Abstracts

Managing epilepsy in pregnancy can be challenging for both the patient and health care provider. Recent literature and pregnancy registries suggest that prenatal anti-epileptic drug (AED) exposure contributes more to major malformations and developmental delay than epilepsy itself. Birth defects are higher in offspring exposed to polytherapy than monotherapy. Therefore, one must balance AEDs and seizure control during pregnancy to optimize outcome: monotherapy being the goal. Epilepsy surgery and Vagal Nerve Stimulation (VNS) can help patients obtain that goal by lessening AED burden. In animal models, VNS has been shown to be safe in pregnancy but there is limited experience in humans. We report here a small case series of our experience of epilepsy in pregnancy and VNS JD is 38 year old woman with intractable left temporal lobe epilepsy documented by video EEG. She declined temporal lobe resection. At her initial visit, she took carbamazepine (CBZ) and lamotrigine (LTG). Preconception counseling was provided and a VNS device was implanted 9/24/01. Settings were titrated to 0.5 mA, 30 Hz, 250 msec , 30 seconds on, 1.1 minutes off, magnet 1.0mA, 60 seconds on, 250 msec. CBZ was tapered off and folate and prenatal vitamins added before she became pregnant. During pregnancy, LTG levels fell and seizures worsened requiring an increase in dosage. She delivered a full term infant with no major malformations on 6/4/03. Apgars were 8 at one minute and 8 at 5 minutes. Denver Developmental scores have been normal.
JD was next seen in 7/2004 and was pregnant again. VNS output current was increased to 0.75mA. LTG was increased as in the prior pregnancy. She delivered her second infant on 3/20/2005. No major malformations have been noted.
KM is a 35 year old woman with intractable non-lesional temporal lobe epilepsy diagnosed in 1994. She delivered one full term infant on 10/21/2002. Preconception counseling ensued shortly after delivery and a VNS model 102 was implanted 2/2003. Settings were titrated to 1.75mA, 30 Hz , 250 msec, 30 seconds on, 0.5 minutes off, magnet output 2mA, 60 seconds on, 250 msec. In addition to VNS, the patient was taking topiramate, clonazepam, lamotrigine, folate, and prenatal vitamins at the beginning of her 2^nd pregnancy. The VNS output current was increased to 2 mA during the third trimester for better seizure control. No adjustments in AEDs were made. Under this regimen, she delivered a full term infant with no major malformations on 9/13/04. This is a report of 3 excellent pregnancy outcomes in two women using VNS therapy in combination with AEDs. Preconception counseling occurred in both cases, resulting in VNS therapy to lessen AED exposure to the fetus. As in prior reports of VNS in pregnancy in humans, there was no pattern of malformation seen with prenatal VNS exposure. VNS can be used in preconception planning to reduce AED exposure in pregnancy. More information regarding the safety of VNS in pregnancy is still needed.