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Epilepsy

Intro

THIS WEBSITE IS CURRENTLY UNDER CONSTRUCTION.

This information is not intended as a substitute for professional healthcare and is not intended to replace the evaluation of a healthcare professional. No responsibility is accepted for clinical decisions arising from use of this tool. Always consult with a healthcare provider for advice concerning your health. Only your healthcare provider can determine the medical recommendations for your neurological condition. Do not disregard professional medical advice or delay seeking advice or treatment because of something you have read here.

Epilepsy and pregnancy are important because it is one of the few illnesses that require continuous treatment during pregnancy. Once you are pregnant it is more important to control your seizures to avoid injury to you and your baby.

In the general population, there is a 1-2% chance that the child can have major birth defects. For women with epilepsy, this risk goes up to 2-8%. These birth defects can include heart defects, spinal cord defects like spina bifida, or facial defects like cleft lip or palate. Fetuses/babies exposed during the first 10-12 weeks of development are at the greatest risk. Fortunately, some birth defects can be identified with early ultrasounds performed at 15-18 weeks of pregnancy. Your doctor may also identify these defects after birth. Drug exposure later in the 2nd or 3rd trimester, specifically with valproate, may also be associated with a slightly higher chance of children developing behavioral problems such as autistic spectrum disorder or learning disabilities.

It is also shown that women with epilepsy naturally have lower folate (folic acid) levels in their blood. Folate (folic acid) is very important for brain and spinal cord development. Some of the medications used for seizure control can decrease folate and increase the risk of birth defects. Though we still need to learn more about how this occurs, it is recommended for women with epilepsy who may become pregnant take folic acid regularly. If you are taking multiple antiseizure medications or higher doses of antiseizure medications, the risk of a major birth defect goes higher.

For most women, there is a greater than 95%-97% chance of having a baby without a major birth defect. You should discuss family planning goals with your doctor before getting pregnant, and depending upon your type of seizure they will help you choose the safest medication at the lowest dose and effective dose for seizure control. Ideally, changing medications is not recommended during pregnancy as it may cause your seizures to return or worsen. Medication changes should be done as part of pre-pregnancy planning with your doctor. Never stop taking medication on your own without consulting your doctor as this can cause life-threatening seizures.

During pregnancy, your body changes. You gain weight and retain more water. As well, your kidneys and liver work at higher rates. These things, along with many changes in pregnancy can cause your medication levels in your blood to lower, sometimes at such low levels that seizures can return. Each medication and person is different and it is important to speak with your doctor about what your risks are and how best to prevent this from happening. Sometimes your doctor can monitor the levels of medications in your blood before and during pregnancy. They might increase the amount of medication you take to ensure that your seizure medication blood levels do not drop too low. In general, women are at the greatest risk for seizures occurring when their drug blood level in pregnancy decreases by more than a third. As an example, if your pre-pregnancy blood level is “100”, during pregnancy, if your blood level falls to “67” or lower, your doctor may increase your medication dose to prevent your blood levels from falling further*. *The numbers used are only used as an example, and should not apply to your specific situation without discussing it with your doctor.

Fortunately, the overwhelming majority of women with epilepsy give birth to healthy babies. There are increased risks but working closely with your doctor can help minimize those risks. A recent study showed that women with epilepsy during pregnancy had similar risks of seizures as women with epilepsy who are not pregnant, as long as their medications were monitored and doses were adjusted during pregnancy (Pennell, 2020).

In this web-based tool, we discuss antiseizure medications, risks of birth defects and developmental delays, as well as medication monitoring during pregnancy. This data is based on pregnancy registries around the world including the North American Registry, the European Registry, and others (link). As some medications are used more than others, still more data is required for future guidance of these medications and their safety during pregnancy.

Disclaimer: Some safety considerations/recommendations provided in this web-based tool are based on limited studies and current best evidence. This web-based tool must not be used as the sole base of decision-making in the use of medicines during pregnancy. Expert health care provider consultation with epilepsy specialists/neurologists/obstetricians is required throughout the process of change, as decisions should be based on an individual’s specific circumstances.

Resources:

  • https://www.ilae.org/patient-care/epilepsy-and-pregnancy
  • Management of epilepsy in pregnancy: a report from the International League Against Epilepsy Task Force on Women and Pregnancy Torbjörn Tomson 1, Dina Battino 2, Rebecca Bromley 3, Silvia Kochen 4, Kimford Meador 5, Page Pennell 6,Sanjeev V. Thomas
  • Epilepsy and Pregnancy
  • CONTINUUM (MINNEAP MINN) 2022;28( 1, NEUROLOGY OF PREGNANCY):34– 5 4 . American academy of neurology By Yi Li, MD, Ph.D.; Kimford J. Meador, MD, FAAN, FAES, FRCPE
  • Pennell PB, French JA, May RC, Gerard E, Kalayjian L, Penovich P, Gedzelman E, Cavitt J, Hwang S, Pack AM, Sam M, Miller JW, Wilson SH, Brown C, Birnbaum AK, Meador KJ; MONEAD Study Group. Changes in Seizure Frequency and Antiepileptic Therapy during Pregnancy. N Engl J Med. 2020 Dec 24;383(26):2547-2556

Medication Safety Checker

Add drug to check for safety

    • Lorazepam (Ativan)

      Lorazepam belongs to the group of medicines known as benzodiazepines and is used for multiple indications including seizures, anxiety, and alcohol withdrawal.

      First trimester

      SafetyConcernNext steps
      Careful use (mother)

      There is a slight increased risk of spontaneous abortion with lorazepam use compared to unexposed individuals.

      Lorazepam can be used short-term for seizure management; however long-term use (regular daily use) of benzodiazepines should be avoided during pregnancy.

      Careful use (fetus)

      NO increased risk of major birth defects compared to the general population with use of lorazepam in the first trimester.

      Lorazepam can be used short-term for seizure management; however long-term use (regular daily use) of benzodiazepines should be avoided during pregnancy.

      Second trimester

      SafetyConcernNext steps
      Careful use (mother)

      There is a slight increased risk of preterm birth/labor with lorazepam use compared to unexposed individuals.

      Lorazepam can be used short-term for seizure management; however long-term use (regular daily use) of benzodiazepines should be avoided during pregnancy.

      Careful use (fetus)

      NO or small risk of decreased birth weight compared to the general population with lorazepam use.

      Lorazepam can be used short-term for seizure management; however long-term use (regular daily use) of benzodiazepines should be avoided during pregnancy.

      Third trimester

      SafetyConcernNext steps
      Careful use (mother)

      There is a slight increased risk of preterm labor with lorazepam use compared to unexposed pregnancies.

      Lorazepam can be used short-term for seizure management; however long-term use (regular daily use) of benzodiazepines should be avoided during pregnancy.

      Careful use (fetus)

      There is a risk of preterm birth with benzodiazepine exposed pregnancies than unexposed individuals.

      NO or small risk of decreased birth weight compared to the general population.

      Long term use of benzodiazepines especially short-acting (clonazepam) can cause neonatal/newborn toxicity and withdrawals including low APGAR score at birth, breathing problems, low temperature, decreased or increased tone of baby, irritable and restless baby, lethargy, tremors, poor feeding/ vomiting. This toxicity and withdrawal are seen more often in preterm babies than full-term babies and can last up to three months after birth.

      Study of >1850 children exposed during pregnancy with benzodiazepines were compared at the age of three with unexposed children who showed no difference in cognitive functioning and motor growth.

      No increased risk of autism spectrum disorder.

      Lorazepam can be used short-term for seizure management; however long-term use (regular daily use) of benzodiazepines should be avoided during pregnancy to avoid newborn toxicity and withdrawal after delivery.

    • Diazepam (Valium)

      Diazepam belongs to the group of medicines known as benzodiazepines and is used for multiple indications including seizures, anxiety, and alcohol withdrawal.

      First trimester

      SafetyConcernNext steps
      Careful use (mother)

      There is a slight increased risk of spontaneous abortion with diazepam use compared to unexposed individuals.

      Diazepam can be used short-term for seizure management; however long-term use (regular daily use) of benzodiazepines should be avoided during pregnancy.

      Careful use (fetus)

      NO increased risk of major birth defects compared to the general population with use of diazepam in the first trimester.

      Diazepam can be used short-term for seizure management; however long-term use (regular daily use) of benzodiazepines should be avoided during pregnancy.

      Second trimester

      SafetyConcernNext steps
      Careful use (mother)

      There is a slight increased risk of preterm birth/labor with diazepam use compared to unexposed individuals.

      Diazepam can be used short-term for seizure management; however long-term use (regular daily use) of benzodiazepines should be avoided during pregnancy.

      Careful use (fetus)

      NO or small risk of decreased birth weight compared to the general population with diazepam use.

      Diazepam can be used short-term for seizure management; however long-term use (regular daily use) of benzodiazepines should be avoided during pregnancy.

      Third trimester

      SafetyConcernNext steps
      Careful use (mother)

      There is a slight increased risk of preterm labor with diazepam use compared to unexposed pregnancies.

      Diazepam can be used short-term for seizure management; however long-term use (regular daily use) of benzodiazepines should be avoided during pregnancy.

      Careful use (fetus)

      There is a risk of preterm birth with benzodiazepine exposed pregnancies than unexposed individuals.

      NO or small risk of decreased birth weight compared to the general population.

      Long term use of benzodiazepines especially short-acting (clonazepam) can cause neonatal/newborn toxicity and withdrawals including low APGAR score at birth, breathing problems, low temperature, decreased or increased tone of baby, irritable and restless baby, lethargy, tremors, poor feeding/ vomiting. This toxicity and withdrawal are seen more often in preterm babies than full-term babies and can last up to three months after birth.

      Study of >1850 children exposed during pregnancy with benzodiazepines were compared at the age of three with unexposed children who showed no difference in cognitive functioning and motor growth.

      No increased risk of autism spectrum disorder.

      Diazepam can be used short-term for seizure management; however long-term use (regular daily use) of benzodiazepines should be avoided during pregnancy to avoid newborn toxicity and withdrawal after delivery.

    • Clonazepam (Klonopin)

      Clonazepam belongs to the group of medicines known as benzodiazepines and is used for multiple indications including seizures, anxiety, and alcohol withdrawal.

      First trimester

      SafetyConcernNext steps
      Careful use (mother)

      There is a slight increased risk of spontaneous abortion with clonazepam use compared to unexposed individuals.

      Clonazepam can be used short-term for seizure management; however long-term use (regular daily use) of benzodiazepines should be avoided during pregnancy.

      Careful use (fetus)

      NO increased risk of major birth defects compared to the general population with use of clonazepam in the first trimester.

      Clonazepam can be used short-term for seizure management; however long-term use (regular daily use) of benzodiazepines should be avoided during pregnancy.

      Second trimester

      SafetyConcernNext steps
      Careful use (mother)

      There is a slight increased risk of preterm birth/labor with clonazepam use compared to unexposed individuals.

      Clonazepam can be used short-term for seizure management; however long-term use (regular daily use) of benzodiazepines should be avoided during pregnancy.

      Careful use (fetus)

      NO or small risk of decreased birth weight compared to the general population with clonazepam use.

      Clonazepam can be used short-term for seizure management; however long-term use (regular daily use) of benzodiazepines should be avoided during pregnancy.

