Unplanned Pregnancy & Epilepsy
It is ideal for patients with epilepsy to consult with their care team as much as 12 months before trying for pregnancy. Screen patients at risk of pregnancy at least once a year to find out if they are planning pregnancy in the future, and either refer for contraception or discuss periconception issues if needed.
However, some studies found that up to 65% of women with epilepsy reported at least one unplanned pregnancy. While each patient situation is unique and will require an individualized approach to counseling and plan formation, common steps should include the following:
Decision-making Regarding Pregnancy Continuation
For every patient, the decision to continue the pregnancy or not is theirs alone. Offer support with open ended-questions and referral for care if needed. Patients will often have specific questions about the effects of their epilepsy and current medications. We recommend discussing the teratogenic and neurodevelopmental outcomes of their ASM regimen. Epilepsy and ASM exposure are typically not an indication for pregnancy termination. While addressing their needs for managing their epilepsy, you should also confirm their desire to continue the pregnancy considering all individualized factors. Either medication abortion or a procedural abortion are safe options. If a patient is on a strongly-inducing ASM, medication abortion using mifepristone may be less effective, however there are no studies to evaluate this. Both medications, mifepristone and misoprostol, are safe to take. Connect the patient with an OB-GYN or other trusted provider as soon as possible, and let them know you will support them regardless of their decision.
Vitamin Supplementation
We recommend starting prenatal vitamins as soon as possible, including at least 400-1000 mcg of folic acid daily. You can find more information on folic acid, B12, and Vitamin D on our Folic Acid & Other Vitamin Supplements page.
Anti-Seizure Medication (ASM) Level Checks
If your patient is on an anti-seizure medication (ASM), get a baseline blood level (if there isn’t one already available), and extrapolate back to figure out a good ASM level (see ASM Level Checks). Continue monthly level checks from this point forward.
Medication Changes
Despite the varied risk profiles of different ASMs (see Anti-Seizure Medications and Pregnancy Suitability), medication switching should ideally be attempted well in advance of pregnancy, not once a patient is already pregnant, as this exposes the fetus to more than one medication and may increase the patient’s risk for seizures. However, you may need to consider early-pregnancy ASM changes for patients taking valproic acid. It may also sometimes be necessary to adjust typical medication management approaches in patients on multiple seizure medications.
Strategies for Handling Valproic Acid
Due to known fetal risks, if the patient is already in the first trimester of pregnancy and is taking valproic acid, consider whether the dose can be lowered or the medication can be removed from the patient’s regimen.
Deciding to remove or lower valproic acid requires careful consideration of the patient’s epilepsy, seizure types, and medication trials. Trained specialists should do this in consultation with the patient. The patient’s healthcare providers may need to collaborate to schedule an appointment quickly.
If quickly removing valproic acid (for example, in the setting of switching to levetiracetam), consider in-patient admission and consult a neurologist/epilepsy specialist for electroencephalogram (EEG) monitoring to ensure no excessive seizure activity is seen, then titrate dose accordingly.
The window in which valproic acid poses a risk of congenital malformations is generally complete by 13 weeks of pregnancy. If it is not possible to lower or remove valproic acid from a pregnant patient’s medication regimen before this point, it is not urgent to do so after. However, stopping continued exposure to valproic acid is likely to reduce the fetus’s risk of adverse neurodevelopmental outcomes. It’s important to consider reducing or removing valproic acid regardless of how far along the patient’s pregnancy is.
NOTE: Switching from valproic acid to lamotrigine once a patient is pregnant is not recommended, given increased metabolism in pregnancy.
Strategies For Handling Multiple Medications
In general it is not recommended to withdraw necessary seizure medications during pregnancy. However, in patients who become pregnant on multiple medications it may be is reasonable to focus on medication dose adjustment of the lower risk medications over the less well studied medications. This requires an deep understanding of the patient’s seizure history and how they have responded to different medications. For example, in an unplanned pregnancy where the mother is on clobazam, levetiracetam and lamotrigine, it may make sense to follow levels for all threess but focus on level-based dose adjustments for levetiracetam and lamotrigine as long as the patient's seizure control is stable.
Guide Your Patients
Counsel your patient on the risks of pregnancy as you would any other patient but take their medication into account (see Anti-Seizure Medications & Pregnancy Suitability). Once blood levels are taken for baselining, ASM changes are made (if the patient takes an ASM with elevated risk to the fetus), and folic acid starts, the pregnancy can follow approaches similar to those outlined on the Pregnancy Planning page.
Reviewed by: EPMC Expert Panel, March 2025