Prophylaxis of bipolar disorder during pregnancy

The management of bipolar disorder in pregnancy is complex—see Considerations in managing bipolar disorder during pregnancy for advice on determining treatment approach.

The recommendations in this section are intended to guide initiation of prophylaxis by a psychiatrist during pregnancy but can be used to guide drug choice if drug therapy needs to be changed in a patient already taking prophylaxis.

When starting prophylaxis of bipolar disorder, consider using the same drug that was effective for acute treatment depending on its safety during pregnancy and breastfeeding. Discuss treatment options with the patient and, if they consent, their significant other(s).

During the first trimester, olanzapine, quetiapine, or, if depression is prominent, lamotrigine are preferred for prophylaxis of bipolar disorder—also see Antipsychotic use during pregnancy and Lamotrigine for psychiatric disorders during pregnancy. Lithium is usually avoided during the first trimester because of the increased risk of congenital malformations; however, if the patient only responds to lithium and the likely benefits of using lithium outweigh the potential harms, lithium may be used with close supervision—see Lithium use during pregnancy.

From the second trimester onwards, lithium is preferred for prophylaxis; however, it should not be used while breastfeeding—for advice on managing lithium use during pregnancy see here. If lithium is not used, olanzapine, quetiapine, or, if depression is prominent, lamotrigine are preferred for prophylaxis of bipolar disorder—see drug regimens here. Carbamazepine can be started in the second trimester for prophylaxis of bipolar disorder—see here for advice on carbamazepine use during pregnancy.

Do not start sodium valproate during pregnancy—see here.