      Third trimester

      SafetyConcernNext steps
      Careful use (mother)

      There is a slight increased risk of preterm labor with clonazepam use compared to unexposed pregnancies.

      Clonazepam can be used short-term for seizure management; however long-term use (regular daily use) of benzodiazepines should be avoided during pregnancy.

      Careful use (fetus)

      There is a risk of preterm birth with benzodiazepine exposed pregnancies than unexposed individuals.

      NO or small risk of decreased birth weight compared to the general population.

      Long term use of benzodiazepines especially short-acting (clonazepam) can cause neonatal/newborn toxicity and withdrawals including low APGAR score at birth, breathing problems, low temperature, decreased or increased tone of baby, irritable and restless baby, lethargy, tremors, poor feeding/ vomiting. This toxicity and withdrawal are seen more often in preterm babies than full-term babies and can last up to three months after birth.

      Study of >1850 children exposed during pregnancy with benzodiazepines were compared at the age of three with unexposed children who showed no difference in cognitive functioning and motor growth.

      No increased risk of autism spectrum disorder.

      Clonazepam can be used short-term for seizure management; however long-term use (regular daily use) of benzodiazepines should be avoided during pregnancy to avoid newborn toxicity and withdrawal after delivery.

    • Clobazam (Onfi)

      Clobazam belongs to the group of medicines known as benzodiazepines and is used for multiple indications including seizures, anxiety, and alcohol withdrawal.

      First trimester

      SafetyConcernNext steps
      Careful use (mother)

      There is a slight increased risk of spontaneous abortion with clobazam use compared to unexposed individuals.

      Clobazam can be used short-term for seizure management; however long-term use (regular daily use) of benzodiazepines should be avoided during pregnancy.

      Careful use (fetus)

      NO increased risk of major birth defects compared to the general population with use of clobazam in the first trimester.

      Clobazam can be used short-term for seizure management; however long-term use (regular daily use) of benzodiazepines should be avoided during pregnancy.

      Second trimester

      SafetyConcernNext steps
      Careful use (mother)

      There is a slight increased risk of preterm birth/labor with clobazam use compared to unexposed individuals.

      Clobazam can be used short-term for seizure management; however long-term use (regular daily use) of benzodiazepines should be avoided during pregnancy.

      Careful use (fetus)

      NO or small risk of decreased birth weight compared to the general population with clobazam use.

      Clobazam can be used short-term for seizure management; however long-term use (regular daily use) of benzodiazepines should be avoided during pregnancy.

      Third trimester

      SafetyConcernNext steps
      Careful use (mother)

      There is a slight increased risk of preterm labor with clobazam use compared to unexposed pregnancies.

      Clobazam can be used short-term for seizure management; however long-term use (regular daily use) of benzodiazepines should be avoided during pregnancy.

      Careful use (fetus)

      There is a risk of preterm birth with benzodiazepine exposed pregnancies than unexposed individuals.

      NO or small risk of decreased birth weight compared to the general population.

      Long term use of benzodiazepines especially short-acting (clonazepam) can cause neonatal/newborn toxicity and withdrawals including low APGAR score at birth, breathing problems, low temperature, decreased or increased tone of baby, irritable and restless baby, lethargy, tremors, poor feeding/ vomiting. This toxicity and withdrawal are seen more often in preterm babies than full-term babies and can last up to three months after birth.

      Study of >1850 children exposed during pregnancy with benzodiazepines were compared at the age of three with unexposed children who showed no difference in cognitive functioning and motor growth.

      No increased risk of autism spectrum disorder.

      Clobazam can be used short-term for seizure management; however long-term use (regular daily use) of benzodiazepines should be avoided during pregnancy to avoid newborn toxicity and withdrawal after delivery.

    • Midazolam (Versed)

      Midazolam belongs to the group of medicines known as benzodiazepines and is used for multiple indications including seizures, anxiety, and alcohol withdrawal.

      First trimester

      SafetyConcernNext steps
      Careful use (mother)

      There is a slight increased risk of spontaneous abortion with midazolam use compared to unexposed individuals.

      Midazolam can be used short-term for seizure management; however long-term use (regular daily use) of benzodiazepines should be avoided during pregnancy.

      Careful use (fetus)

      NO increased risk of major birth defects compared to the general population with use of midazolam in the first trimester.

      Midazolam can be used short-term for seizure management; however long-term use (regular daily use) of benzodiazepines should be avoided during pregnancy.

      Second trimester

      SafetyConcernNext steps
      Careful use (mother)

      There is a slight increased risk of preterm birth/labor with midazolam use compared to unexposed individuals.

      Midazolam can be used short-term for seizure management; however long-term use (regular daily use) of benzodiazepines should be avoided during pregnancy.

      Careful use (fetus)

      NO or small risk of decreased birth weight compared to the general population with midazolam use.

      Midazolam can be used short-term for seizure management; however long-term use (regular daily use) of benzodiazepines should be avoided during pregnancy.

      Third trimester

      SafetyConcernNext steps
      Careful use (mother)

      There is a slight increased risk of preterm labor with midazolam use compared to unexposed pregnancies.

      Midazolam can be used short-term for seizure management; however long-term use (regular daily use) of benzodiazepines should be avoided during pregnancy.

      Careful use (fetus)

      There is a risk of preterm birth with benzodiazepine exposed pregnancies than unexposed individuals.

      NO or small risk of decreased birth weight compared to the general population.

      Long term use of benzodiazepines especially short-acting (clonazepam) can cause neonatal/newborn toxicity and withdrawals including low APGAR score at birth, breathing problems, low temperature, decreased or increased tone of baby, irritable and restless baby, lethargy, tremors, poor feeding/ vomiting. This toxicity and withdrawal are seen more often in preterm babies than full-term babies and can last up to three months after birth.

      Study of >1850 children exposed during pregnancy with benzodiazepines were compared at the age of three with unexposed children who showed no difference in cognitive functioning and motor growth.

      No increased risk of autism spectrum disorder.

      Midazolam can be used short-term for seizure management; however long-term use (regular daily use) of benzodiazepines should be avoided during pregnancy to avoid newborn toxicity and withdrawal after delivery.

    • Nitrazepam

      Nitrazepam belongs to the group of medicines known as benzodiazepines and is used for multiple indications including seizures, anxiety, and alcohol withdrawal.

      First trimester

      SafetyConcernNext steps
      Careful use (mother)

      There is a slight increased risk of spontaneous abortion with nitrazepam use compared to unexposed individuals.

      Nitrazepam can be used short-term for seizure management; however long-term use (regular daily use) of benzodiazepines should be avoided during pregnancy.

      Careful use (fetus)

      NO increased risk of major birth defects compared to the general population with use of nitrazepam in the first trimester.

      Nitrazepam can be used short-term for seizure management; however long-term use (regular daily use) of benzodiazepines should be avoided during pregnancy.

      Second trimester

      SafetyConcernNext steps
      Careful use (mother)

      There is a slight increased risk of preterm birth/labor with nitrazepam use compared to unexposed individuals.

      Nitrazepam can be used short-term for seizure management; however long-term use (regular daily use) of benzodiazepines should be avoided during pregnancy.

      Careful use (fetus)

      NO or small risk of decreased birth weight compared to the general population with nitrazepam use.

      Nitrazepam can be used short-term for seizure management; however long-term use (regular daily use) of benzodiazepines should be avoided during pregnancy.

      Third trimester

      SafetyConcernNext steps
      Careful use (mother)

      There is a slight increased risk of preterm labor with nitrazepam use compared to unexposed pregnancies.

      Nitrazepam can be used short-term for seizure management; however long-term use (regular daily use) of benzodiazepines should be avoided during pregnancy.

      Careful use (fetus)

      There is a risk of preterm birth with benzodiazepine exposed pregnancies than unexposed individuals.

      NO or small risk of decreased birth weight compared to the general population.

      Long term use of benzodiazepines especially short-acting (clonazepam) can cause neonatal/newborn toxicity and withdrawals including low APGAR score at birth, breathing problems, low temperature, decreased or increased tone of baby, irritable and restless baby, lethargy, tremors, poor feeding/ vomiting. This toxicity and withdrawal are seen more often in preterm babies than full-term babies and can last up to three months after birth.

      Study of >1850 children exposed during pregnancy with benzodiazepines were compared at the age of three with unexposed children who showed no difference in cognitive functioning and motor growth.

      No increased risk of autism spectrum disorder.

      Nitrazepam can be used short-term for seizure management; however long-term use (regular daily use) of benzodiazepines should be avoided during pregnancy to avoid newborn toxicity and withdrawal after delivery.

    • Levetiracetam (Keppra)

      Levetiracetam is an antiseizure medication used to treat certain types of seizures in people with epilepsy. Levetiracetam has limited side effects and is effective for both focal and generalized epilepsy.

      First trimester

      SafetyConcernNext steps
      Safe use (mother)

      Levetiracetam is a safe medication in pregnant women with epilepsy. Drug clearance and breakdown increase during pregnancy so drug level monitoring is required.

      Levetiracetam is a favorable choice for both focal and generalized epilepsy in women of childbearing age due to the lower risk of birth defects.

      Drug breakdown and kidney clearance (primarily increased in second and third trimesters). Thus, drug level monitoring throughout pregnancy is recommended and dose adjustment is required to prevent seizures.

      Safe use (fetus)

      Levetiracetam is a safe medication in pregnant women with epilepsy.

      Data from >1000 pregnancies exposed to levetiracetam monotherapy suggests the overall risk of major birth defects/malformation is 0.7% to 2.4%, which is not increased compared to the general population.

      No association between dose of levetiracetam and malformation rate was found.

      Levetiracetam is a favorable choice for both focal and generalized epilepsy in women of childbearing age due to the lower risk of birth defects.

      Drug breakdown and kidney clearance (primarily increased in second and third trimesters). Thus, drug level monitoring throughout pregnancy is recommended and dose adjustment is required to prevent seizures.

      Second trimester

      SafetyConcernNext steps
      Safe use (mother)

      Levetiracetam levels start to drop in the second trimester and drug level monitoring is required to prevent seizures.

      It does not increase depression during pregnancy.

      Levetiracetam is a favorable choice for both focal and generalized epilepsy in women of childbearing age due to the lower risk of birth defects.

      Drug breakdown and kidney clearance (primarily increased in second and third trimesters). Thus, drug level monitoring throughout pregnancy is recommended and dose adjustment is required to prevent seizures.

      Safe use (fetus)

      No increased risk of miscarriage or preterm labor with levetiracetam use in pregnancy.

      Levetiracetam is a favorable choice for both focal and generalized epilepsy in women of childbearing age due to the lower risk of birth defects.

      Drug breakdown and kidney clearance (primarily increased in second and third trimesters). Thus, drug level monitoring throughout pregnancy is recommended and dose adjustment is required to prevent seizures.

      Third trimester

      SafetyConcernNext steps
      Safe use (mother)

      Small study has shown that levetiracetam levels significantly dropped (40%-60%) in the third trimester from preconception (baseline) drug levels, which is due to increased drug breakdown and clearance of medication from kidneys. Thus, dose adjustment is required to prevent seizures.

      It does not increase peripartum or postpartum depression

      Levetiracetam is a favorable choice for both focal and generalized epilepsy in women of childbearing age due to the lower risk of birth defects.

      Drug breakdown and kidney clearance (primarily increased in second and third trimesters). Thus, drug level monitoring throughout pregnancy is recommended and dose adjustment is required to prevent seizures.

