Pharmacological treatment of acute mania during pregnancy

The management of bipolar disorder during pregnancy is complex—see Principles of treating bipolar disorder during pregnancy for advice on determining treatment approach.

The recommendations in this section are intended for a first episode of acute mania during pregnancy but can be used to guide drug choice if drug therapy needs to be changed in a patient with existing bipolar disorder.

If an episode of acute mania occurs during pregnancy, urgently seek psychiatric advice. Depending on the severity of the episode and the pregnancy trimester, monotherapy is usually preferred to reduce potential harms to the fetus associated with polypharmacy.

Throughout pregnancy, but particularly in the first trimester, monotherapy with an antipsychotic may be preferred—olanzapine, risperidone or quetiapine have the most pregnancy safety data; see also Antipsychotic use during pregnancy.

Only start lithium in the first trimester if the patient does not respond to antipsychotic therapy because of the increased (although low) risk of congenital malformations with its use. Lithium therapy can be started from the second trimester onwards but should not be used with concurrent breastfeeding. For advice on lithium use during pregnancy, see here and breastfeeding, see here.

Carbamazepine can be used from the second trimester, but should not be used in the first trimester—see Sodium valproate or carbamazepine use during pregnancy.

Do not start sodium valproate during pregnancy—see Sodium valproate or carbamazepine use during pregnancy.

Drug choice is also influenced by the patient’s desire to breastfeed—see Principles of psychotropic use while breastfeeding.