Teratogenesis, Perinatal, and Neurodevelopmental Outcomes After In Utero Exposure to Antiseizure Medication: Practice Guideline From the AAN, AES, and SMFM

Clinicians should counsel their patients that there are limited data on pregnancy-related outcomes for these drugs.

Clinicians should counsel PWECP that the prevalence of intrauterine death does not differ among different ASM exposures in monotherapy.

Clinicians should counsel that adherence to recommended folic acid supplementation preconceptionally and during pregnancy is important to minimize the risk of MCMs and poor neurodevelopmental outcomes.

Obstetricians should recommend fetal screening for MCMs (e.g., a detailed anatomical ultrasound, where available) to enable early detection and timely intervention.

Obstetricians should recommend screening cardiac investigations of the fetus to enable early detection and timely intervention of congenital heart defects.

Obstetricians should recommend screening of fetal growth throughout pregnancy to enable early identification of fetal growth restriction.

Clinicians should implement age-appropriate developmental screening.

Clinicians should recommend ASMs and doses that optimize both seizure control and fetal outcomes should pregnancy occur, at the earliest possible opportunity preconceptionally (e.g., at the time of starting an ASM in a person post-menarche).

Clinicians should engage in joint decision-making, taking individual preferences into account when selecting ASMs and monitoring their dosing.

Clinicians must minimize the occurrence of convulsive seizures (generalized tonic-clonic seizures and focal-to-bilateral tonic-clonic seizures) to minimize potential risks to the birth parent (e.g., seizure-related mortality) and to the fetus.

Clinicians should exercise caution in attempting to remove or replace an ASM that is effective in controlling generalized tonic-clonic or focal-to-bilateral tonic-clonic seizures, even if it is not an optimal choice with regards to the risk to the fetus (e.g., valproic acid).

Clinicians should monitor ASM levels as guided by individual ASM pharmacokinetics and patient clinical presentation.

Clinicians should adjust the dose of ASMs at their clinical discretion.

Clinicians must consider using lamotrigine, levetiracetam, or oxcarbazepine when appropriate based on the patient's epilepsy syndrome, likelihood of achieving seizure control, and comorbidities, to minimize the risk of major congenital malformations (MCMs).

Clinicians must avoid the use of valproic acid to minimize the risk of MCMs (composite outcome) or neural tube defects (NTDs), if clinically feasible.

Clinicians must avoid the use of phenobarbital in PWECP, if clinically feasible.

Clinicians should avoid the use of phenobarbital and topiramate in PWECP, if clinically feasible.

Clinicians should avoid the use of valproic acid in PWECP, if clinically feasible.

Clinicians should avoid the use of valproic acid or topiramate in PWECP, if clinically feasible.

Clinicians must avoid the use of valproic acid in PWECP, if clinically feasible.

Clinicians should prescribe at least 0.4 mg of folic acid supplementation daily preconceptionally and during pregnancy to any PWECP treated with an ASM.

Clinicians must prescribe at least 0.4 mg of folic acid supplementation daily preconceptionally and during pregnancy to any PWECP treated with an ASM.