      Safe use (fetus)

      No effect on cognitive ability, language development, and behavioral outcomes on children exposed to levetiracetam monotherapy compared to the general population.

      Levetiracetam is a favorable choice for both focal and generalized epilepsy in women of childbearing age due to the lower risk of birth defects.

      Drug breakdown and kidney clearance (primarily increased in second and third trimesters). Thus, drug level monitoring throughout pregnancy is recommended and dose adjustment is required to prevent seizures.

    • Oxcarbazepine (Trileptal)

      Oxcarbazepine is an antiseizure medication used to treat certain types of seizures in people with epilepsy. It may also be used to treat neuropathic pain.

      First trimester

      SafetyConcernNext steps
      Safe use (mother)

      Drug clearance and breakdown increase during pregnancy so drug level monitoring throughout pregnancy is required. No increased risk of spontaneous abortion.

      During pregnancy, drug breakdown and clearance increase, which decreases oxcarbazepine drug levels in the mother and can cause seizures. Drug level monitoring throughout pregnancy is required.

      If oxcarbazepine drug levels have decreased by 30-40% from preconception levels a dose adjustment should be made.

      Safe use (fetus)

      Based data from 1000 pregnancies exposed to oxcarbazepine monotherapy suggests the overall risk of major birth defects/malformation is 2-3%, which is not increased compared to the general population 1-2%.

      It is a safe anti-seizure medication for women with epilepsy during pregnancy and childbearing age due to a lower risk of birth defects.

      Careful use (fetus)

      Second trimester

      SafetyConcernNext steps
      Safe use (mother)

      Drug clearance and breakdown increase during pregnancy so level monitoring is required.

      During pregnancy, drug breakdown and clearance increase, which decreases oxcarbazepine drug levels in the mother and can cause seizures. Drug level monitoring throughout pregnancy is required.

      If oxcarbazepine drug levels have decreased by 30-40% from preconception levels a dose adjustment should be made.

      Safe use (fetus)

      No significant increase in the risk of growth restriction with oxcarbazepine use.

      Oxcarbazepine is safe anti-seizure medication for women with epilepsy during pregnancy and childbearing age.

      Third trimester

      SafetyConcernNext steps
      Safe use (mother)

      Drug clearance and breakdown increase during pregnancy, so drug level monitoring is required especially in the third trimester and may worsen seizure control.

      During pregnancy, drug breakdown and clearance increase, which decreases oxcarbazepine drug levels in the mother and can cause seizures. Drug level monitoring throughout pregnancy is required.

      If oxcarbazepine drug levels have decreased by 30-40% from preconception levels a dose adjustment should be made.

      Safe use (fetus)

      No increased risk of autism spectrum disorder, no long-term effect on cognition and motor development has been seen with oxacarbazepine use in pregnancy.

      Oxcarbazepine is safe anti-seizure medication for women with epilepsy during pregnancy and childbearing age.

    • Phenytoin (Dilantin)

      Phenytoin is an antiseizure medication used to treat certain types of seizures in people with epilepsy. It is effective for both focal and generalized epilepsy.

      First trimester

      SafetyConcernNext steps
      Careful use (mother)

      During pregnancy phenytoin levels are decreased in serum levels by 30-60%, due to an increase in the breakdown and drug clearance.

      If phenytoin needs to be used during pregnancy for seizure prevention, drug levels should be monitored and adjusted throughout pregnancy to prevent breakthrough seizures.

      Unsafe use (fetus)

      High risk of major birth defect which is 6.2% with monotherapy and higher with polytherapy.

      Common birth defect includes heart defects 0.3% including an enlarged heart and ventricular septum defects, urine tube abnormality (hypospadias) 0.4%, oral cleft 0.4%, other malformations including fetal hydantoin syndrome (microcephaly, craniofacial anomalies, hypertelorism, flattened nasal root, ptosis, wide mouth, cleft palate-lip, cardiac defects, urogenital malformations, and hypoplastic distal phalanx and nails) Fetal hydantoin syndrome can be seen in approximately 5–10% of infants with in utero exposure to phenytoin, whereas incomplete clinical syndrome can be seen in about one-third of them.

      It decreases the folic acid in blood by up to 90% which increases the risk of brain and spinal cord defects.

      Phenytoin should be avoided during pregnancy due to concerns of birth defects and high risk of major malformation with monotherapy 6.2% and more with polytherapy.

      High-dose folic acid (4mg daily) is recommended.

      Second trimester

      SafetyConcernNext steps
      Careful use (mother)

      During pregnancy phenytoin levels are decreased in serum levels by 30-60%, due to an increase in the breakdown and drug clearance.

      If phenytoin needs to be used during pregnancy for seizure prevention, drug levels should be monitored and adjusted throughout pregnancy to prevent breakthrough seizures.

      Careful use (fetus)

      Phenytoin use in pregnancy is associated with a lower risk of neurocognitive effect.

      Phenytoin should be avoided during pregnancy due to concerns of birth defects, but if used should be used at the lowest effective does and with high-dose folic acid (4mg daily).

      Third trimester

      SafetyConcernNext steps
      Careful use (mother)

      During pregnancy phenytoin levels are decreased in serum levels by 30-60%, due to an increase in the breakdown and drug clearance.

      Life-threatening bleeding disorders in the newborn may also occur due to decreased concentrations of vitamin K-dependent clotting factors following phenytoin exposure in utero.

      If phenytoin needs to be used during pregnancy for seizure prevention, drug levels should be monitored and adjusted throughout pregnancy to prevent breakthrough seizures.

      Vitamin K administration to the mother before delivery and the newborn after birth is recommended.

      Careful use (fetus)

      Life-threatening bleeding disorders in the newborn may also occur due to decreased concentrations of vitamin K-dependent clotting factors following phenytoin exposure in utero.

      Vitamin K administration to the mother before delivery and the newborn after birth is recommended.

    • Lacosamide (Vimpat)

      Lacosamide is an antiseizure medication used to treat certain types of seizures in people with epilepsy. It is effective for both focal and generalized epilepsy.

      First trimester

      SafetyConcernNext steps
      Unsafe use (mother)

      Safety data for lacosamide use in pregnancy is not available.

      Limited to no safety data is available during pregnancy, with an uncertain risk of major malformation, therefore lacosamide should NOT be prescribed to pregnant women with epilepsy.

      Unsafe use (fetus)

      Limited or no safety data for lacosamide use in pregnancy.

      Limited to no safety data is available during pregnancy, with an uncertain risk of major malformation, therefore lacosamide should NOT be prescribed to pregnant women with epilepsy.

      Second trimester

      SafetyConcernNext steps
      Unsafe use (mother)

      Safety data for lacosamide use in pregnancy is not available.

      Limited to no safety data is available during pregnancy, with an uncertain risk of major malformation and uncertain long-term neurocognitive effects, therefore this medication should not be prescribed to pregnant women with epilepsy

      Unsafe use (fetus)

      Limited or no safety data for lacosamide use in pregnancy.

      Limited to no safety data is available during pregnancy, with an uncertain risk of major malformation and uncertain long-term neurocognitive effects, therefore this medication should not be prescribed to pregnant women with epilepsy

      Third trimester

      SafetyConcernNext steps
      Unsafe use (mother)

      Safety data for lacosamide use in pregnancy is not available.

      Limited to no safety data is available during pregnancy, with an uncertain risk of major malformation and uncertain long-term neurocognitive effects, therefore this medication should not be prescribed to pregnant women with epilepsy

      Unsafe use (fetus)

      Limited or no safety data for lacosamide use in pregnancy.

      Limited to no safety data is available during pregnancy, with an uncertain risk of major malformation and uncertain long-term neurocognitive effects, therefore this medication should not be prescribed to pregnant women with epilepsy

    • Zonisamide (Zonegran)

      Zonisamide is an antiseizure medication used to treat certain types of seizures in people with epilepsy.

      First trimester

      SafetyConcernNext steps
      Careful use (mother)

      Limited data suggest that there is a 35% drop in prepregnancy zonisamide drug levels, which is due to increase breakdown and clearance of the medication.

      Drug monitoring and dose adjustments throughout pregnancy are required to prevent seizures.

      Unsafe use (fetus)

      Limited safety data during its use in pregnancy, 26 pregnancies exposed to zonisamide monotherapy showed major birth defects in 41 pregnancies (13%).

      Limited safety data is available during pregnancy, with an uncertain risk of major malformation, therefore this medication should not be prescribed to pregnant women with epilepsy.

      Second trimester

      SafetyConcernNext steps
      Careful use (mother)

      Limited data suggest that there is a 35% drop in prepregnancy zonisamide drug levels, which is due to increase breakdown and clearance of the medication.

      Drug monitoring and dose adjustments throughout pregnancy are required to prevent seizures.

      Unsafe use (fetus)

      Limited safety data during its use in pregnancy, however, fetal growth restrictions have been seen with zonisamide use.

      Limited safety data is available during pregnancy with an uncertain risks, therefore this medication should not be prescribed to pregnant women with epilepsy.

      Third trimester

      SafetyConcernNext steps
      Careful use (mother)

      Limited data suggest that there is a 35% drop in prepregnancy zonisamide drug levels, which is due to increase breakdown and clearance of the medication.

      Drug monitoring and dose adjustments throughout pregnancy are required to prevent seizures.

      Unsafe use (fetus)

      Limited safety data during its use in pregnancy, however, fetal growth restrictions seen with zonisamide use.

      Limited safety data is available during pregnancy, with an uncertain risks and uncertain long-term neurocognitive effects, therefore this medication should not be prescribed to pregnant women with epilepsy.

    • Brivaracetam

      Brivaracetam is an antiseizure medication used to treat certain types of seizures in people with epilepsy. Brivaracetam has limited side effects and is effective for both focal and generalized epilepsy.

      First trimester

      SafetyConcernNext steps
      Unsafe use (mother)

      Safety data for brivaracetam use in pregnancy is not available.

      NO safety data is available during pregnancy, with an uncertain risk of major malformation and uncertain long-term neurocognitive effects, therefore this medication should not be prescribed to pregnant women with epilepsy.

      Unsafe use (fetus)

      Limited or no safety data for brivaracetam use in pregnancy.

      NO safety data is available during pregnancy, with an uncertain risk of major malformation and uncertain long-term neurocognitive effects, therefore this medication should not be prescribed to pregnant women with epilepsy.

      Second trimester

      SafetyConcernNext steps
      Unsafe use (mother)

      Safety data for brivaracetam use in pregnancy is not available.

      NO safety data is available during pregnancy, with an uncertain risk of major malformation and uncertain long-term neurocognitive effects, therefore this medication should not be prescribed to pregnant women with epilepsy.

      Unsafe use (fetus)

      Limited or no safety data for brivaracetam use in pregnancy.

      NO safety data is available during pregnancy, with an uncertain risk of major malformation and uncertain long-term neurocognitive effects, therefore this medication should not be prescribed to pregnant women with epilepsy.

      Third trimester

      SafetyConcernNext steps
      Unsafe use (mother)

      Safety data for brivaracetam use in pregnancy is not available.

      NO safety data is available during pregnancy, with an uncertain risk of major malformation and uncertain long-term neurocognitive effects, therefore this medication should not be prescribed to pregnant women with epilepsy.

      Unsafe use (fetus)

      Limited or no safety data for brivaracetam use in pregnancy.

