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Epilepsy management-Does gender matter? How should initial treatment choices be impacted by gender? How do birth control options impact epilepsy therapy and vice versa?

      Antiepileptic drugs (AEDS) should be selected with consideration of all stages of a woman’s life, including impact on hormonal milieu, impact on choice of birth control, potential for teratogenicity, maintenance of AED exposure during pregnancy, and prevention of seizures in pregnancy, to name a few. Hepatic enzyme inducing antiepileptic drugs such as carbamazepine, phenytoin, and phenobarbital, and to a lesser extent oxcarbazepine and topiramate, can reduce the effectiveness of the oral contraceptive pill (OCP) leading to unwanted pregnancy, whereas the OCP increases clearance of lamotrigine, putting women at risk of breakthrough seizures. This consequence can be avoided by doubling the dose of lamotrigine. A good option for birth control in women with epilepsy is an intrauterine device. All women of childbearing age should receive folic acid supplementation. Care should be taken to avoid the most teratogenic AEDs such as valproic acid, topiramate and phenobarbital if other options are appropriate and available. Women with epilepsy may be at higher risk for a number of adverse pregnancy outcomes including eclampsia, infection, babies small for gestational age, and preterm birth, among others. Some AEDs, particularly lamotrigine, levetiracetam and oxcarbazepine have substantially increased clearance during pregnancy which can lead to destabilization of seizures. This may be one cause of a higher than expected maternal death rate during pregnancy. If available, blood levels should be carefully monitored during pregnancy and after delivery, and appropriate adjustments should be made to keep serum concentrations stable.
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