Optimizing Pregnancy and Delivery Management In Women With Epilepsy: An Evidence-Based Narrative Review

Abstract

Background: Pregnancy in women with epilepsy requires simultaneous prevention of maternal seizures and reduction of fetal exposure to potentially teratogenic antiseizure medications (ASMs). Decisions made before conception, altered drug clearance during gestation, and continuity of treatment during labour all influence outcomes. Objective: To synthesize contemporary evidence and develop a practical, stage-specific approach to pregnancy and delivery management in women with epilepsy. Methods: A focused narrative review was undertaken using major clinical guidance from the American Academy of Neurology, American Epilepsy Society and Society for Maternal-Fetal Medicine (2024), Royal College of Obstetricians and Gynaecologists guidance, and selected prospective pregnancy-registry and cohort studies. This was not a systematic review or meta-analysis. Results: Available evidence favours individualized preconception planning and, when clinically appropriate, monotherapy with lamotrigine, levetiracetam or oxcarbazepine. In the 2024 EURAP report, major congenital malformations occurred in 2.5%, 3.1% and 2.9% of pregnancies exposed to levetiracetam, lamotrigine and oxcarbazepine monotherapy, respectively, compared with 9.9% following valproate monotherapy. Pregnancy-related reductions in ASM concentrations require targeted surveillance and individualized dose adjustment. Vaginal delivery is generally appropriate, and planned postpartum dose reassessment and support for breastfeeding are important. Conclusion: A multidisciplinary, longitudinal care pathway prioritizing seizure control, informed prescribing, therapeutic monitoring and coordinated childbirth planning is the most defensible optimization strategy. Prospective trials are still needed to establish the effect of individual pathway components.