TY - JOUR T1 - Women and valproate: what should neurologists do? JF - Practical Neurology JO - Pract Neurol DO - 10.1136/practneurol-2018-001932 SP - practneurol-2018-001932 AU - John J Craig Y1 - 2018/04/19 UR - http://pn.bmj.com/content/early/2018/04/19/practneurol-2018-001932.abstract N2 - Valproate first received its UK licence for treating epilepsy in 1973; reports of congenital malformations appeared within 10 years1 and fetal valproate syndrome soon after.2 More recently, pregnancy registries have provided information on the risks for major congenital malformations in pregnancies exposed to antiepileptic drugs, consistently showing greater risks to infants exposed to valproate: approximately 10% for monotherapy and dose-related.3–5 This is significantly higher than the background rate—pregnancies in women with epilepsy not taking antiepileptic drugs—and the rate with other antiepileptic drugs, including lamotrigine, levetiracetam and carbamazepine (table 1).3–5 Studies have defined the types of major congenital malformation associated with valproate, predominantly neural tube defects, clefting abnormalities, cardiovascular defects, genitourinary defects in male and musculoskeletal defects. However, it is the risk of neurodevelopmental disability, including cognitive impairment, autistic spectrum disorder and autism, that has resulted in recommendations to avoid valproate in women of childbearing years and in pregnancy, in particular.6 With some studies reporting risks of 30%–40% for certain aspects of neurodevelopment, such caution and plans to mitigate the risks seem justified. However, much is still to be learnt: the true overall risk for neurodevelopmental disability is unknown for valproate, a situation mirrored for all antiepileptic drugs.View this table:In this windowIn a new windowTable 1 Major congenital malformation rate for pregnancies exposed to valproate, carbamazepine, lamotrigine … ER -