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Question 9 of 10
A 34-year-old female with a history of primary generalised epilepsy presents to her GP as she
plans to start a family. She currently takes lamotrigine as monotherapy. What advice should be
given regarding the prevention of neural tube defects?
Folic acid 400 mcg per day once pregnancy has been confirmed 2%
Folic acid 1 mg per day once pregnancy has been confirmed 0%
Folic acid 5 mg per day starting now 88%
Folic acid 10 mg per day starting now 1%
Folic acid 400 mcg per day starting now 9%
Epilepsy + pregnancy = 5mg folic acid
Important for me Less important
The correct answer is that folic acid 5 mg per day should be started now. Women taking anti-
epileptic medications, including lamotrigine, have an increased risk of having a baby with neural
tube defects. The UK epilepsy guidelines recommend that all women with epilepsy who are
planning pregnancy should take high-dose folic acid (5 mg daily) before conception and continue
until the end of the first trimester. This higher dose is necessary because anti-epileptic drugs
interfere with folate metabolism. Starting before conception is crucial as neural tube closure
occurs very early in pregnancy, often before the woman knows she is pregnant.
Folic acid 400 mcg per day once pregnancy has been confirmed is incorrect because this is the
standard dose recommended for women without risk factors, and waiting until pregnancy is
confirmed would be too late to prevent neural tube defects, which develop in the first few weeks
after conception.
Folic acid 1 mg per day once pregnancy has been confirmed is incorrect for the same reasons -
the dose is insufficient for women on anti-epileptic medications, and starting after pregnancy
confirmation would be too late to provide optimal protection.
Folic acid 10 mg per day starting now is incorrect because this dose is unnecessarily high and
exceeds the recommended dose for women taking anti-epileptic medications. There is no
evidence that doses higher than 5 mg provide additional benefit.
Folic acid 400 mcg per day starting now is incorrect because although the timing of starting
before conception is appropriate, this is the standard dose recommended for women without risk
factors and is insufficient for women taking anti-epileptic medications who require the higher 5
mg dose.
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Epilepsy: pregnancy and breast feeding
The risks of uncontrolled epilepsy during pregnancy generally outweigh the risks of medication to
the fetus. All women thinking about becoming pregnant should be advised to take folic acid 5mg
per day well before pregnancy to minimise the risk of neural tube defects. Around 1-2% of
newborns born to non-epileptic mothers have congenital defects. This rises to 3-4% if the mother
takes antiepileptic medication.
Other points
aim for monotherapy
there is no indication to monitor antiepileptic drug levels
sodium valproate: associated with neural tube defects
carbamazepine: often considered the least teratogenic of the older antiepileptics
phenytoin: associated with cleft palate
lamotrigine: studies to date suggest the rate of congenital malformations may be low. The
dose of lamotrigine may need to be increased in pregnancy
Breast feeding is generally considered safe for mothers taking antiepileptics with the possible
exception of the barbiturates
It is advised that pregnant women taking phenytoin are given vitamin K in the last month of
pregnancy to prevent clotting disorders in the newborn
Sodium valproate
The November 2013 issue of the Drug Safety Update also carried a warning about new evidence
showing a significant risk of neurodevelopmental delay in children following maternal use of
sodium valproate.
The update concludes that sodium valproate should not be used during pregnancy and in women
of childbearing age unless clearly necessary. Women of childbearing age should not start
treatment without specialist neurological or psychiatric advice.
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Textbooks
High-yield textbook
Extended textbook
Links
SIGN 9 8
2018 Diagnosis and management of epilepsy in adults
NICE 10 7
2022 Epilepsy guidelines
Royal College of Obstetricians and Gynaecologists 8 3
2016 Epilepsy in Pregnancy
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Score: 77.8%
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