Women with epilepsy in reproductive age group: special issues and management strategies

Women with epilepsy (WWE) have several gender based problems pertaining to social and biological domains. The stigma of epilepsy and its consequences appear to be more for women than men. They have more difficulty in getting married and sustaining a married life. The cyclical variations in the reproductive hormones can adversely impact the seizure pattern in WWE. Epileptiform discharges in the brain can influence the hypothalamic functions and lead to sexual dysfunction. The Antiepileptic drugs (AED) may alter their metabolic and hormone profile and contribute to this disorder. Most WWE tend to have uneventful pregnancies and healthy babies. Nevertheless, the risk of fetal malformations appears to be increased when AEDs are used during pregnancy. This risk is higher for those who are on polytherapy, or using valproate. Recent studies have also demonstrated that antenatal exposure to AEDs could lead to neurocognitive and developmental impairment, low IQ or language problems in exposed infants. Clinicians need to consider these special issues while initiating AED therapy in adolescent girls. All WWE need to have a detailed pre conception evaluation wherein the need to continue AEDs, the ideal AED and dosage are reassessed. The AED therapy would have to be individualized according to the clinical situations, obstetric background and family concerns. Folic acid should be prescribed to all women who could potentially become pregnant. Detailed screening for fetal malformations by estimation of serum alpha fetoprotein and fetal ultrasonography need to be carried out between 14 - 18 weeks of pregnancy. The dosage of AEDs may have to be escalated in the second half of pregnancy in selected patients. The family should be provided detailed counseling and information on how to cope with the pregnancy, childbirth, lactation, and contraception.