• For women planning a pregnancy:
• Inform the woman about the risks associated with pregnancy and epilepsy.
• Although most women with epilepsy have a normal pregnancy and delivery, the risk of complications during pregnancy and labour is higher than for women without epilepsy.
• The risks associated with inadequate seizure control may be more detrimental to the fetus than the use of antiepileptic drugs.
• Although there is an increased risk of seizures in the children of parents with epilepsy, the probability that a child will be affected is generally low.
• Refer the woman to an epilepsy specialist if she is taking antiepileptic drugs for review of her epilepsy treatment before she becomes pregnant, to discuss the relative risks and benefits of adjusting her medication. Advise her to:
• Continue using effective contraception until a full assessment by the specialist has taken place.
• Continue her antiepileptic drugs and make an urgent appointment to see a GP if she becomes unexpectedly pregnant.
• Prescribe folic acid 5 mg daily. This should be continued throughout the first trimester of pregnancy.
• For further information, see the CKS topic on Pre-conception - advice and management.
• For women who have become pregnant:
• Advise the woman to continue her antiepileptic drugs and refer her urgently for review by an epilepsy specialist (if she has not been reviewed before becoming pregnant).
• Encourage her to notify the pregnancy, or allow her clinician to notify the pregnancy, to the UK Epilepsy and Pregnancy Register (www.epilepsyandpregnancy.co.uk).

The risks to the fetus from antiepileptic drugs (AEDs).

• Impaired cognitive function is more common in children exposed to sodium valproate during pregnancy, when assessed at 3 years of age, compared with children of mothers taking other antiepileptic drugs [Meador et al, 2009].
• Major and minor malformations are more common in infants exposed to AEDs during pregnancy [SIGN, 2003; Morrow et al, 2006].
• The overall risk of a major fetal abnormality in any pregnancy in the general population is about 2%.
• This risk is increased in women taking AEDs and is dependant on the individual drug, the dose, and the number of AEDs taken. For women taking a single AED:
• The risk with carbamazepine is 2.2%.
• The risk with lamotrigine is about 3% at a daily dose of 200 mg or less, and about 5% at a daily dose of more than 200 mg.
• The risk with sodium valproate is about 5% at a daily dose of less than 1000 mg, and about 9% at a daily dose of more than 1000 mg.
• The risk is increased with an increasing number of AEDs taken, and may be up to 24% in women taking four AEDs.
• The most common major malformations associated with established AEDs are:
• Neural tube defects.
• Orofacial defects.
• Congenital heart abnormalities.
• Hypospadias.
• At present there is insufficient evidence on which to advise on the risk of abnormalities from the newer AEDs.

• The recommendation to inform women about the risks of antiepileptic drugs (AEDs) in pregnancy is based on expert advice, to ensure that women can make informed choices about the risks affecting their pregnancy [SIGN, 2003; NICE, 2004c; SIGN, 2005].
• The risk of major malformations has been examined by a prospective study from the UK Epilepsy and Pregnancy Register of 3607 pregnancies of women taking AEDs during pregnancy [Morrow et al, 2006].
• The risk of impaired cognitive function in children exposed to sodium valproate during pregnancy has been examined by a prospective study of 309 children at 3 years of age who were exposed to AEDs during pregnancy [Meador et al, 2009]. On average, children exposed to valproate had an IQ 9 points lower than children exposed to lamotrigine (95% CI 3.1 to 14.6).
• The recommendation to refer all women receiving AEDs for specialist review is based on expert opinion [SIGN, 2003; NICE, 2004c; SIGN, 2005]. This is recommended to ensure the woman receives expert advice about the risks and benefits of adjusting her treatment to manage the risk to herself and her fetus in the most acceptable way. Adjustments that may be considered include:
• Withdrawal of treatment or a dose reduction if seizures have been well controlled.
• Switching from sodium valproate to an AED that is less likely to cause harm to the fetus.
• The recommendation to prescribe folic acid 5 mg daily is based on evidence of the effectiveness of folic acid at reducing the incidence of neural tube defects. A summary of the evidence is available in the CKS topic on Pre-conception - advice and management.
• The recommendation to encourage women with epilepsy who become pregnant to notify the UK Epilepsy and Pregnancy Register is to allow information to be gathered to improve the future management of pregnant women with epilepsy [NICE, 2004c].