A 22-year-old primigravida comes to the office at 12 weeks gestation for her first prenatal visit. The patient was unaware that she was pregnant until last week, when she went to the emergency department for persistent vomiting; an ultrasound confirmed an intrauterine pregnancy. The patient has irregular menstrual cycles due to polycystic ovary syndrome. Nine months ago, she stopped taking oral contraceptives due to intolerable side effects; she did not inform her provider. The patient also has a history of idiopathic seizures beginning in childhood and receives valproate monotherapy. She states, "I just read in one of those maternity books that seizure medications can be bad for my baby. Should I stop now? I have not had a seizure in a long time." Her last seizure occurred a year ago after an attempt to change her medication regimen; she was hospitalized for aspiration pneumonia afterward. The patient does not use tobacco, alcohol, or illicit drugs. There is no family history of congenital abnormalities. Item 1 of 2
Which of the following is the best strategy for management of this patient?

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Explanation: 11ec2b69_c020_5f39_8f63_49acc7205bb3_MD0005_00 Women with epilepsy are at increased risk for obstetric complications, including preeclampsia, preterm labor, and abruptio placentae. Antiepileptic drug (AED) use is also associated with an increased risk of congenital abnormalities, including neural tube defects, congenital heart anomalies, and cleft palate. Despite these risks, the majority of women with epilepsy have a normal pregnancy. Valproate carries the highest teratogenicity risk of all AEDs; therefore, changing to an alternate regimen should be tried 6 months prior to attempts to conceive. It is preferable to switch to the lowest possible dose of a single medication to limit teratogenicity. However, no changes to the AED regimen should be made after conception, as abrupt changes may trigger seizure activity. Gradually changing the patient's regimen by overlapping medications in early gestation exposes the fetus to possible additional teratogens. In addition, there is likely little benefit to changes in medication once pregnancy is confirmed, as the majority of organogenesis has already occurred. Management of patients on AEDs includes initiating high-dose folic acid supplementation and screening for congenital anomalies (eg, neural tube defects) with serum alpha-fetoprotein and an anatomy ultrasound. If major abnormalities are present, pregnancy termination may be considered (Choice E). (Choice B) AEDs are continued in patients whose epilepsy is unstable without medications. Seizures during pregnancy can cause fetal hypoxia or other complications of maternal trauma (eg, spontaneous abortion, abruptio placentae). (Choices C and D) Changes to AED regimens should not be made after confirmation of pregnancy. Patients with epilepsy are not at increased risk of fetal aneuploidy; therefore, aneuploidy screening using chorionic villus sampling or first-trimester combined screening is not specifically indicated. Educational objective: The use of antiepileptics, especially valproate, is associated with an increased risk of congenital anomalies. However, changes should not be made to a patient's AED regimen after confirmation of pregnancy. Patients are started on high-dose folic acid and screened for congenital anomalies with serum alpha-fetoprotein and an anatomy ultrasound. References: Placental passage of antiepileptic drugs at delivery and neonatal outcomes. (http://www.ncbi.nlm.nih.gov/pubmed/28387929) Status epilepticus in pregnant women with epilepsy after valproate adjustment: a case series. (http://www.ncbi.nlm.nih.gov/pubmed/27875769)

A 22-Year-Old Primigravida Comes to the Office at 12 Weeks