Epilepsy in women of reproductive age: Teratogenic risk and individualized antiseizure treatment across pregnancy

Epilepsy management during the reproductive years requires simultaneous protection against seizures and reduction of fetal exposure to treatments associated with adverse developmental outcomes. This narrative review examines how evidence on congenital malformations, neurodevelopment, fetal growth, and pregnancy-related pharmacokinetics should inform therapeutic decisions before conception, during gestation, and after delivery. Literature retrieved in 2026 included pregnancy registries, prospective cohorts, comparative effectiveness trials, systematic reviews, and recommendations from neurological and maternal-fetal medicine societies. Valproate has the most consistent evidence of substantial structural and neurodevelopmental risk, with important dose associations. Lamotrigine, levetiracetam, and oxcarbazepine have comparatively favorable malformation profiles, but suitability depends on epilepsy syndrome and previous treatment response. Evidence concerning topiramate requires separate consideration of oral clefts, growth restriction, and conflicting neurodevelopmental findings. Pregnancy can markedly reduce concentrations of several medications, while postpartum reversal creates a risk of toxicity if increased doses are maintained. Individualized concentration targets, clinical surveillance, and a planned postpartum taper are therefore complementary strategies. Folic acid supplementation is recommended, although the optimal dose remains uncertain. Effective care begins before pregnancy and combines transparent risk communication, reliable contraception when desired, preservation of seizure control, and coordinated neurological and obstetric follow-up.