The American Academy of Neurology (AAN), in collaboration with the American Epilepsy Society (AES) and the Society for Maternal-Fetal Medicine (SMFM), has released an updated practice guideline focused on the use of antiseizure medications (ASMs) during pregnancy.

The guideline, published in the June 2024 issue of Neurology, provides evidence-based recommendations to help clinicians and patients make informed decisions about epilepsy treatment during pregnancy while minimizing risks to the developing fetus.

Key recommendations from the guideline include:

1. Clinicians should engage in shared decision-making with patients, considering individual preferences when selecting ASMs and monitoring dosing.
2. Valproic acid should be avoided in pregnant patients with epilepsy, if clinically feasible, to minimize the risk of major congenital malformations, autism spectrum disorder, and lower IQ in offspring.
3. Lamotrigine, levetiracetam, or oxcarbazepine should be considered when appropriate based on the patient's specific needs, as they are associated with lower risks of major congenital malformations.
4. Clinicians should monitor ASM levels throughout pregnancy and adjust dosing as needed to maintain seizure control and accommodate changes in drug metabolism.
5. At least 0.4 mg of daily folic acid supplementation should be prescribed preconceptionally and during pregnancy to reduce the risk of neural tube defects and potentially improve neurodevelopmental outcomes.

The guideline emphasizes the importance of optimizing both seizure control and fetal safety, recognizing that uncontrolled seizures pose risks to both the pregnant individual and the developing fetus. It also highlights the need for early intervention, recommending that clinicians discuss pregnancy planning and epilepsy treatment with their patients of childbearing potential at the earliest opportunity.

While the guideline provides valuable insights, it also identifies several areas where further research is needed, including the risks associated with newer ASMs, the impact of ASM polytherapy on pregnancy outcomes, and optimal folic acid dosing and timing.

By offering clear, evidence-based recommendations, this new guideline aims to support clinicians and patients in making informed decisions about epilepsy treatment during pregnancy, ultimately improving outcomes for both parents and their children.