Key takeaways:
- New Neurology guidelines offer detailed, week-by-week recommendations for antiseizure medication dose adjustments during pregnancy and postpartum.
- Most pregnant women with epilepsy required antiseizure medication dose increases during pregnancy, followed by dose reductions shortly after delivery.
- Lamotrigine and levetiracetam showed the most frequent and substantial dose adjustments across pregnancy and postpartum periods.
- Seizure control remained stable throughout pregnancy, supporting the safety of proactive, evidence-based dose management.
- The guidance fills a longstanding clinical gap, giving clinicians confidence to individualize antiseizure medication care for pregnant women with epilepsy.
Evidence-based guidelines published in Neurology have provided clinicians with a clear roadmap for managing antiseizure medication during and after pregnancy.1
These strategies were designed to guide clinical practice and ensure women with epilepsy undergo healthy pregnancies. They provide detailed week-by-week recommendations for dose adjustment during these periods, fulfilling a longstanding gap in practice.1
“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, MD, senior study author and chair of neurology at the University of Pittsburgh School of Medicine.1
Frequency and timing of dose adjustments
The observational cohort study was conducted to evaluate how antiseizure medications (ASMs) were administered in a large cohort of pregnant women with epilepsy (PWWE) reporting favorable seizure outcomes.2 PWWE aged 14 to 45 years at less than 20 weeks’ gestation were eligible for inclusion and recruited across 20 US epilepsy centers.
A daily diary was used to record seizures, ASM types, and ASM doses. Rates of participants undergoing at least 1 dose change of ASMs during pregnancy and postpartum were reported, alongside the time of first dose change after enrollment, time to subsequent changes, amount of each dose adjustment, and percent of conception dose at delivery and 6 weeks postpartum.2
There were 299 participants aged a median of 31 years eligible for inclusion. Of ASMs, 67.8% underwent dose increases from a median of 32 days post-enrollment onward, while 47.9% underwent decreases within 6 weeks post-delivery. The decreases began a median of 6 days postpartum.2
Medication-specific dose adjustment patterns
Dose changes for specific types of ASMs were also reported, including a median 100 mg/d increase in lamotrigine reported by 87.7% of participants receiving the medication. This reached a mean of 191% of the conception dose by delivery. Additionally, 70.5% had dose tapers postpartum, with a 100 mg/d median increase to 116% of the conception dose by 6 weeks.2
In patients taking levetiracetam, 56% increased their dose, with a median of 500 mg/d, leading to a mean 136% of the conception dose by week 6. There were 14 patients taking other ASMs, with 10 reporting increased doses in pregnancy and 8 being tapered early postpartum.2
Overall, the results highlighted no differences in seizure control during pregnancy among women with vs without epilepsy. Investigators concluded these findings could be used to guide PWWE management.2
Clinical need for pregnancy-specific ASM guidance
Over 1 million childbearing women in the United States are impacted by epilepsy, facing uncertainty about how to safely manage ASMs during the pregnancy and postpartum periods.1 Pregnancy influences how these medications are processed, indicating a potential need to adjust the doses for maternal and infant protection.
Pennell and other researchers have also identified a drop in blood levels of epilepsy medications early in pregnancy. Previous data has indicated more frequent adjustments in ASM doses among women with epilepsy despite the same degree of seizure stability as non-pregnant women. Building on this research, the new study provides detailed guidance for dose management.1
“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, MD, lead study author and assistant professor of neurology at Pitt. “This guidance gives clinicians the confidence to adjust antiseizure medication doses.”1
References
- Evidence-based recommendations empower clinicians to manage epilepsy in pregnancy. University of Pittsburgh. December 29, 2025. Accessed January 5, 2026. https://www.eurekalert.org/news-releases/1111131
- Pennell PB, Li D, Kett WT. Antiseizure medication dosing strategy during pregnancy and early postpartum in women with epilepsy in MONEAD. Neurology. 2025;106(2). doi:10.1212/WNL.0000000000214483
