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Preconception management of epilepsy treated with pregabalin — DFSRH MCQ

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HardPregabalinPreconception management of epilepsy treated with pregabalinDFSRH

A 31-year-old woman attends for removal of her 52 mg levonorgestrel intrauterine device because she wishes to conceive. She has focal epilepsy treated with pregabalin 300 mg twice daily and levetiracetam. She has been seizure-free for 18 months and has not had a preconception neurology review. She takes no folic acid. Her intrauterine device is correctly positioned, and pregnancy is reasonably excluded. She says that pregabalin was described as not reducing hormonal contraceptive efficacy and has therefore assumed it is safe in pregnancy. She is willing to defer removal if this is clinically advisable. Which management plan is most appropriate today?

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Correct answer: D — Retain the intrauterine device, continue pregabalin unchanged, prescribe folic acid 5 mg daily and urgently refer for specialist preconception review

Pregabalin's lack of a clinically important interaction with oral contraceptive steroids does not establish reproductive safety. UK product information requires effective contraception during treatment, and observational data suggest a small increase in major congenital malformations after first-trimester exposure, although residual confounding and imprecision limit causal inference. She should therefore be advised to retain effective contraception until her antiseizure treatment has been reviewed jointly with an epilepsy specialist. Pregabalin must not be stopped abruptly: withdrawal can cause symptoms and convulsions, while loss of seizure control also presents substantial maternal and fetal risk. UK MHRA advice is to refer a person with epilepsy who is planning pregnancy urgently and offer folic acid 5 mg daily before any possibility of conception. Thus E provides the correct sequence. A is unsafe because it combines immediate conception risk with abrupt withdrawal. B provides appropriate referral but removes contraception before treatment optimisation and uses an inadequate folic-acid dose for this context. C recognises the need for contraception and folic acid but initiates withdrawal without specialist assessment; even a nominal one-week taper is not automatically appropriate for long-term high-dose treatment or epilepsy. D maintains contraception and treatment but delays time-critical preconception review and folate initiation.

Reference: Pregabalin (Lyrica): findings of safety study on risks during pregnancy (19 April 2022) — https://www.gov.uk/drug-safety-update/pregabalin-lyrica-findings-of-safety-study-on-risks-during-pregnancy Pregabalin (Lyrica): reminder for prescribers of any antiepileptic drug (19 April 2022) — https://www.gov.uk/drug-safety-update/pregabalin-lyrica-findings-of-safety-study-on-risks-during-pregnancy Lyrica 50 mg hard capsules — Summary of Product Characteristics (Text revised February 2026; emc updated 14 May 2026) — https://www.medicines.org.uk/emc/product/10301/smpc