Taking folic acid 5 mg daily (as discussed above) is thought to reduce the risk from anti-epilepsy medicines during pregnancy.
• Pregnant women who are taking anti-epilepsy medicines are usually offered a high-resolution ultrasound scan to screen for birth defects at 18-20 weeks pregnancy. However, earlier scanning may allow major birth defects to be detected sooner.
• If you have an unplanned pregnancy, do not stop your anti-epilepsy medication without advice which may put you at risk or having a seizure. However, see a doctor as soon as possible and start taking folic acid 5 mg daily straight away.

Breastfeeding
Breastfeeding for most women taking anti-epilepsy medication is generally safe.

Further information

Epilepsy Action
New Anstey House, Gateway Drive, Leeds, LS19 7XY
Helpline: 0808 800 50 50    Web: www.epilepsy.org.uk

National Society For Epilepsy
Chesham Lane, Chalfont St Peter, Gerrards Cross, Bucks, SL9 0RJ
Helpline: 01494 601 400    Web: www.epilepsynse.org.uk

Epilepsy Scotland
48 Govan Road, Glasgow, Scotland, G51 1JL
Helpline: 0808 800 2 200    Web: www.epilepsyscotland.org.uk

Epilepsy Wales
PO Box 4168, Cardiff, CF14 0WZ
Helpline: 0845 7413774    Web: www.epilepsy-wales.co.uk

© EMIS and PIP 2005   Updated: September 2005   PRODIGY Validated

The authors and editors of this article are employed to create accurate and up to date content reflecting reliable research evidence, guidance and best clinical practice. They are free from any commercial conflicts of interest. Find out more about updating.

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