Pregnancy and epilepsy

A 28-year-old right-handed female came to the clinic 3 days after her first seizure. The seizure occurred out of sleep and was described by her boyfriend as a convulsion. The emergency medical service took her to the nearest hospital where she was diagnosed with new-onset generalized tonic-clonic seizure. The patient was amnestic for the event and was without memory recall until she arrived at the hospital. She had no significant past medical history and did not use alcohol or illicit drugs. She worked in marketing and had been very successful in her career. Her routine and neurological examinations were unrevealing, excepting the post-ictal state. A CT of the head and routine laboratory assessment, including a urine drug screen, were normal. She recovered gradually to baseline and was discharged from the emergency department with neurological consultation planned. There were no definite triggers and she had no risk factors for epilepsy. She lived alone but had a steady boyfriend with whom she planned to marry and have children. She was seen for neurological evaluation and discussion of family planning. A brain MRI was performed and was normal. A routine outpatient EEG was performed and showed bursts of generalized anterior-predominant 3 Hz spike-and-slow-waves, consistent with Genetic Generalized Epilepsy (Fig. 23.1). The patient was subsequently started on lamotrigine (LTG) and told to refrain from operating a motor vehicle. During titration of LTG, she experienced a second generalized tonic-clonic seizure 2 weeks later, which occurred at work. Her employer was nervous about her returning to work, due to concerns that she would have a seizure at work, and that a diagnosis of epilepsy would impact her ability to perform her job.