The management of women with epilepsy who are planning a pregnancy or who are currently pregnant remains one of the most perplexing and engaging clinical issues for neurologists. A refinement of surveillance methods, along with a greater understanding of teratogenesis, has provided us with better information regarding specific antiepileptic drug (AED)-associated teratogenic risk than in the past. A recent finding from multiple worldwide AED pregnancy registries is an increased teratogenic risk with valproate compared with the other AEDs, supporting previous retrospective reports. Valproate use and independently having more than five convulsive seizures during pregnancy are associated with a risk of decreased verbal intelligence quotient (IQ) in the offspring. The European pregnancy register confirms that most women who are seizure-free early in pregnancy have an excellent chance of maintaining seizure freedom throughout pregnancy. The management of AEDs during pregnancy continues to be explored, and considerations for dosing and therapeutic monitoring are discussed herein. The metabolism of both lamotrigine and oxcarbazepine is induced during pregnancy, and careful clinical monitoring and frequent level assessment are emerging as important for these AEDs.