Antiseizure Medication Dosing Strategy During Pregnancy and Early Postpartum in Women With Epilepsy in MONEAD

Women with epilepsy face significant risks during pregnancy and postpartum due to rapid pharmacokinetic changes that alter anti-seizure medication levels—yet many clinicians lack clear guidance on how to adjust dosing. In a landmark analysis of the MONID study, Paige Fennell and colleagues reveal real-world dosing patterns across 20 U.S. epilepsy centers, showing that lamotrigine doses typically need to be doubled by the end of pregnancy, while levetiracetam increases by 75%. Crucially, the study confirms that postpartum tapering should be empirical—starting within days of delivery—rather than waiting for lab results, which are often delayed and misleading during rapid metabolic shifts. The paper also identifies carbamazepine as an exception, with minimal pharmacokinetic changes, and offers practical, patient-centered strategies such as pre-pregnancy medication level baselines, early monitoring after a positive test, and pre-written postpartum taper plans. These findings challenge outdated practices and provide a much-needed roadmap for safe, effective management of epilepsy in pregnancy. The episode underscores that seizure control during pregnancy is not inherently worse than in non-pregnant women—when managed properly. The real danger lies in under-treatment due to fear of side effects or lack of protocol.