      NO safety data is available during pregnancy, with an uncertain risk of major malformation and uncertain long-term neurocognitive effects, therefore this medication should not be prescribed to pregnant women with epilepsy.

    • Eslicarbazepine (Aptiom)

      Eslicarbazepine is an antiseizure medication used to treat certain types of seizures in people with epilepsy.

      First trimester

      SafetyConcernNext steps
      Unsafe use (mother)

      No safety data available during pregnancy.

      NO safety data is available during pregnancy, with an uncertain risk of major malformation and uncertain long-term neurocognitive effects, therefore this medication should not be prescribed to pregnant women with epilepsy.

      Unsafe use (fetus)

      No safety data available during pregnancy.

      NO safety data is available during pregnancy, with an uncertain risk of major malformation and uncertain long-term neurocognitive effects, therefore this medication should not be prescribed to pregnant women with epilepsy.

      Second trimester

      SafetyConcernNext steps
      Unsafe use (mother)

      No safety data available during pregnancy.

      NO safety data is available during pregnancy, with an uncertain risk of major malformation and uncertain long-term neurocognitive effects, therefore this medication should not be prescribed to pregnant women with epilepsy.

      Unsafe use (fetus)

      No safety data available during pregnancy.

      NO safety data is available during pregnancy, with an uncertain risk of major malformation and uncertain long-term neurocognitive effects, therefore this medication should not be prescribed to pregnant women with epilepsy.

      Third trimester

      SafetyConcernNext steps
      Unsafe use (mother)

      No safety data available during pregnancy.

      NO safety data is available during pregnancy, with an uncertain risk of major malformation and uncertain long-term neurocognitive effects, therefore this medication should not be prescribed to pregnant women with epilepsy.

      Unsafe use (fetus)

      No safety data available during pregnancy.

      NO safety data is available during pregnancy, with an uncertain risk of major malformation and uncertain long-term neurocognitive effects, therefore this medication should not be prescribed to pregnant women with epilepsy.

    • Primidone (Mysoline)

      Primidone belongs to the group of medicines known as barbiturates and is used to tremors along with focal and generalized seizures.

      First trimester

      SafetyConcernNext steps
      Unsafe use (mother)

      Safety data for primidone use in pregnancy is not available.

      Unsafe use (fetus)

      Limited data shows 8.49% risk of major birth defects with primidone use during pregnancy with the most common defect being orofacial clefts.

      The use of primidone in pregnancy can be associated with major birth defects, thus the use of folic acid throughout pregnancy is recommended.

      Second trimester

      SafetyConcernNext steps
      Unsafe use (mother)

      Safety data for primidone use in pregnancy is not available.

      The use of primidone can be associated with adverse events. The use of folic acid throughout pregnancy and vitamin K during the last month of pregnancy is recommended.

      Unsafe use (fetus)

      Increased risk of small head size is seen among children exposed to polytherapy or monotherapy with primidone.

      The use of primidone can be associated with adverse events. The use of folic acid throughout pregnancy and vitamin K during the last month of pregnancy is recommended.

      Third trimester

      SafetyConcernNext steps
      Unsafe use (mother)

      Safety data for primidone use in pregnancy is not available.

      The use of primidone can be associated with adverse events. The use of folic acid throughout pregnancy and vitamin K during the last month of pregnancy is recommended.

      Unsafe use (fetus)

      Increased risk of small head size is seen among children exposed to polytherapy or monotherapy with primidone.

      Withdrawal symptoms may occur in the neonate and may be delayed due to the long half-life of primidone and its metabolites, it should be monitored carefully.

      The use of primidone can be associated with adverse events. The use of folic acid throughout pregnancy and vitamin K during the last month of pregnancy is recommended.

    • Felbamate (Felbatol)

      Felbamate is an antiseizure medication used to treat certain types of seizures in people with epilepsy.

      First trimester

      SafetyConcernNext steps
      Unsafe use (mother)

      No safety data available for felbamate use during pregnancy.

      No safety data is available during pregnancy, with an uncertain risk of major malformation and uncertain long-term neurocognitive effects, therefore this medication should not be prescribed to pregnant women with epilepsy.

      Unsafe use (fetus)

      No safety data available for felbamate use during pregnancy.

      No safety data is available during pregnancy, with an uncertain risk of major malformation and uncertain long-term neurocognitive effects, therefore this medication should not be prescribed to pregnant women with epilepsy.

      Second trimester

      SafetyConcernNext steps
      Unsafe use (mother)

      No safety data available for felbamate use during pregnancy.

      No safety data is available during pregnancy, with an uncertain risk of major malformation and uncertain long-term neurocognitive effects, therefore this medication should not be prescribed to pregnant women with epilepsy.

      Unsafe use (fetus)

      No safety data available for felbamate use during pregnancy.

      No safety data is available during pregnancy, with an uncertain risk of major malformation and uncertain long-term neurocognitive effects, therefore this medication should not be prescribed to pregnant women with epilepsy.

      Third trimester

      SafetyConcernNext steps
      Unsafe use (mother)

      No safety data available for felbamate use during pregnancy.

      No safety data is available during pregnancy, with an uncertain risk of major malformation and uncertain long-term neurocognitive effects, therefore this medication should not be prescribed to pregnant women with epilepsy.

      Unsafe use (fetus)

      No safety data available for felbamate use during pregnancy.

      No safety data is available during pregnancy, with an uncertain risk of major malformation and uncertain long-term neurocognitive effects, therefore this medication should not be prescribed to pregnant women with epilepsy.

    • Rufinamide (Banzel)

      Rufinamide is an antiseizure medication used to treat certain types of seizures in people with epilepsy.

      First trimester

      SafetyConcernNext steps
      Unsafe use (mother)

      No safety data available during pregnancy.

      No safety data is available during pregnancy, with an uncertain risk of major malformation and uncertain long-term neurocognitive effects, therefore this medication should not be prescribed to pregnant women with epilepsy.

      Unsafe use (fetus)

      No safety data available during pregnancy.

      No safety data is available during pregnancy, with an uncertain risk of major malformation and uncertain long-term neurocognitive effects, therefore this medication should not be prescribed to pregnant women with epilepsy.

      Second trimester

      SafetyConcernNext steps
      Unsafe use (mother)

      No safety data available during pregnancy.

      No safety data is available during pregnancy, with an uncertain risk of major malformation and uncertain long-term neurocognitive effects, therefore this medication should not be prescribed to pregnant women with epilepsy.

      Unsafe use (fetus)

      No safety data available during pregnancy.

      No safety data is available during pregnancy, with an uncertain risk of major malformation and uncertain long-term neurocognitive effects, therefore this medication should not be prescribed to pregnant women with epilepsy.

      Third trimester

      SafetyConcernNext steps
      Unsafe use (mother)

      No safety data available during pregnancy.

      No safety data is available during pregnancy, with an uncertain risk of major malformation and uncertain long-term neurocognitive effects, therefore this medication should not be prescribed to pregnant women with epilepsy.

      Unsafe use (fetus)

      No safety data available during pregnancy.

      No safety data is available during pregnancy, with an uncertain risk of major malformation and uncertain long-term neurocognitive effects, therefore this medication should not be prescribed to pregnant women with epilepsy.

    • Ethosuximide (Zarontin)

      Ethosuximide is an antiseizure medication used to treat certain types of seizures in people with epilepsy.

      First trimester

      SafetyConcernNext steps
      Unsafe use (mother)

      Safety data for ethosuximide use in pregnancy is not available.

      Ethosuximide drug levels in the blood decrease during pregnancy and may cause seizures.

      Not recommended during pregnancy, with an uncertain risk of major malformation and uncertain long-term neurocognitive effects, therefore this medication should not be prescribed to pregnant women with epilepsy.

      If this medication needs to be used in pregnancy, the lowest effective dose should be used and should not be combined with other antiseizure medication as it can increase the risk of birth defects.

      If ethosuximide is used in pregnancy, drug level monitoring and drug adjustments are recommended.

      Unsafe use (fetus)

      No safety data is available for ethosuximide use during human pregnancies. A birth defect has been reported in animal studies.

      Not recommended during pregnancy, with an uncertain risk of major malformation and uncertain long-term neurocognitive effects, therefore this medication should not be prescribed to pregnant women with epilepsy.

      Second trimester

      SafetyConcernNext steps
      Unsafe use (mother)

      Safety data for ethosuximide use in pregnancy is not available.

      Ethosuximide drug levels in the blood decrease during pregnancy and may cause seizures.

      Not recommended during pregnancy, with an uncertain risk of major malformation and uncertain long-term neurocognitive effects, therefore this medication should not be prescribed to pregnant women with epilepsy.

      If this medication needs to be used in pregnancy, the lowest effective dose should be used and should not be combined with other antiseizure medication as it can increase the risk of birth defects.

      If ethosuximide is used in pregnancy, drug level monitoring and drug adjustments are recommended.

      Unsafe use (fetus)

      No safety data is available for ethosuximide use during human pregnancies. A birth defect has been reported in animal studies.

      Not recommended during pregnancy, with an uncertain risk of major malformation and uncertain long-term neurocognitive effects, therefore this medication should not be prescribed to pregnant women with epilepsy.

      If this medication needs to be used in pregnancy, the lowest effective dose should be used and should not be combined with other antiseizure medication as it can increase the risk of birth defects.

      Third trimester

      SafetyConcernNext steps
      Unsafe use (mother)

      Safety data for ethosuximide use in pregnancy is not available.

      Ethosuximide drug levels in the blood decrease during pregnancy and may cause seizures.

      Not recommended during pregnancy, with an uncertain risk of major malformation and uncertain long-term neurocognitive effects, therefore this medication should not be prescribed to pregnant women with epilepsy.

      If this medication needs to be used in pregnancy, the lowest effective dose should be used and should not be combined with other antiseizure medication as it can increase the risk of birth defects.

      If ethosuximide is used in pregnancy, drug level monitoring and drug adjustments are recommended.

      Unsafe use (fetus)

      No safety data is available for ethosuximide use during human pregnancies. A birth defect has been reported in animal studies.

      Not recommended during pregnancy, with an uncertain risk of major malformation and uncertain long-term neurocognitive effects, therefore this medication should not be prescribed to pregnant women with epilepsy.

      If this medication needs to be used in pregnancy, the lowest effective dose should be used and should not be combined with other antiseizure medication as it can increase the risk of birth defects.

    • Vigabatrin (Sabril)

      Vigabatrin is an antiseizure medication used to treat certain types of seizures in people with epilepsy.

      First trimester

      SafetyConcernNext steps
      Unsafe use (mother)

      Safety data for vigabatrin use in pregnancy is not available.

      Limited safety data for its safety during pregnancy, with the risk of major malformation and uncertain long-term neurocognitive effects. Its long-term use is associated with visual field defects and suicidal risk is also reported but pregnancy exposure data is limited. Given limited evidence of safety, this medication should not be prescribed to pregnant women with epilepsy.

      Unsafe use (fetus)

      Birth defects have been reported with the use of Vigabatrin during pregnancy, which includes cardiac defects, limb defects, male genital malformations, fetal antiseizure syndrome, and renal and ear abnormalities.

      No data is available on the relationship of these defects to any specific dose (unclear drug dose relationship).

