“I’ve just found out I’m pregnant — and I’m on those epilepsy tablets, sodium valproate”

A positive pregnancy test in a woman on SODIUM VALPROATE is a high-stakes, urgent consultation, and the single most important immediate message is: do NOT stop valproate abruptly — suddenly stopping anti-seizure medication risks uncontrolled seizures that are dangerous to mother and pregnancy (status epilepticus, injury, SUDEP), so the action is to continue for now and obtain urgent specialist review, NOT to panic-stop (countering the instinct and online advice to halt immediately). Be honest that valproate is the most teratogenic anti-seizure medication — around an 11% risk of major birth defects (neural tube defects, cleft lip and palate, heart and limb defects) and, importantly, neurodevelopmental disorders (learning difficulties, autism, ADHD, affecting up to 30–40%) — which is why it is subject to the MHRA Pregnancy Prevention Programme and, under MHRA NatPSA/2023/013 (November 2023; Drug Safety Update January 2024), must not be started in anyone under 55 from 31 January 2024 unless two specialists independently document that no other effective or tolerated treatment exists, with a second specialist signature on the Annual Risk Acknowledgement Form; convey this without catastrophising or inducing panic-stopping. The correct pathway is URGENT joint review by epilepsy/neurology AND obstetrics/maternal medicine to reassess medication safely (any change made carefully by specialists, not abruptly by the patient) and plan antenatal care/anomaly scanning; start HIGH-DOSE FOLIC ACID 5 mg daily (best pre-conception; start now and continue to 12 weeks — NICE NG217, NG247), arrange early antenatal referral (NICE NG217: epilepsy specialist team plus specialist obstetric team), give seizure-safety advice, discuss her options about the pregnancy non-directively, and tell her about the UK Epilepsy and Pregnancy Register. Sensitively explore how the pregnancy occurred on valproate (Pregnancy Prevention Programme, contraception, prior counselling) to inform care and prevent recurrence — not to blame — and note the future need for the PPP, effective contraception and pre-conception counselling for any woman of childbearing potential on valproate. The hidden agenda is fear and guilt (that she has harmed the baby, uncertainty whether to stop); lead with the safety message, give honest prioritised information with compassion, make the urgent referral, start folic acid, and ensure she leaves with a clear plan rather than alone with online fear.