Evidence-based recommendations empower clinicians to manage epilepsy in pregnancy

For the first time, clinicians have access to a clear, evidence-based roadmap for adjusting antiseizure medication doses during pregnancy and after childbirth.

The strategies, practiced by a group of leading women’s neurology experts in the nationwide landmark Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs (MONEAD) study, were published today in Neurology. They are expected to inform clinical practice and help ensure healthy pregnancies for women with epilepsy.

“Our goal was to generate practical evidence that empowers clinicians everywhere—from rural hospitals to urban subspecialty centers—to provide the best possible care for women with epilepsy during pregnancy,” said Page Pennell, M.D., senior author of the study and chair of neurology at the University of Pittsburgh School of Medicine. “These strategies are based on real-world data from hundreds of successful pregnancies and can be applied in the clinic immediately.”

Epilepsy affects more than one million American women of childbearing age, but for decades, both patients and physicians have faced uncertainty about how to safely manage antiseizure medications during pregnancy. While some modern antiseizure medications are safer than older drugs, pregnancy changes how the body processes these medications, often necessitating careful dose adjustments to maintain seizure control and protect both mother and baby.

The MONEAD study followed women with epilepsy and their children from pregnancy through age six years. Researchers at 20 academic medical centers, including UPMC as a key clinical partner to Pitt, recorded real-world epilepsy care during pregnancy and postpartum and analyzed the patterns that led to healthy deliveries.

Leading up to the analysis for this new publication, Pennell and her research collaborators were the first to show that blood levels of epilepsy medications often drop early in pregnancy, requiring proactive dose adjustments to prevent breakthrough seizures. A prior MONEAD study report published in the New England Journal of Medicine revealed that pregnant women with epilepsy experienced the same degree of seizure stability as non-pregnant women with epilepsy, but had their medication doses adjusted significantly more often. The MONEAD research also provided critical evidence that children born to women with epilepsy and who were exposed to antiseizure medications in utero reach neurodevelopmental milestones on par with their peers.

Despite these advances, translating knowledge into everyday clinical practice remains challenging. Research conducted by UPMC pediatric neurologist Laura Kirkpatrick, M.D., found that a significant percentage of healthcare providers report low confidence in managing epilepsy during pregnancy—a gap compounded by historical misconceptions and stigma, which contribute to lower birth rates among women with epilepsy.

The new study builds upon this earlier work and offers a detailed and practical week-by-week playbook for dose adjustments during pregnancy and postpartum, filling a longstanding gap in clinical care.

“As a practicing physician who specializes in women’s neurology and pregnancy, I see firsthand how critical timely dose adjustments are for protecting both mother and baby,” said Denise Li, M.D., lead author of the study and assistant professor of neurology at Pitt. “This guidance gives clinicians the confidence to adjust antiseizure medication doses precisely at every stage of pregnancy and postpartum.”

Ongoing studies at UPMC and partner sites continue to refine medication management strategies for pregnant women with epilepsy to further improve outcomes and support raising awareness of best practices through initiatives such as the Epilepsy and Pregnancy Medical Consortium website.

Other authors of this research are Wesley Kerr, M.D., Ph.D., and Katherine McFarlane, M.S., of Pitt; Alison Pack, M.D., of Columbia University; Jacqueline French, M.D., of NYU Langone; Elizabeth Gerard, M.D., of Northwestern University; Angela Birnbaum, Ph.D., of the University of Minnesota; and Kimford Meador, M.D., of Stanford University.

This research was supported by the National Institute of Neurological Disorders and Stroke and Eunice Kennedy Shriver National Institute of Child Health and Human Development (grants U01-NS038455, U01-NS050659 and R01-HD105305).