      Limited safety data for its safety during pregnancy, with the risk of major malformation and uncertain long-term neurocognitive effects. Its long-term use is associated with visual field defects and suicidal risk is also reported but pregnancy exposure data is limited. Given limited evidence of safety, this medication should not be prescribed to pregnant women with epilepsy.

      Second trimester

      SafetyConcernNext steps
      Unsafe use (mother)

      Safety data for vigabatrin use in pregnancy is not available.

      Limited safety data for its safety during pregnancy, with the risk of major malformation and uncertain long-term neurocognitive effects. Its long-term use is associated with visual field defects and suicidal risk is also reported but pregnancy exposure data is limited. Given limited evidence of safety, this medication should not be prescribed to pregnant women with epilepsy.

      Unsafe use (fetus)

      Limited safety data available during pregnancy and found to be NOT safe during pregnancy.

      Limited safety data for its safety during pregnancy, with the risk of major malformation and uncertain long-term neurocognitive effects. Its long-term use is associated with visual field defects and suicidal risk is also reported but pregnancy exposure data is limited. Given limited evidence of safety, this medication should not be prescribed to pregnant women with epilepsy.

      Third trimester

      SafetyConcernNext steps
      Unsafe use (mother)

      Safety data for vigabatrin use in pregnancy is not available.

      Limited safety data for its safety during pregnancy, with the risk of major malformation and uncertain long-term neurocognitive effects. Its long-term use is associated with visual field defects and suicidal risk is also reported but pregnancy exposure data is limited. Given limited evidence of safety, this medication should not be prescribed to pregnant women with epilepsy.

      Unsafe use (fetus)

      Limited safety data available during pregnancy and found to be NOT safe during pregnancy.

      Limited safety data for its safety during pregnancy, with the risk of major malformation and uncertain long-term neurocognitive effects. Its long-term use is associated with visual field defects and suicidal risk is also reported but pregnancy exposure data is limited. Given limited evidence of safety, this medication should not be prescribed to pregnant women with epilepsy.

    • Acetazolamide (Diamox)

      Acetazolamide belongs to the group of medicines known as carbonic anhydrase inhibitors and is used for multiple indications including idiopathic intracranial hypertension, acute mountain sickness, metabolic alkalosis, and in catamenial epilepsy.

      First trimester

      SafetyConcernNext steps
      Unsafe use (mother)

      Safety data for acetazolamide use in pregnancy is not available.

      There is no safety data for its safety during pregnancy, with uncertain risk of major malformation during pregnancy and uncertain long-term neurocognitive effects on child its use is not recommended during pregnancy.

      Unsafe use (fetus)

      Not recommended as acetazolamide use has been associated with birth defects in animal pregnancy models. No safety data available during its use in human pregnancies.

      There is no safety data for its safety during pregnancy, with uncertain risk of major malformation during pregnancy and uncertain long-term neurocognitive effects on child its use is not recommended during pregnancy.

      Second trimester

      SafetyConcernNext steps
      Unsafe use (mother)

      Safety data for acetazolamide use in pregnancy is not available.

      There is no safety data for its safety during pregnancy, with uncertain risk of major malformation during pregnancy and uncertain long-term neurocognitive effects on child its use is not recommended during pregnancy.

      Unsafe use (fetus)

      Safety data for acetazolamide use in pregnancy is not available.

      There is no safety data for its safety during pregnancy, with uncertain risk of major malformation during pregnancy and uncertain long-term neurocognitive effects on child its use is not recommended during pregnancy.

      Third trimester

      SafetyConcernNext steps
      Unsafe use (mother)

      Safety data for acetazolamide use in pregnancy is not available.

      There is no safety data for its safety during pregnancy, with uncertain risk of major malformation during pregnancy and uncertain long-term neurocognitive effects on child its use is not recommended during pregnancy.

      Unsafe use (fetus)

      Safety data for acetazolamide use in pregnancy is not available.

      There is no safety data for its safety during pregnancy, with uncertain risk of major malformation during pregnancy and uncertain long-term neurocognitive effects on child its use is not recommended during pregnancy.

    • Stiripentol (Diacom)

      Stiripentol is an antiseizure medication used to treat certain types of seizures in people with epilepsy.

      First trimester

      SafetyConcernNext steps
      Unsafe use (mother)

      Safety data for stiripentol use in pregnancy is not available.

      There is no safety data for its safety during pregnancy, with uncertain risk of major malformation during pregnancy and uncertain long-term neurocognitive effects on the child, its use is not recommended during pregnancy.

      Unsafe use (fetus)

      Safety data for stiripentol use in pregnancy is not available.

      There is no safety data for its safety during pregnancy, with uncertain risk of major malformation during pregnancy and uncertain long-term neurocognitive effects on the child, its use is not recommended during pregnancy.

      Second trimester

      SafetyConcernNext steps
      Unsafe use (mother)

      Safety data for stiripentol use in pregnancy is not available.

      There is no safety data for its safety during pregnancy, with uncertain risk of major malformation during pregnancy and uncertain long-term neurocognitive effects on the child, its use is not recommended during pregnancy.

      Unsafe use (fetus)

      Safety data for stiripentol use in pregnancy is not available.

      There is no safety data for its safety during pregnancy, with uncertain risk of major malformation during pregnancy and uncertain long-term neurocognitive effects on the child, its use is not recommended during pregnancy.

      Third trimester

      SafetyConcernNext steps
      Unsafe use (mother)

      Safety data for stiripentol use in pregnancy is not available.

      There is no safety data for its safety during pregnancy, with uncertain risk of major malformation during pregnancy and uncertain long-term neurocognitive effects on the child, its use is not recommended during pregnancy.

      Unsafe use (fetus)

      Safety data for stiripentol use in pregnancy is not available.

      There is no safety data for its safety during pregnancy, with uncertain risk of major malformation during pregnancy and uncertain long-term neurocognitive effects on the child, its use is not recommended during pregnancy.

    • Lamotrigine

      Lamotrigine belongs to the group of medicines known as anticonvulsants and is used primarily for epilepsy and bipolar disorder. It may be used for headache prevention, but is not first line.

      First trimester

      SafetyConcernNext steps
      Safe use (mother)

      Increased kidney and liver clearance of medication starts as early as 5th-week, which can lower medication effectiveness.

      Lamotrigine is not the first-line treatment for headache prevention but it is the preferred medication for seizure prevention due to the lower risk of birth defects compared to other anti-seizure medications and broad-spectrum coverage of both focal and generalized epilepsy. It can be used for seizure patients for migraine prevention due to its antiseizure effects.

      Lamotrigine levels decrease 40-60% during pregnancy which decreases its effectiveness and can result in breakthrough seizures. Thus, lamotrigine requires frequent drug level monitoring and dose adjustments as its clearance from the kidney and liver increases during pregnancy.

      Folic acid supplementation is recommended.

      Safe use (fetus)

      Lamotrigine is a SAFE medication and can be used in seizure patients for migraine and seizure prevention during pregnancy due to its headache prevention and antiseizure effect.

      Most studied drug, data from >9000 lamotrigine exposed pregnancies suggest the risk of major malformation with lamotrigine monotherapy (single medication used) was 2-3%, which is the lowest among other antiseizure medications and this risk is approximately equal to the general population which is 1-2%

      No risk of miscarriage or preterm labor.

      One of the pregnancy databases showed that the risk of major birth defect is significantly increased with higher doses of lamotrigine which is <325mg/day with 2.5% and >325mg/day with 4.3%.

      Most common birth defects in lamotrigine exposed fetuses are cardiac malformations 0.6% (abnormalities of the heart), hypospadias 0.3%(birth defect of urine tube), neural tube defects 0.1% (birth defects of the brain and spinal cord), cleft lip and cleft palate 0.1% (birth defect when babies have slit lips and/or slit mouth or not formed properly).

      Lamotrigine is not the first-line treatment for headache prevention but it is the preferred medication for seizure prevention due to the lower risk of birth defects compared to other anti-seizure medications and broad-spectrum coverage of both focal and generalized epilepsy. It can be used for seizure patients for migraine prevention due to its antiseizure effects.

      If polytherapy with lamotrigine is needed, a lower lamotrigine dose should be tried at <325 mg per day to decrease the risk of birth defects.

      Lamotrigine levels decrease 40-60% during pregnancy which decreases its effectiveness and can result in breakthrough seizures. Thus, lamotrigine requires frequent drug level monitoring and dose adjustments as its clearance from the kidney and liver increases during pregnancy.

      Folic acid supplementation is recommended.

      Second trimester

      SafetyConcernNext steps
      Safe use (mother)

      Lamotrigine blood levels drop as pregnancy advances, which can lower medication effectiveness.

      Lamotrigine is not the first-line treatment for headache prevention but it is the preferred medication for seizure prevention due to the lower risk of birth defects compared to other anti-seizure medications and broad-spectrum coverage of both focal and generalized epilepsy. It can be used for seizure patients for migraine prevention due to its antiseizure effects.

      Lamotrigine levels decrease 40-60% during pregnancy which decreases its effectiveness and can result in breakthrough seizures. Thus, lamotrigine requires frequent drug level monitoring and dose adjustments as its clearance from the kidney and liver increases during pregnancy.

      Folic acid supplementation is recommended.

      Safe use (fetus)

      Small risk of growth restriction (small for gestational age) 7% with lamotrigine exposed babies compared to the unexposed babies which are 5%. No increased risk of preterm labor.

      Lamotrigine is not the first-line treatment for headache prevention but it is the preferred medication for seizure prevention due to the lower risk of birth defects compared to other anti-seizure medications and broad-spectrum coverage of both focal and generalized epilepsy. It can be used for seizure patients for migraine prevention due to its antiseizure effects.

      If polytherapy with lamotrigine is needed, a lower lamotrigine dose should be tried at <325 mg per day to decrease the risk of birth defects.

      Lamotrigine levels decrease 40-60% during pregnancy which decreases its effectiveness and can result in breakthrough seizures. Thus, lamotrigine requires frequent drug level monitoring and dose adjustments as its clearance from the kidney and liver increases during pregnancy.

      Folic acid supplementation is recommended.

      Third trimester

      SafetyConcernNext steps
      Safe use (mother)

      Lamotrigine blood levels drop as pregnancy advances, which can lower medication effectiveness. Seizure recurrence risk is highest in the third trimester, as peak drop in lamotrigine levels.

      Lamotrigine is not the first-line treatment for headache prevention but it is the preferred medication for seizure prevention due to the lower risk of birth defects compared to other anti-seizure medications and broad-spectrum coverage of both focal and generalized epilepsy. It can be used for seizure patients for migraine prevention due to its antiseizure effects.

      Lamotrigine levels decrease 40-60% during pregnancy which decreases its effectiveness and can result in breakthrough seizures. Thus, lamotrigine requires frequent drug level monitoring and dose adjustments as its clearance from the kidney and liver increases during pregnancy.

      Folic acid supplementation is recommended.

      Safe use (fetus)

      Lamotrigine does not affect IQ (intelligence quotient) scores in children exposed to lamotrigine compared to no exposure.

      It has low or no risk of adverse neurobehavioral or cognitive outcomes including autism compared to other antiseizure medications.

      No increased risk of preterm labor.

      Lamotrigine is not the first-line treatment for headache prevention but it is the preferred medication for seizure prevention due to the lower risk of birth defects compared to other anti-seizure medications and broad-spectrum coverage of both focal and generalized epilepsy. It can be used for seizure patients for migraine prevention due to its antiseizure effects.

