By Jean Cibula, MD, FAES
On May 9, 2019, the Google doodle (the picture or animation on the Google search page) highlighted Dr Lucy Wills, a British hematologist who first identified folic acid. Folic acid is one of the B vitamin family (also known as vitamin B9). She studied macrocytic (large cell) anemia in pregnancy and was able to distinguish the difference from pernicious anemia, which is caused by vitamin B12 deficiency. The cause was related to diet during pregnancy, and the anemia could be both prevented and treated using yeast extracts (like Marmite or Vegemite which are nonalcoholic food spreads made from the byproducts of beer brewing or brewers’ yeast). Folic acid was first called the “Wills factor” and was identified as folate in the 1940s. Dr Wills’ work contributed to positive pregnancy outcomes by identifying dietary contributors to pregnancy related deaths (moms and babies) and led to the supplementation of vitamins, particularly of iron and the B vitamins during pregnancy.
More than half of neural tube defects (spina bifida and other problems with the correct formation of the brain and spinal cord) in children have been associated with low levels of folate early in pregnancy. Folate occurs naturally in food, especially in leafy green vegetables like spinach and kale. The USDA also adds folic acid to grains used for bread, cereal, and so on. It is an essential ingredient to cell growth and division, making it important for both pregnancy and child development as well as male fertility. Studies also show an impact on stroke and cancer risks as well as age related macular degeneration.
So how does this relate to epilepsy?
At one time, it was thought that women with epilepsy should not have children because of birth defects related to the anti-seizure medications. There are certain medications which may carry a higher risk for birth defects, including spina bifida, cleft lip and cleft palate as well as autism in the babies. It is really important for women of childbearing age to discuss their medications with their doctors if they are considering becoming pregnant. Since half of pregnancies are actually “unplanned”, it’s also important to ensure that ALL women who could become pregnant are taking B vitamin supplements including folic acid whether they are planning a pregnancy or not.
The American Congress of Obstetrics & Gynecology recommends 4 mg of folic acid daily for pregnancy. Although there is no officially recommended amount from the American Epilepsy Society, the general consensus is 1 – 2 mg of folic acid daily. The average multivitamin contains only 0.4 mg of folic acid daily. For this reason, you should read labels carefully and talk to your pharmacist for assistance in selecting an appropriate vitamin. Prenatal vitamins typically contain higher doses of iron and the B vitamins.
The risk of having a child with a brain or spinal cord problem is related to which medication mom is taking, the dose, and how many medications are involved. If mom is on more than one seizure medication, the risks add together. So before pregnancy, we need to minimize both the number and amount of medicine as well as keeping the seizures under the best control possible. Women should NOT stop seizure medication on their own.
A baby’s brain and spinal cord are formed by day 28 (week 4) of pregnancy. Women are often not aware they are pregnant until 6-8 weeks have passed and at least one menstrual cycle is missed. Therefore, it is important to take B vitamins prior to pregnancy since most women aren’t aware that they are pregnant until after baby’s brain and spinal cord are formed. After this, the greatest risk to baby is that mom will have a big seizure, resulting in abdominal injury, loss of oxygen levels, and so on.
If you’re thinking about pregnancy, please talk to your neurologist right away! We work with high risk maternal-fetal specialists to optimize pregnancy care and monitoring of seizure and medication levels, which can change throughout pregnancy.