Which antiepileptic drug is generally avoided in women of childbearing potential due to teratogenic risk, and what alternative measures are recommended?

• A. Valproate; alternatives include levetiracetam or lamotrigine with folic acid supplementation preconception.
• B. Lamotrigine; alternatives include valproic acid.
• C. Levetiracetam; alternatives include phenytoin.
• D. Topiramate; alternatives include carbamazepine.

Answer: (A)

When planning epilepsy treatment for someone who may become pregnant, the safest approach is to minimize fetal risk while maintaining seizure control. Valproate has the strongest association with birth defects, especially neural tube defects, and the risk rises with higher doses. Because of this, valproate is generally avoided in women of childbearing potential. The best course is to switch to safer alternatives before conception—options such as levetiracetam or lamotrigine—while also adding folic acid supplementation prior to conception (and continuing through early pregnancy) to help reduce the risk of neural tube defects. If changing medications isn’t feasible, this should be managed with close neurology supervision and a careful risk–benefit discussion.

Other options don’t fit as well because they either involve continuing a drug with notable teratogenic risk or rely on substitutes that have higher fetal risk compared with the safer alternatives mentioned.