      If polytherapy with lamotrigine is needed, a lower lamotrigine dose should be tried at <325 mg per day to decrease the risk of birth defects.

      Lamotrigine levels decrease 40-60% during pregnancy which decreases its effectiveness and can result in breakthrough seizures. Thus, lamotrigine requires frequent drug level monitoring and dose adjustments as its clearance from the kidney and liver increases during pregnancy.

      Folic acid supplementation is recommended.

    • Valproic Acid (Divalproex sodium , Epival, Depakote)

      Valproic Acid and its derivatives belongs to the group of medicines known as anticonvulsants and is used for migraine prevention, epilepsy, and bipolar disorder.

      First trimester

      SafetyConcernNext steps
      Unsafe use (mother)

      Valproic acid is NOT a safe medication during pregnancy due to adverse effects on the fetus.

      Valproic acid is NOT a safe medication during pregnancy due to adverse effects on the fetus.

      Valproic acid levels in the blood are minimally affected during pregnancy usually 10% to 20%

      Studies from animal epilepsy models (rats) have shown that valproic acid lowers folic acid brain levels which is important in brain development, thus lower folic acid levels can affect brain and spine development and cause birth defects and later in life growth and developmental problems. F

      Next Steps

      Valproic acid is NOT a safe medication during pregnancy and it is NOT recommended for headache prevention during pregnancy.

      It should be avoided where possible and only be prescribed to women of childbearing age in a specialist setting by a neurologist/epileptologist.

      In some women, valproic acid may be the only drug that can achieve acceptable seizure control. In this situation, risks should be discussed and a dose reduction should be carefully reduced if possible before conception. Valproic acid use should be avoided with a combination of other antiseizure medications with higher risk like topiramate. Single treatment with valproic acid at the lowest effective dose is preferred, if feasible.

      Folic acid is recommended in pregnant women using valproic acid (4-5mg per day). It should be noted that there is no convincing evidence that high dose folic acid supplementation protects specifically against valproic acid-associated birth defects (teratogenicity).

      Drug level monitoring and dose adjustments should be performed throughout pregnancy.

      Half of pregnancies are unplanned, thus scheduling a discussion once a pregnancy is planned will be too late for many pregnancies. Women should be informed of the risk at the time of valproic acid prescription.

      Safety issues with valproic acid are also of great importance in psychiatry, where valproic acid may be used for bipolar disorder in women of childbearing potential.

      Unsafe use (fetus)

      Valproic acid is NOT a safe medication during pregnancy. There is a high rate of major birth defects reported at 7-14% compared to the normal population which is 1-2%.

      Higher risk of birth defects are seen with higher doses of valproic acid, 6.4% with daily doses <650mg, 11% with daily dose between 650-1450mg, and 24% with daily dose >1450mg. Another pregnancy epilepsy data (registry) showed a 5.0% risk with a daily dose of valproic acid <600 mg, 6.1% with a daily dose of 600–1000 mg, and 10.4% of birth defects with a daily dose>1000 mg. This means that even with the lowest doses of valproic acid the risk of major birth defects is higher than any other anti-seizure medication.

      Major birth defects include 1.8% neural tube defects (50 cases over 2721 pregnancies), 1.7% cardiac congenital malformations (47 cases over 2721 pregnancies), 1.3%hypospadias (38 cases over 2721 pregnancies), and 0.9% cleft palate and cleft lip (25 cases over 2721 pregnancies)

      If Valproic acid is taken with other antiseizure medications (polytherapy) the risk is even higher.

      Valproic acid is NOT a safe medication during pregnancy and it is NOT recommended for headache prevention during pregnancy.

      Given valproic acid has the highest risk of major birth defects it should be avoided where possible and only be prescribed to women of childbearing age in a specialist setting by a neurologist/epileptologist.

      In some women, valproic acid may be the only drug that can achieve acceptable seizure control. In this situation, risks should be discussed and a dose reduction should be carefully reduced if possible before conception. Valproic acid use should be avoided with a combination of other antiseizure medications with higher risk like topiramate. Single treatment with valproic acid at the lowest effective dose is preferred, if feasible.

      Folic acid is recommended in pregnant women using valproic acid (4-5mg per day). It should be noted that there is no convincing evidence that high dose folic acid supplementation protects specifically against valproic acid-associated birth defects (teratogenicity).

      Half of pregnancies are unplanned, thus scheduling a discussion once a pregnancy is planned will be too late for many pregnancies. Women should be informed of the risk at the time of valproic acid prescription.

      Safety issues with valproic acid are also of great importance in psychiatry, where valproic acid may be used for bipolar disorder in women of childbearing potential.

      Second trimester

      SafetyConcernNext steps
      Unsafe use (mother)

      Valproic acid is NOT a safe medication during pregnancy due to adverse effects on the fetus and is associated with a higher risk of preeclampsia.

      Valproic acid is NOT a safe medication during pregnancy and it is NOT recommended for headache prevention during pregnancy.

      It should be avoided where possible and only be prescribed to women of childbearing age in a specialist setting by a neurologist/epileptologist.

      In some women, valproic acid may be the only drug that can achieve acceptable seizure control. In this situation, risks should be discussed and a dose reduction should be carefully reduced if possible before conception. Valproic acid use should be avoided with a combination of other antiseizure medications with higher risk like topiramate. Single treatment with valproic acid at the lowest effective dose is preferred, if feasible.

      Folic acid is recommended in pregnant women using valproic acid (4-5mg per day). It should be noted that there is no convincing evidence that high dose folic acid supplementation protects specifically against valproic acid-associated birth defects (teratogenicity).

      Drug level monitoring and dose adjustments should be performed throughout pregnancy.

      Half of pregnancies are unplanned, thus scheduling a discussion once a pregnancy is planned will be too late for many pregnancies. Women should be informed of the risk at the time of valproic acid prescription.

      Safety issues with valproic acid are also of great importance in psychiatry, where valproic acid may be used for bipolar disorder in women of childbearing potential.

      Unsafe use (fetus)

      Valproic acid is NOT a safe medication during pregnancy and may can cause low birth weight in babies.

      Valproic acid is NOT a safe medication during pregnancy and it is NOT recommended for headache prevention during pregnancy.

      It should be avoided where possible and only be prescribed to women of childbearing age in a specialist setting by a neurologist/epileptologist.

      In some women, valproic acid may be the only drug that can achieve acceptable seizure control. In this situation, risks should be discussed and a dose reduction should be carefully reduced if possible before conception. Valproic acid use should be avoided with a combination of other antiseizure medications with higher risk like topiramate. Single treatment with valproic acid at the lowest effective dose is preferred, if feasible.

      Folic acid is recommended in pregnant women using valproic acid (4-5mg per day). It should be noted that there is no convincing evidence that high dose folic acid supplementation protects specifically against valproic acid-associated birth defects (teratogenicity).

      Half of pregnancies are unplanned, thus scheduling a discussion once a pregnancy is planned will be too late for many pregnancies. Women should be informed of the risk at the time of valproic acid prescription.

      Safety issues with valproic acid are also of great importance in psychiatry, where valproic acid may be used for bipolar disorder in women of childbearing potential.

      Third trimester

      SafetyConcernNext steps
      Unsafe use (mother)

      Valproic acid is NOT a SAFE medication during pregnancy due to adverse effects on the fetus. It does not have a higher risk of preterm birth.

      Valproic acid is NOT a safe medication during pregnancy and it is NOT recommended for headache prevention during pregnancy.

      It should be avoided where possible and only be prescribed to women of childbearing age in a specialist setting by a neurologist/epileptologist.

      In some women, valproic acid may be the only drug that can achieve acceptable seizure control. In this situation, risks should be discussed and a dose reduction should be carefully reduced if possible before conception. Valproic acid use should be avoided with a combination of other antiseizure medications with higher risk like topiramate. Single treatment with valproic acid at the lowest effective dose is preferred, if feasible.

      Folic acid is recommended in pregnant women using valproic acid (4-5mg per day). It should be noted that there is no convincing evidence that high dose folic acid supplementation protects specifically against valproic acid-associated birth defects (teratogenicity).

      Drug level monitoring and dose adjustments should be performed throughout pregnancy.

      Half of pregnancies are unplanned, thus scheduling a discussion once a pregnancy is planned will be too late for many pregnancies. Women should be informed of the risk at the time of valproic acid prescription.

      Safety issues with valproic acid are also of great importance in psychiatry, where valproic acid may be used for bipolar disorder in women of childbearing potential.

      Unsafe use (fetus)

      Valproic acid is NOT a safe medication during pregnancy.

      Exposed children of valproic acid have an increased risk of intellectual disability with delayed childhood milestones compared with offspring without prenatal exposure.

      The risk of autism spectrum disorder with valproic acid exposure is 4.4%, compared to 1.5% in the general population there is a significantly greater risk for a diagnosis of attention-deficit/ hyperactivity disorder (ADHD) with children exposed to valproic acid in utero.

      At 3 and 6 years of follow-up, fetal exposure to valproic acid was associated with a reduced IQ of 7–10 points.

      Lower doses of valproic acid (<800mg daily) were associated with mildly reduced IQ with impaired verbal abilities and a six-fold increase in the need for educational intervention, Higher doses of daily valproic acid (> 800 mg daily) were associated with a 9.7 points lower adjusted IQ and an eightfold increased need for educational intervention.

      Valproic acid is NOT a safe medication during pregnancy and it is NOT recommended for headache prevention during pregnancy.

      Given valproic acid has an increased risk of offspring developing learning difficulties and autism spectrum disorder, it should be avoided where possible and only be prescribed to women of childbearing age in a specialist setting by a neurologist/epileptologist.

      In some women, valproic acid may be the only drug that can achieve acceptable seizure control. In this situation, risks should be discussed and a dose reduction should be carefully reduced if possible before conception. Valproic acid use should be avoided with a combination of other antiseizure medications with higher risk like topiramate. Single treatment with valproic acid at the lowest effective dose is preferred, if feasible.

      Consider whether the patient could be on single therapy with valproic acid with a lower dosage, although no dose of valproate has been proven to be devoid of neurodevelopmental risks, and doses of <400 mg/day have been associated with decreased verbal IQ and increased need for educational assistance.

      Folic acid is recommended in pregnant women using valproic acid (4-5mg per day). It should be noted that there is no convincing evidence that high dose folic acid supplementation protects specifically against valproic acid-associated birth defects (teratogenicity).

      Half of pregnancies are unplanned, thus scheduling a discussion once a pregnancy is planned will be too late for many pregnancies. Women should be informed of the risk at the time of valproic acid prescription.

      Safety issues with valproic acid are also of great importance in psychiatry, where valproic acid may be used for bipolar disorder in women of childbearing potential.

    • Gabapentin

      Gabapentin belongs to the group of medicines known as anticonvulsants and is used for multiple indications including headache prevention, epilepsy, restless leg syndrome, neuropathic pain, and other psychiatric indications.

      First trimester

      SafetyConcernNext steps
      Careful use (mother)

      Limited safety data during its use in pregnancy.

      There is limited evidence of the safety of gabapentin during pregnancy. There is a low risk of birth defects based on a small number of cases, but it is associated with low birth weight and preterm birth. It can cause withdrawals in newborns and require ICU care after birth.

      Given these effects, it is advised women consult a family doctor/ neurologist to taper gabapentin before a planned pregnancy or discontinue for unplanned pregnancies, at the time pregnancy is confirmed after discussion with your doctor.

