title: Seizure control and treatment changes in pregnancy: observations from the EURAP epilepsy pregnancy registry.
abstract: OBJECTIVE
  To analyze seizure control, dose adjustments, and other changes of antiepileptic drug (AED) treatment during pregnancy in a large cohort of women with epilepsy entering pregnancy on monotherapy with carbamazepine, lamotrigine, phenobarbital, or valproate.
  
  
  METHODS
  Seizure control and AED treatment were recorded prospectively in 3,806 pregnancies of 3,451 women with epilepsy taking part in European and International Registry of Antiepileptic Drugs and Pregnancy (EURAP), an international AED and pregnancy registry.
  
  
  RESULTS
  Of all cases, 66.6% remained seizure-free throughout pregnancy. Generalized tonic-clonic seizures (GTCS) occurred in 15.2% of the pregnancies. Women with idiopathic generalized epilepsies were more likely to remain seizure-free (73.6%) than women with localization-related epilepsy (59.5%; p < 0.0001). Worsening in seizure control from the first to second or third trimesters occurred in 15.8% of pregnancies. The AED dose was increased during pregnancy in 26.0% and a second AED added to the initial monotherapy in 2.6% of all pregnancies. Seizures were more likely to occur in the first trimester in pregnancies with an increased drug load (35%; increased dose and/or addition of another AED) than in pregnancies without an increased drug load (15.3%) (p < 0.0001). Compared with other monotherapies, pregnancies exposed to lamotrigine were less likely to be seizure-free, 58.2% (p < 0.0001); had more GTCS, 21.1% (p < 0.0001); had a greater likelihood of deterioration in seizure control from first to second or third trimesters, 19.9% (p < 0.01), and were more likely to require an increase in drug load, 47.7% (p < 0.0001). The mean dose increases from the first to third trimesters were 26% for lamotrigine, 5% for carbamazepine, 11% for phenobarbital, and 6% for valproate. There were 21 cases of status epilepticus (10 convulsive): none with maternal mortality and only one with a subsequent stillbirth.
  
  
  CONCLUSIONS
  Although the majority of women remain seizure-free throughout pregnancy, our data suggest that a more proactive approach to adjusting the dose of all AEDs in pregnancy should be considered, in particular for those pregnancies with seizures occurring in the first trimester and those exposed to lamotrigine, to reduce the risk of deterioration in seizure control.
authors.affiliation: Epilepsy Center, Department of Neurophysiology and Experimental Epileptology, I.R.C.C.S. Neurological Institute "Carlo Besta" Foundation, Milan, Italy.
authors.forename: Dina
authors.initials: D
authors.lastname: Battino
authors.forename: Torbjörn
authors.initials: T
authors.lastname: Tomson
authors.forename: Erminio
authors.initials: E
authors.lastname: Bonizzoni
authors.forename: John
authors.initials: J
authors.lastname: Craig
authors.forename: Dick
authors.initials: D
authors.lastname: Lindhout
authors.forename: Anne
authors.initials: A
authors.lastname: Sabers
authors.forename: Emilio
authors.initials: E
authors.lastname: Perucca
authors.forename: Frank
authors.initials: F
authors.lastname: Vajda
mesh_terms: D000927:Anticonvulsants / Q000627:therapeutic use*; D002220:Carbamazepine / Q000627:therapeutic use; D005260:Female; D006801:Humans; D000077213:Lamotrigine; D010634:Phenobarbital / Q000627:therapeutic use; D011247:Pregnancy; D011248:Pregnancy Complications / Q000175:diagnosis / Q000628:therapy*; D012042:Registries; D012640:Seizures / Q000188:drug therapy* / Q000209:etiology; D016896:Treatment Outcome; D014227:Triazines / Q000627:therapeutic use; D014635:Valproic Acid / Q000627:therapeutic use
chemical_list: D000927:Anticonvulsants; D014227:Triazines; D002220:Carbamazepine; D014635:Valproic Acid; D000077213:Lamotrigine; D010634:Phenobarbital
keywords: Antiepileptic drugs; Epilepsy; Pregnancy; Seizures