there is an increased incidence of major and minor congenital abnormalities in infants born to epileptic mothers ( 6 - 7% compared with 2c3% in the general population ) .
sodium valproate is a popular drug because of its broad range of anticonvulsant effects and relative freedom from sedative and behavioral effects .
exposure to valproic acid during first trimester can result in the constellation of minor craniofacial anomalies and major organ malformations in human fetuses . here , we report a case of a 3-month - old baby with facial dysmorphism , as a case of fetal valproate syndrome ( fvs ) based on the phenotype and maternal use of valproic acid during the antenatal period .
a 3-month - old male child admitted with complaints of breathlessness since 3 days with fever . it was a full - term normal delivery with birth weight of 2.5 kg without any postnatal complications . mother was known case of epilepsy and was controlled on sodium valproate 800 mg / day since 3 years . before delivering this child mother had three spontaneous abortions within first trimester during those 3 years . on admission ,
the child was in congestive cardiac failure with heart rate-168/min , respiratory rate - 64/min .
child had severe failure to thrive with current weight 3.8 kg at 3 months of age despite on exclusive breastfeeding .
features of facial dysmorphism [ figure 1 ] such as prominent metopic sutures , trigonocephaly , tall forehead , epicanthal folds , infraorbital groove , and medial deficiency of eyebrows , shallow philtrum , anteverted nares , and broad root of nose , low set ears , thin upper lip , and small mouth were present . broad hands and feet , loose skin [ figure 2 ] , and hypospadias were other features . based on facial dysmorphism , congenital heart disease and hypospadias in the setting of maternal valproic acid consumption during antenatal period , diagnosis of fvs
prominent metopic suture fetal valproate syndrome on auscultation , pansystolic murmur with loud pulmonary component of second heart sound were present .
two - dimensional echocardiography showed moderate atrial septal defect , ventricular septal defect with tiny patent ductus arteriosus with moderate pulmonary hypertension .
ophthal evaluation , ultrasonography abdomen , and x - ray spine were within normal limits .
valproic acid crosses the placenta and is present in a higher concentration in the fetus than in the mother .
complications of epilepsy and antiepileptic drug treatment , include stillbirths , prematurity , low birth weight , major and minor malformations , and cognitive delay later in life .
following several other case reports of the teratogenic effects of vpa , all of which documented similar major and minor anomalies . the facial features seen in fvs are trigonocephaly , tall forehead with bifrontal narrowing , epicanthic folds , infraorbital groove , medial deficiency of eyebrows , flat nasal bridge , broad nasal root , antiverted nares , shallow philtrum , long upper lip and thin vermillion borders , thick lower lip , small downturned mouth .
our patient had almost all facial features of fvs that has previously been described in literature .
the timing of exposure and the dose of the drug are important in influencing the outcome of pregnancy .
first - trimester exposures are more likely to result in malformations as this is the main period of structural development in the fetus .
the efficacy of valproic acid as an antiepileptic drug can not be disputed , but the extent of its teratogenic effects can not be under - estimated either .
hence , the balance between the therapeutic effects of this drug and its teratogenic effects is critical in the management of women with epilepsy . high - dose folic acid ( 4 mg / day ) is recommended during pregnancy , starting at least 6 weeks preconception and continuing through the first trimester .
 antenatal use of anticonvulsant valproic acid can result in a well - recognized cluster of facial dysmorphism , congenital anomalies and neurodevelopmental retardation . in this report 
 , we describe a case with typical features of fetal valproate syndrome ( fvs ) . a 26-year - old female with epilepsy controlled on sodium valproate 800 mg 
 / day since 3 years , gave birth to a male child with characteristic features of fvs . 
 she also had 3 spontaneous first - trimester abortions during those 3 years . 
 sodium valproate , a widely used anticonvulsant and mood regulator , is a well - recognized teratogen that can result in facial dysmorphism , craniosynostosis , neural tube defects , and neurodevelopmental retardation . 
 therefore , we strongly recommend avoidance of valproic acid and supplementation of folic acid during pregnancy . 
Introduction
Case Report
Discussion