      Careful use (fetus)

      Limited safety data is available during pregnancy, the risk of major birth defect is 1.5% which is equal to the risk for the general population, based on a small number of exposed cases. 223 gabapentin-exposed pregnancies compared with 223 unexposed rates of major birth defects were similar.

      There is limited evidence of the safety of gabapentin during pregnancy. There is a low risk of birth defects based on a small number of cases, but it is associated with low birth weight and preterm birth. It can cause withdrawals in newborns and require ICU care after birth.

      Given these effects, it is advised women consult a family doctor/ neurologist to taper gabapentin before a planned pregnancy or discontinue for unplanned pregnancies, at the time pregnancy is confirmed after discussion with your doctor.

      Second trimester

      SafetyConcernNext steps
      Unsafe use (mother)

      Gabapentin use is associated with an increased risk of preterm birth.

      There is limited evidence of the safety of gabapentin during pregnancy. There is a low risk of birth defects based on a small number of cases, but it is associated with low birth weight and preterm birth. It can cause withdrawals in newborns and require ICU care after birth.

      Given these effects, it is advised women consult a family doctor/ neurologist to taper gabapentin before a planned pregnancy or discontinue for unplanned pregnancies, at the time pregnancy is confirmed after discussion with your doctor.

      Unsafe use (fetus)

      Gabapentin is associated with low birth weight and a premature baby.

      There is limited evidence of the safety of gabapentin during pregnancy. There is a low risk of birth defects based on a small number of cases, but it is associated with low birth weight and preterm birth. It can cause withdrawals in newborns and require ICU care after birth.

      Given these effects, it is advised women consult a family doctor/ neurologist to taper gabapentin before a planned pregnancy or discontinue for unplanned pregnancies, at the time pregnancy is confirmed after discussion with your doctor.

      Third trimester

      SafetyConcernNext steps
      Unsafe use (mother)

      Gabapentin use is associated with the risk of preterm birth.

      There is limited evidence of the safety of gabapentin during pregnancy. There is a low risk of birth defects based on a small number of cases, but it is associated with low birth weight and preterm birth. It can cause withdrawals in newborns and require ICU care after birth. These newborns should be carefully observed for excess sedation and additional caution if an infant is born prematurely or is ill.

      Given these effects, it is advised women consult a family doctor/ neurologist to taper gabapentin before a planned pregnancy or discontinue for unplanned pregnancies, at the time pregnancy is confirmed after discussion with your doctor.

      Unsafe use (fetus)

      Gabapentin is associated with low birth weight and premature baby. It can cause withdrawal effects in newborns.

      There is limited evidence of the safety of gabapentin during pregnancy. There is a low risk of birth defects based on a small number of cases, but it is associated with low birth weight and preterm birth. It can cause withdrawals in newborns and require ICU care after birth. These newborns should be carefully observed for excess sedation and additional caution if an infant is born prematurely or is ill.

      Given these effects, it is advised women consult a family doctor/ neurologist to taper gabapentin before a planned pregnancy or discontinue for unplanned pregnancies, at the time pregnancy is confirmed after discussion with your doctor.

    • Topiramate

      Topiramate belongs to the group of medicines known as anticonvulsants and is used for migraine prevention, epilepsy, and bipolar disorder.

      First trimester

      SafetyConcernNext steps
      Unsafe use (mother)

      Pregnant women and their newborns should be monitored for metabolic acidosis (acidic blood) from topiramate use. Metabolic acidosis may result in adverse effects and fetal death.

      Topiramate is associated with weight loss. Weight should carefully be monitored throughout pregnancy.

      Topiramate is NOT recommended for headache prevention during pregnancy.

      If you are using topiramate and planning a pregnancy or are currently pregnant, discuss with your family physician/ neurologist to find a better and safer option for you for headache prevention during pregnancy.

      When it is used during pregnancy, it has been associated with a moderate to high risk of major birth defects should be discussed with women of childbearing age before prescribing this medication.

      If topiramate has to be used for seizure control during pregnancy then these risks should be discussed and the patient should be in the care of a specialist setting (neurologist/epileptologist). The lowest effective dose should be used and use of topiramate should be avoided with a combination of other antiseizure medications with a higher risk of birth defects like valproic acid. Drug monitoring and dose adjustments should be performed throughout the pregnancy to prevent seizures during pregnancy. Weight and signs of metabolic acidosis should also be carefully monitored throughout pregnancy.

      Unsafe use (fetus)

      Topiramate is NOT safe in pregnancy for the baby. It has a moderate to high risk of major birth defects which is between 1.9% and 7.1%.

      Risk of a major birth defect is 2x higher when combined with other anti-seizure medications.

      Common birth defects include face abnormality with slit lips (oral cleft).

      Risk is further increased with higher doses of topiramate (>100mg daily dose).

      Other defects include heart abnormalities (cardiac malformations) and urine tube abnormality (hypospadias), NO higher risk of brain and spinal cord abnormalities are reported.

      Topiramate is NOT recommended for headache prevention during pregnancy.

      When it is used during pregnancy, it has been associated with a moderate to high risk of major birth defects which is between 1.9% and 7.1%, with the most common defect being oral cleft. Its use during pregnancy can increase the risk of fetal growth restriction and low birth weight. This risk should be discussed with women of childbearing age before prescribing this medication.

      If you are using topiramate and planning a pregnancy or are currently pregnant, discuss with your family physician/ neurologist to find a better and safer option for you for headache prevention during pregnancy.

      If topiramate has to be used for seizure control during pregnancy then these risks should be discussed and the patient should be in the care of a specialist setting (neurologist/epileptologist). The lowest effective dose should be used and use of topiramate should be avoided with a combination of other antiseizure medications with a higher risk of birth defects like valproic acid. Drug monitoring and dose adjustments should be performed throughout the pregnancy to prevent seizures during pregnancy.

      Second trimester

      SafetyConcernNext steps
      Unsafe use (mother)

      There is a 30% decrease in topiramate blood levels are seen in the second and third trimester due to increased medication breakdown and elimination during pregnancy, thus drug monitoring and dose adjustment is required to prevent seizures.

      Topiramate is NOT recommended for headache prevention during pregnancy.

      If you are using topiramate and planning a pregnancy or are currently pregnant, discuss with your family physician/ neurologist to find a better and safer option for you for headache prevention during pregnancy.

      If topiramate has to be used for seizure control during pregnancy then these risks should be discussed and the patient should be in the care of a specialist setting (neurologist/epileptologist). The lowest effective dose should be used and use of topiramate should be avoided with a combination of other antiseizure medications with a higher risk of birth defects like valproic acid. Drug monitoring and dose adjustments should be performed throughout the pregnancy to prevent seizures during pregnancy. Weight and signs of metabolic acidosis should also be carefully monitored throughout pregnancy.

      Unsafe use (fetus)

      More than 2-fold increase in the risk of fetal growth restrictions (smaller babies/low birth weight) with topiramate exposure at 18%, which is higher than other anti-seizure medications,topiramate exposure can cause a risk of small head size at 11%.

      When used in pregnancy, topiramate levels in the blood start to decrease in the second and third trimester by 30%.

      Topiramate is NOT recommended for headache prevention during pregnancy.

      Its use during pregnancy can increase the risk of fetal growth restriction and low birth weight. This risk should be discussed with women of childbearing age before prescribing this medication.

      If you are using topiramate and planning a pregnancy or are currently pregnant, discuss with your family physician/ neurologist to find a better and safer option for you for headache prevention during pregnancy.

      If topiramate has to be used for seizure control during pregnancy then these risks should be discussed and the patient should be in the care of a specialist setting (neurologist/epileptologist). The lowest effective dose should be used and use of topiramate should be avoided with a combination of other antiseizure medications with a higher risk of birth defects like valproic acid. Drug monitoring and dose adjustments should be performed throughout the pregnancy to prevent seizures during pregnancy.

      Third trimester

      SafetyConcernNext steps
      Unsafe use (mother)

      Drug breakdown and elimination increase during pregnancy, so likely medication effectiveness is reduced as pregnancy advances.

      Topiramate is NOT recommended for headache prevention during pregnancy.

      If you are using topiramate and planning a pregnancy or are currently pregnant, discuss with your family physician/ neurologist to find a better and safer option for you for headache prevention during pregnancy.

      If topiramate has to be used for seizure control during pregnancy then these risks should be discussed and the patient should be in the care of a specialist setting (neurologist/epileptologist). The lowest effective dose should be used and use of topiramate should be avoided with a combination of other antiseizure medications with a higher risk of birth defects like valproic acid. Drug monitoring and dose adjustments should be performed throughout the pregnancy to prevent seizures during pregnancy. Weight and signs of metabolic acidosis should also be carefully monitored throughout pregnancy.

      Unsafe use (fetus)

      Some studies showed exposure of topiramate in the third trimester resulted in lower IQ scores across several domains as well as poorer motor and visual-spatial skills in the children exposed to topiramate in comparison to control children.

      Other studies have shown no major effects on neurodevelopment after birth and fewer effects on a child's cognitive abilities (limited data).

      High risk of developmental delay is seen in babies with low birth weight.

      Topiramate is NOT recommended for headache prevention during pregnancy.

      Its use during pregnancy can increase the risk of fetal growth restriction and low birth weight. This risk should be discussed with women of childbearing age before prescribing this medication.

      If you are using topiramate and planning a pregnancy or are currently pregnant, discuss with your family physician/ neurologist to find a better and safer option for you for headache prevention during pregnancy.

      If topiramate has to be used for seizure control during pregnancy then these risks should be discussed and the patient should be in the care of a specialist setting (neurologist/epileptologist). The lowest effective dose should be used and use of topiramate should be avoided with a combination of other antiseizure medications with a higher risk of birth defects like valproic acid. Drug monitoring and dose adjustments should be performed throughout the pregnancy to prevent seizures during pregnancy.

    • Pregabalin

      Pregabalin belongs to the group of medicines known as anticonvulsants and is used for multiple indications including headache prevention, epilepsy, restless leg syndrome, neuropathic pain, and other psychiatric indications.

      First trimester

      SafetyConcernNext steps
      Unsafe use (mother)

      Safety data for the use of pregabalin in pregnancy is not available.

      Limited safety data is available for pregabalin during pregnancy, thus this medication should not be prescribed to pregnant women.

      Unsafe use (fetus)

      Limited safety data available for pregabalin during pregnancy, 477 infants exposed during the first trimester showed a 5.9% risk of major birth defect which is higher than the general population.

      Limited safety data is available for pregabalin during pregnancy, given its risk of major birth defects and uncertain long-term developmental effects (neurocognitive effects), this medication should not be prescribed to pregnant women.

      Second trimester

      SafetyConcernNext steps
      Unsafe use (mother)

      Safety data for the use of pregabalin in pregnancy is not available.

      Limited safety data is available for pregabalin during pregnancy, thus this medication should not be prescribed to pregnant women.

      Unsafe use (fetus)

      Limited safety data available for pregabalin during pregnancy.

      Limited safety data is available for pregabalin during pregnancy, given its risk of major birth defects and uncertain long-term developmental effects (neurocognitive effects), this medication should not be prescribed to pregnant women.

      Third trimester

      SafetyConcernNext steps
      Unsafe use (mother)

      Safety data for the use of pregabalin in pregnancy is not available.

