Considerations in managing bipolar disorder during pregnancy

Managing a patient with bipolar disorder during pregnancy is complex and requires a multidisciplinary approach including the patient’s general practitioner, psychiatrist (preferably with perinatal expertise), and obstetric team, and a paediatrician. If possible, refer the patient to a specialist perinatal mental health service.

If a patient with bipolar disorder becomes (or is planning to become) pregnant, formulate a management plan with their multidisciplinary team and, if they consent, their significant others—in addition to the factors listed here, consider and discuss:

• as relevant:
  • lithium is associated with an increased rate of congenital malformations—depending on the patient’s risk of relapse, it is often desirable to withhold it before and during the first trimester. Concurrent use of lithium while breastfeeding is not recommended
  • carbamazepine is associated with an increased rate of congenital malformations—depending on the patient’s risk of relapse, it is often desirable to withhold it before and during the first trimester. If the patient has taken carbamazepine while pregnant or trying to get pregnant (regardless of whether they will continue to take it during pregnancy), give them high-dose folic acid—see the folic acid regimen here
  • sodium valproate is associated with high rates of congenital malformations and neurodevelopmental disorders in exposed infants—it is preferable to stop it before or during pregnancy. If the patient has taken sodium valproate while pregnant or trying to get pregnant (regardless of whether they will continue to take it during pregnancy), give them high-dose folic acid—see the folic acid regimen here
  • antipsychotics, antidepressants and lamotrigine may be used with caution during pregnancy
• relapse can occur during pregnancy and is common during the postnatal period—create a relapse management plan
• stopping a psychotropic used for bipolar disorder during pregnancy is associated with increased risk of relapse and its associated harms (eg impulsivity, problem drug use, loss of reputation, negative effect on relationships, self-harm and suicidality, psychiatric admission, potential exposure to multiple drugs in the setting of an acute behavioural disturbance)
• patients with bipolar disorder should ideally give birth in a tertiary hospital with specialist neonatal care and a psychiatric team. If this is not possible, seek advice from the patient’s psychiatrist and a paediatrician at birth
• if a psychotropic is not used during pregnancy, plan to start a drug late in pregnancy or immediately after birth because of the high risk of relapse—see Considerations in managing bipolar disorder in the postpartum for advice.

Avoid stopping a psychotropic if doing so is likely to lead to relapse, psychiatric admission or exposure to multiple drugs in the setting of an acute behavioural disturbance. For a person with severe, unstable or currently symptomatic bipolar disorder, the priority is to optimise their mental state—the benefits of continuing a psychotropic (particularly lithium) throughout the perinatal period outweigh the risks of harm. This may involve continuing psychotropics or considering electroconvulsive therapy (ECT). However, if possible, avoid using sodium valproate because of the high risk of fetal malformation and neurodevelopmental disorders—see here.

If a patient’s drug regimen is changed, review their mental state every 1 to 2 weeks for the next 4 to 8 weeks to monitor for signs of relapse. Seek psychiatrist advice for treatment and monitoring—the patient should see them within weeks of any change.

Regardless of the treatment decisions made, the most important aspect of managing bipolar disorder during the perinatal period is to closely monitor the patient’s mental state.

For advice on pharmacological treatment, see:

• here for acute mania during pregnancy
• here for bipolar depression during pregnancy
• here for advice on prophylaxis of bipolar disorder during pregnancy.

The advice can also be used in conjunction with the principles listed above to help guide a change of drug, if required.