New guidelines issued on antiepileptic drug use in women with epilepsy who may become pregnant

A joint practice guideline from the American Academy of Neurology (AAN), American Epilepsy Society (AES), and Society for Maternal-Fetal Medicine (SMFM) provides updated recommendations on the use of antiepileptic drugs (AEDs) in women with epilepsy who are pregnant or planning pregnancy.

The guideline, published in Neurology [1], addresses the critical issue of minimizing major congenital malformations, adverse foetal growth, and neurodevelopmental disorders, while maintaining seizure control.


“Most children born to people with epilepsy are healthy, but there is a small risk of pregnancy-related problems, partly due to seizures and partly due to the effects of antiseizure medications,” said author Alison M. Pack, MD, MPH, of Columbia University in New York City, a Fellow of the American Academy of Neurology and a member of the American Epilepsy Society. “This guideline provides recommendations regarding the effects of antiseizure medications and folic acid supplementation on malformations at birth and the development of children during pregnancy so that doctors and people with epilepsy can determine which treatments may be best for them.”

The guideline states when treating people with epilepsy who may become pregnant, doctors should recommend medications and doses that optimize both seizure control and foetal development at the earliest possible opportunity before pregnancy.

Key Points of the updated Guideline:

  1. Pre-Conception Counselling
  • Discuss AED risks, need for seizure control, and optimal AED regimen prior to conception
  • Recommend pre-conception folic acid 0.4mg daily to reduce neural tube defects
  1. AED Selection
  • Avoid valproic acid, phenobarbital, topiramate when possible due to increased risk of major congenital malformations
  • Prefer lamotrigine, levetiracetam, oxcarbazepine when appropriate to minimize teratogenic risk
  • – Avoid valproic acid to reduce risks of autism spectrum disorder and lower IQ scores
  1. Seizure Management
  • Minimize tonic-clonic seizures via optimized AED regimen due to risks from repetitive apnoea
  • Do not routinely discontinue AEDs, as uncontrolled seizures can harm the fetus
  1. Folic Acid Supplementation
  • 0.4mg folic acid daily pre-conception through pregnancy reduces neural tube defects
  • Higher doses may improve neurodevelopmental outcomes but require further study

“Achieving seizure control while minimizing foetal adverse effects is the overarching goal,” said guideline lead author Dr Alison Pack. “With judicious AED selection informed by this evidence-based guideline, we can optimize maternal and foetal outcomes.”

The authors note that data are lacking for some AEDs. As new safety and pregnancy registry data emerges, updates will refine the therapeutic paradigm. Open communication between providers and patients is crucial for shared decision-making.