During pregnancy, which anticonvulsant carries higher risk for congenital anomalies and cognitive outcomes in children?

• A. Valproic acid
• B. Carbamazepine
• C. Phenytoin
• D. Lamotrigine

Answer: (A)

Valproic acid carries the highest risk of both congenital anomalies and adverse cognitive outcomes when used during pregnancy. Exposure is strongly linked to neural tube defects, craniofacial and cardiac malformations, and a broader pattern of congenital anomalies. In terms of cognitive effects, children exposed in utero to valproate tend to have lower average IQ scores and greater risk of developmental problems, especially at higher maternal doses. Because of these consistently stronger associations, valproate is usually avoided in women who are pregnant or planning pregnancy unless no alternatives can control the seizures. Other antiseizure medications, such as lamotrigine, generally show lower teratogenic risk and better cognitive outcomes, with carbamazepine and phenytoin occupying intermediate risk levels. If valproate exposure occurs, using the lowest effective dose and providing high-dose folic acid preconception and during pregnancy are prudent considerations.