NICE NG217: Epilepsies — Reproductive Health Considerations
Scope Note
NG217 ("Epilepsies in children, young people and adults") is an 11-section, 150+ page guideline covering diagnosis, seizure-type-specific drug choice, status epilepticus, non-pharmacological treatment, comorbidities, SUDEP, and service transition — almost all of which is outside MRCOG's remit. The two sections below (4.4 and 4.6) are the only parts that speak directly to women's reproductive health, and this file summarises only those.
Section 4.4: Antiseizure Medications for Women and Girls
- Information given to women and girls with epilepsy should be reviewed regularly and specifically cover: contraception, folic acid supplementation, conception, pregnancy, breastfeeding, caring for children, and menopause (rec 4.4.1).
- Clinicians should discuss the risks to an unborn child of antiseizure medications (congenital malformation, neurodevelopmental impairment, fetal growth restriction) with any woman or girl with epilepsy who is able to have children — including girls who are likely to need treatment once they reach childbearing age — not only those actively planning pregnancy (rec 4.4.2).
- Prescribers must assess risks and benefits of individual antiseizure drugs for women/girls who are able to have children now or in the future, following MHRA safety advice on antiepileptic drugs in pregnancy, and being aware that evidence is particularly limited for newer drugs (rec 4.4.3).
- Sodium valproate risk in pregnancy — including the dose- and polytherapy-dependent increase in risk — must be specifically discussed, following MHRA safety advice on valproate use by women and girls (rec 4.4.4).
AED–Contraception Interactions (Recs 4.4.5–4.4.6)
- Enzyme-inducing AEDs reduce hormonal contraceptive efficacy. NG217 explicitly names carbamazepine, oxcarbazepine, phenytoin, and topiramate as impairing the effectiveness of hormonal contraceptives, and directs prescribers to the SPC and BNF/BNF for Children for individual drug–contraceptive interaction advice (rec 4.4.5).
- The interaction also runs the other way. Oestrogen-containing hormonal contraceptives and HRT can impair the effectiveness of lamotrigine (rec 4.4.6) — a commonly tested bidirectional interaction, since lamotrigine is not itself an enzyme-inducing AED.
- Breastfeeding on antiseizure medication is generally safe for most women and girls and should be encouraged and supported; individual drug decisions should be made jointly between the woman/girl and prescriber, weighing breastfeeding benefits against drug-specific risk (recs 4.4.7–4.4.8).
Section 4.6: Support and Monitoring for Women Planning Pregnancy or Who Are Pregnant
- Women and girls with epilepsy who are planning pregnancy or are pregnant should be referred to an epilepsy specialist team for review of their antiseizure medication options, with care information shared between the epilepsy specialist team, a specialist obstetric team, and primary care (recs 4.6.1–4.6.2).
- Adherence should be explicitly reinforced — medication should not be stopped without medical supervision (rec 4.6.3), and any adjustment decision should be made jointly, weighing the risk of poorly controlled seizures against fetal drug exposure risk (rec 4.6.4).
- Consider more frequent monitoring in pregnancy for women/girls who: have a learning disability, are under 16, have had a seizure in the past 12 months, have bilateral tonic-clonic seizures, or have modifiable SUDEP risk factors (rec 4.6.5).
- For women/girls on carbamazepine, lamotrigine, levetiracetam, oxcarbazepine, phenobarbital, or phenytoin who are pregnant or planning pregnancy: obtain a pre-conception baseline drug level, monitor levels through pregnancy per MHRA advice, and discuss any dose changes with the patient (recs 4.6.6–4.6.9). Doses increased during pregnancy should be planned to return toward pre-conception levels in the first few days after birth (rec 4.6.10).
High-Yield Exam Points
- Four enzyme-inducing AEDs named by NICE as reducing hormonal contraceptive efficacy: carbamazepine, oxcarbazepine, phenytoin, topiramate.
- The interaction is bidirectional for lamotrigine: it is not enzyme- inducing, but oestrogen-containing contraceptives/HRT reduce lamotrigine levels, risking breakthrough seizures — the opposite direction from the enzyme-inducer-reduces-contraceptive-efficacy pattern.
- NICE frames contraception counselling as a standing part of routine information review for any woman or girl with epilepsy who is able to have children — not only those already planning pregnancy.
- Pre-conception AED level monitoring establishes a baseline so that in-pregnancy dose changes can be deliberately tapered back afterward, rather than left elevated postpartum.
- For AED dose/teratogenicity detail and full antenatal/intrapartum/ postpartum obstetric management, see the companion RCOG GTG 68 summary — NG217 does not duplicate that clinical management content.
Source: National Institute for Health and Care Excellence (NICE) — this summary covers only the reproductive-health-relevant sections of a much broader general epilepsy guideline; see rcog-gtg/gtg-68-epilepsy-in-pregnancy.md for pregnancy-specific management (Published 27 April 2022; last updated 30 January 2025)
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