A safety topic that keeps appearing
Prescribing anti-seizure medicines for people who could become pregnant is one of the most important safety topics in neurology, and it appears frequently in the Neurology SCE. UK regulation has changed several times in recent years, so make sure your knowledge is up to date with current MHRA guidance.
Why valproate is restricted
Sodium valproate taken in pregnancy carries a high risk of major congenital malformations and of neurodevelopmental disorders in the child. For this reason the MHRA introduced the Valproate Pregnancy Prevention Programme. Valproate must not be used in girls and women of childbearing potential unless the conditions of the programme are met, including highly effective contraception, regular review and signed risk acknowledgement.
In 2024 the MHRA strengthened the rules further. Valproate should not be started in new patients, male or female, younger than 55 years unless two specialists independently consider and document that there is no other effective or tolerated treatment, or that there are compelling reasons why the reproductive risks do not apply. Men taking valproate, and their female partners, are advised to use effective contraception during treatment and for at least three months after stopping. In February 2025 the MHRA confirmed that men already taking valproate do not need the two-specialist review, which still applies whenever valproate is started in anyone under 55. Expect exam questions to test whether you know when valproate can and cannot be prescribed.
Choosing an alternative
For focal epilepsy, lamotrigine and levetiracetam are widely used first-line options. For generalised epilepsy in a person who could become pregnant, lamotrigine or levetiracetam are commonly chosen alternatives to valproate, accepting that they may be less effective for some generalised syndromes. Remember that oestrogen-containing contraceptives lower lamotrigine levels, while enzyme-inducing anti-seizure medicines such as carbamazepine reduce the effectiveness of hormonal contraception.
Pre-conception and pregnancy
People with epilepsy who are planning a pregnancy should be reviewed by a specialist before conception. Do not stop or switch medicines abruptly, because uncontrolled seizures carry their own risks to mother and baby. NICE recommends folic acid 5 mg daily for women taking anti-seizure medicines who are planning a pregnancy or could become pregnant. Lamotrigine levels often fall during pregnancy, so dose adjustment and monitoring may be needed.
Exam tips
When a stem describes a young woman with newly diagnosed generalised epilepsy, the correct answer is rarely valproate. When a woman already taking valproate becomes pregnant, the answer is urgent specialist review rather than stopping the drug immediately. Read each option carefully for references to contraception, folic acid and the Pregnancy Prevention Programme.
Practise with License Medical
The License Medical Neurology SCE question bank includes exam-style Best of Five questions on this topic and across the curriculum, each with a guideline-based explanation. Start revising at license-medical.com/question-bank-details/neurology-sce/.
Sources: MHRA guidance on valproate (2018, 2024 and 2025); NICE guideline NG217, Epilepsies in children, young people and adults (2022).