Elsevier

Epilepsy & Behavior

Volume 20, Issue 4, April 2011, Pages 719-720
Epilepsy & Behavior

Case Report
Old and new antiepileptic drugs during pregnancy and lactation – report of a case

https://doi.org/10.1016/j.yebeh.2011.01.028Get rights and content

Abstract

We describe a case of a woman with epilepsy treated with primidone/phenobarbital (so-called “old” antiepileptic drug) and levetiracetam (so-called “new” antiepileptic drug) who was discouraged from breastfeeding, resulting in clinically significant withdrawal seizures in her newborn. As a consequence, even when two or more antiepileptic drugs are needed for the treatment of women with epilepsy, breastfeeding should be recommended, mothers should be informed about the possiblity of drug effects on the neonate, and infants of mothers treated with primidone/phenobarbital should be closely monitored for possible signs of sedation.

Introduction

Three to five of 1000 births are reported from women with epilepsy (WWE) [1], [2]. Close monitoring at frequent intervals is essential for WWE, as antiepileptic drug (AED) treatment might be associated with an increased risk for an abnormal pregnancy outcome. There is a mounting wall of literature reporting on transfer of AEDs into breast milk in an inverse proportion to their extent of protein binding [3] (Table 1). However, with the exception of barbiturates (bearing the risk of sedation), plasma concentrations in the breastfed infant are usually lower than those the fetus is exposed to via placental transfer during pregnancy [4]. Of note and as described in 1988 by Kuhnz and co-workers, withdrawal symptoms were observed in phenobarbital (PB)- and primidone (PRM)-exposed neonates of mothers who refrained from breastfeeding (PB is a metabolite of PRM), whereas in nursed infants no such symptoms occurred possibly because of slower elimination [4].

With the growing number of so-called “new” drugs (e.g., levetiracetam [LEV]), possible adverse effects on newborns ingesting AEDs via breast milk might produce anxiety. Data concerning new AEDs and breastfeeding are sparse and often misinterpreted, and as a consequence, the increasing number of WWE treated with “old” and “new” AEDs in combination leads to uncertainty.

We describe the case of a woman with epilepsy treated with PRM/PB (so-called “old” AED) and LEV (so-called “new” AED) who was discouraged from breastfeeding, resulting in clinically significant withdrawal seizures in her newborn.

Section snippets

Case report

A 30-year-old woman known to have juvenile myoclonic epilepsy since the age of 14 was referred for delivery to the Department of Gynaecology, Medical University Innsbruck, Innsbruck, Austria. Long-term anticonvulsive therapy comprised PRM 187.5 mg per day (2.5 mg/kg body wt per day) for 10 years and LEV 3000 mg per day (40 mg/kg body wt per day) for 3 years. Initially, seizure semiology (and EEG) was uniform, including typical myoclonias of the arms and generalized tonic–clonic seizures with low

Discussion

The benefits of breastfeeding to mother and infant are not to be called into question, and there are only a few reasons justifying advice against nursing by WWE on long-term AED treatment. This is the first case demonstrating the complexity of recommendations for WWE resulting from the growing number of patients treated with combinations of so-called “new” AEDs and so-called “old” AEDs.

Although the overwhelming majority of AEDs are known to be transferred from maternal plasma to breast milk and

Conflict of interest statement

The authors report no conflicts of interest.

References (12)

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    Children born to mothers taking high-dose barbiturates, such as primidone or phenobarbital, and benzodiazepines are potentially vulnerable to withdrawal and may need observation, but this should be evaluated on a case-by-case basis. One case report suggested that breastfeeding may minimize withdrawal symptoms, suggesting that over time the child experiences less medication.5 There are few criteria for withdrawal in neonates, and there is usually greater scrutiny in offspring of WWE, biasing observation of potential withdrawal symptoms.

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