      Limited safety data is available for pregabalin during pregnancy, thus this medication should not be prescribed to pregnant women.

      Unsafe use (fetus)

      Limited safety data available for pregabalin during pregnancy.

      Limited safety data is available for pregabalin during pregnancy, given its risk of major birth defects and uncertain long-term developmental effects (neurocognitive effects), this medication should not be prescribed to pregnant women.

    • Ketogenic diet

      Ketogenic diets consist of a restriction of carbohydrate consumption to 5 to 10 percent of energy needs, providing only 25 to 50 grams per day of carbohydrates. Ketogenic diet therapy may be used in the treatment of epilepsy.

      First trimester

      SafetyConcernNext steps
      Unsafe use (mother)

      Safety data for ketogenic diet use in pregnancy is not available.

      Not recommended during pregnancy, as no safety data available during its use in human pregnancy.

      Given the current animal data and concerns about a very low-carbohydrate diet in the absence of folic acid supplementation, we recommend avoiding ketogenic diets during pregnancy.

      Pregnant patients are daily recommended intake of 175 grams per day and we recommend avoiding extremely low-carbohydrate diets during pregnancy. They should consult with a health professional before restricting carbohydrates below the daily recommended dose.

      Unsafe use (fetus)

      Studies in animals (rodent studies) have reported adverse fetal effects, such as fetal overgrowth, and changes in organ (heart) size and brain structures as associated with birth defects in animal pregnancy models. Furthermore, rodent mothers fed a ketogenic diet exhibited a reduction in fertility and litter size.

      Not recommended during pregnancy, as no safety data available during its use in human pregnancy.

      Given the current animal data and concerns about a very low-carbohydrate diet in the absence of folic acid supplementation, we recommend avoiding ketogenic diets during pregnancy.

      Pregnant patients are daily recommended intake of 175 grams per day and we recommend avoiding extremely low-carbohydrate diets during pregnancy. They should consult with a health professional before restricting carbohydrates below the daily recommended dose.

      Second trimester

      SafetyConcernNext steps
      Unsafe use (mother)

      Safety data for ketogenic diet use in pregnancy is not available.

      Not recommended during pregnancy, as no safety data available during its use in human pregnancy.

      Given the current animal data and concerns about a very low-carbohydrate diet in the absence of folic acid supplementation, we recommend avoiding ketogenic diets during pregnancy.

      Pregnant patients are daily recommended intake of 175 grams per day and we recommend avoiding extremely low-carbohydrate diets during pregnancy. They should consult with a health professional before restricting carbohydrates below the daily recommended dose.

      Unsafe use (fetus)

      Safety data for ketogenic diet use in pregnancy is not available.

      Not recommended during pregnancy, as no safety data available during its use in human pregnancy.

      Given the current animal data and concerns about a very low-carbohydrate diet in the absence of folic acid supplementation, we recommend avoiding ketogenic diets during pregnancy.

      Pregnant patients are daily recommended intake of 175 grams per day and we recommend avoiding extremely low-carbohydrate diets during pregnancy. They should consult with a health professional before restricting carbohydrates below the daily recommended dose.

      Third trimester

      SafetyConcernNext steps
      Unsafe use (mother)

      Safety data for ketogenic diet use in pregnancy is not available.

      Not recommended during pregnancy, as no safety data available during its use in human pregnancy.

      Given the current animal data and concerns about a very low-carbohydrate diet in the absence of folic acid supplementation, we recommend avoiding ketogenic diets during pregnancy.

      Pregnant patients are daily recommended intake of 175 grams per day and we recommend avoiding extremely low-carbohydrate diets during pregnancy. They should consult with a health professional before restricting carbohydrates below the daily recommended dose.

      Unsafe use (fetus)

      Safety data for ketogenic diet use in pregnancy is not available.

      Not recommended during pregnancy, as no safety data available during its use in human pregnancy.

      Given the current animal data and concerns about a very low-carbohydrate diet in the absence of folic acid supplementation, we recommend avoiding ketogenic diets during pregnancy.

      Pregnant patients are daily recommended intake of 175 grams per day and we recommend avoiding extremely low-carbohydrate diets during pregnancy. They should consult with a health professional before restricting carbohydrates below the daily recommended dose.

    • Cannabidiol oil

      Cannabidiol oil is a type of cannabinoid extract from a cannabis plant. It may be used to treat certain types of seizures in people with epilepsy.

      First trimester

      SafetyConcernNext steps
      Unsafe use (mother)

      Safety data for cannabidiol oil use in pregnancy is not available.

      There is no safety data for its safety during pregnancy, with uncertain risk of major malformation during pregnancy and uncertain long-term neurocognitive effects on the child, its use is not recommended during pregnancy.

      Unsafe use (fetus)

      Safety data for cannabidiol oil use in pregnancy is not available.

      There is no safety data for its safety during pregnancy, with uncertain risk of major malformation during pregnancy and uncertain long-term neurocognitive effects on the child, its use is not recommended during pregnancy.

      Second trimester

      SafetyConcernNext steps
      Unsafe use (mother)

      Safety data for cannabidiol oil use in pregnancy is not available.

      There is no safety data for its safety during pregnancy, with uncertain risk of major malformation during pregnancy and uncertain long-term neurocognitive effects on the child, its use is not recommended during pregnancy.

      Unsafe use (fetus)

      Safety data for cannabidiol oil use in pregnancy is not available.

      There is no safety data for its safety during pregnancy, with uncertain risk of major malformation during pregnancy and uncertain long-term neurocognitive effects on the child, its use is not recommended during pregnancy.

      Third trimester

      SafetyConcernNext steps
      Unsafe use (mother)

      Safety data for cannabidiol oil use in pregnancy is not available.

      There is no safety data for its safety during pregnancy, with uncertain risk of major malformation during pregnancy and uncertain long-term neurocognitive effects on the child, its use is not recommended during pregnancy.

      Unsafe use (fetus)

      Safety data for cannabidiol oil use in pregnancy is not available.

      There is no safety data for its safety during pregnancy, with uncertain risk of major malformation during pregnancy and uncertain long-term neurocognitive effects on the child, its use is not recommended during pregnancy.

    • Carbamazepine (Tegretol)

      Carbamazepine is an antiseizure medication used to treat certain types of seizures in people with epilepsy. It may also be used to treat neuropathic pain and in certain psychiatric conditions.

      First trimester

      SafetyConcernNext steps
      Safe use (mother)

      Careful use (mother)

      No increased risk of spontaneous abortion with carbamazepine use.

      Carbamazepine may be used in pregnancy, but drug levels should be monitored throughout pregnancy.

      Careful use (fetus)

      Based on data from 8000 pregnancies exposed to carbamazepine monotherapy suggests the overall risk of major birth defects/malformation is 2.6% to 7.2%, which is not increased compared to the general population.

      Dose-dependent effect that has been seen in different studies for major birth defects in babies exposed to carbamazepine, which is 4.5% for daily carbamazepine dose for <700mg/day, and 7.2% for daily carbamazepine doses of >700mg /day.

      Major malformations/birth defects with carbamazepine exposed fetuses are 0.3% neural tube defect( birth defects of the brain and spinal cord), 0.8% cardiac malformations (abnormalities of the heart), 0.4% hypospadias (birth defect of urine tube), 0.3% oral cleft (birth defect when babies has slit lips and/or mouth not formed properly), and genitourinary tract defects, skeletal malformations including club foot and polydactyly and respiratory and gastrointestinal malformations (abnormal genitalia, bladder, lung, feeding tube and body abnormalities including deformities in hips, feet, and hands).

      It decreases the folic acid in blood by up to 90% which increases the risk of brain and spinal cord defects.

      During pregnancy, carbamazepine monotherapy is associated with a moderate risk of major birth defects with an average rate of 4-5% and a high risk of neural tube defects. Thus, the lowest effective dose of carbamazepine and supplementation with higher folic acid dosing of 4mg daily is recommended.

      Second trimester

      SafetyConcernNext steps
      Careful use (mother)

      Carbamazepine is less likely to require dose adjustment during pregnancy as drug levels are not significantly changed during pregnancy (approximately reduced by 10%), with a low risk of seizure worsening.

      Carbamazepine may be used in pregnancy, but drug levels should be monitored throughout pregnancy.

      Careful use (fetus)

      There is a risk of growth restriction with use of carbamazepine during pregnancy.

      During pregnancy, the lowest effective dose of carbamazepine and supplementation with higher folic acid dosing of 4mg daily is recommended.

      Third trimester

      SafetyConcernNext steps
      Careful use (mother)

      No increased risk of preterm labor. No dose adjustment is required with a low risk of seizure worsening.

      Carbamazepine may be used in pregnancy, but drug levels should be monitored throughout pregnancy.

      Careful use (fetus)

      Less effects on IQ, verbal intelligence, motor or mental development, low or no risk of adverse neurobehavioral or cognitive outcomes. No increased risk of autism spectrum disorder.

      During pregnancy, the lowest effective dose of carbamazepine and supplementation with higher folic acid dosing of 4mg daily is recommended.

    • Perampanel (Fycompa)

      Perampanel is an antiseizure medication used to treat certain types of seizures in people with epilepsy.

      First trimester

      SafetyConcernNext steps
      Unsafe use (mother)

      No safety data available during pregnancy.

      NO safety data is available during pregnancy, with an uncertain risk of major malformation and uncertain long-term neurocognitive effects, therefore this medication should not be prescribed to pregnant women with epilepsy.

      Unsafe use (fetus)

      No safety data available during pregnancy.

      NO safety data is available during pregnancy, with an uncertain risk of major malformation and uncertain long-term neurocognitive effects, therefore this medication should not be prescribed to pregnant women with epilepsy.

      Second trimester

      SafetyConcernNext steps
      Unsafe use (mother)

      No safety data available during pregnancy.

      NO safety data is available during pregnancy, with an uncertain risk of major malformation and uncertain long-term neurocognitive effects, therefore this medication should not be prescribed to pregnant women with epilepsy.

      Unsafe use (fetus)

      No safety data available during pregnancy.

      NO safety data is available during pregnancy, with an uncertain risk of major malformation and uncertain long-term neurocognitive effects, therefore this medication should not be prescribed to pregnant women with epilepsy.

      Third trimester

      SafetyConcernNext steps
      Unsafe use (mother)

      No safety data available during pregnancy.

      NO safety data is available during pregnancy, with an uncertain risk of major malformation and uncertain long-term neurocognitive effects, therefore this medication should not be prescribed to pregnant women with epilepsy.

      Unsafe use (fetus)

      No safety data available during pregnancy.

      NO safety data is available during pregnancy, with an uncertain risk of major malformation and uncertain long-term neurocognitive effects, therefore this medication should not be prescribed to pregnant women with epilepsy.

    Disclaimer

    Some safety considerations/recommendations provided in this web-based tool are based on limited studies and current evidence. This web-based tool must not be used as the sole base of decision-making in the use of medicines during pregnancy.

    Expert health care provider consultation with a family doctor/neurologist/cardiologist/obstetrician is required throughout the process of change, as decisions should be based on an individual’s specific circumstances.

    Many other medications are used following a stroke and they may cause fetal harm (e.g., cholesterol, blood pressure, and diabetes medications) but this tool focuses ONLY on the safety of blood thinners use for mother and baby. If you have questions about the other medications you are taking, please talk to your physician.