A 25-year-old woman presents with recurrent episodes of bilateral tonic-clonic seizures that always begin with visual aura (flickering lights). MRI is normal. EEG shows generalised 3 Hz spike-and-wave discharges. She is planning pregnancy. Which antiepileptic drug should be AVOIDED as monotherapy in her?
- A Valproate ✓
- B Lamotrigine
- C Levetiracetam
- D Ethosuximide
Explanation
Valproate is the most teratogenic antiepileptic drug — it causes neural tube defects (3–5%), major congenital malformations, and long-term cognitive impairment in children (IQ reduction, autism spectrum disorder). It is contraindicated in women of childbearing potential unless no other alternatives exist, per MHRA and EMA guidelines updated in 2023 (Valproate Pregnancy Prevention Programme). This patient has juvenile myoclonic epilepsy (JME) pattern (generalised 3 Hz SWD + visual triggers); although valproate is highly effective for JME, lamotrigine and levetiracetam are safer alternatives in pregnancy.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.