A prospective, population-based registry study in Nordic countries found higher risks for both perinatal and maternal morbidity and mortality in pregnant women with epilepsy compared with pregnant women without epilepsy.

Clinicians caring for women with epilepsy (WWE) during pregnancy must carefully balance risks from inadequate seizure control against risks for adverse outcomes associated with exposure to antiseizure medications (ASMs). Limited data suggest higher maternal morbidity in WWE. To better understand the associations between epilepsy, ASM exposure and maternal and perinatal outcomes, researchers conducted a prospective, Nordic population-based cohort study between 1996 and 2017. They linked maternal diagnosis of epilepsy and ASM prescriptions filled during pregnancy with selected adverse outcomes between 22 weeks’ gestation and 42 days’ postpartum. The primary outcomes were a composite of severe maternal morbidity and mortality (e.g. death, organ failure, conditions with high-case fatality and serious sequela) and a composite of stillbirth, perinatal/neonatal death and severe neonatal morbidity.

Of about 4.5 million singleton deliveries, 35,283 were to WWE, with 46% of offspring exposed to ASMs. The composite maternal outcome occurred in 3.7% of WWE, the composite offspring outcome in 4.7%. After adjustment for maternal characteristics and prepregnancy factors, WWE had higher rates of maternal death (adjusted odds ratio [aOR], 3.86), severe maternal morbidity (aOR, 1.23) and perinatal death/severe neonatal morbidity (aOR, 1.44) than those without epilepsy. Among WWE, those exposed to ASMs had higher odds of maternal death/ morbidity (aOR, 1.24) and perinatal death/severe neonatal morbidity (aOR, 1.37) than WWE not exposed to ASMs. Compared with no ASM use, monotherapy use of the first generation ASMs valproate and carbamazepine was associated with higher odds of adverse outcomes, whereas monotherapy use of lamotrigine or levetiracetam was not.

Comment: Although less than 5% of WWE experienced severe adverse maternal and perinatal outcomes, this study’s findings support increased prepregnancy counselling about risks and access to specialised monitoring during pregnancy and postpartum. Further exploration of reasons for no ASM use in WWE during pregnancy and whether seizure exacerbation may have contributed to adverse outcomes is warranted.

Tanya J.W. McDonald, MD, PhD, Assistant Professor of Neurology, Department of Neurology, Division of Epilepsy, Johns Hopkins University School of Medicine, Baltimore USA.

Razaz N, et al. Risk of perinatal and maternal morbidity and mortality among pregnant women with epilepsy. JAMA Neurol 2024 Aug 5; e-pub (https://doi. org/10.1001/jamaneurol.2024.2375).

This summary is taken from the following Journal Watch title: Neurology.