Bipolar Disorder and Pregnancy
With the typical onset of bipolar disorder (BD) in women occurring between late adolescence and early adulthood, the chances of mood episodes recurring throughout the reproductive years is considerable. Therefore, treatment of the disorder during pregnancy and postpartum stages must be closely monitored, for both the mother and the fetus.
Finer and Henshaw report that fifty percent of pregnancies in the United States are not planned, and with manic episodes bringing about impulsive behavior, women with bipolar disorder who are of reproductive age should be advised of the risks of an unplanned pregnancy and prescribed effective birth control. However, several mood stabilizers are known to decrease the effectiveness of oral contraceptives, and several oral contraceptives are known to decrease the effectiveness of mood stabilizers. Therefore, women with bipolar disorder should be educated about supplementary forms of birth control.
According to Vemuri and Williams, prenatal counseling should begin at least three months before pregnancy, and the risks associated with pregnancy and mood stabilizers should be mentioned when the patient is first started on medication, even if the woman is not planning to become pregnant.1 If possible, medication during the first trimester of pregnancy should be avoided due to risk of malformation of the fetus, and should be supplemented with increased psychosocial and clinical supports to monitor for relapse. Also, prenatal vitamins are strongly recommended, especially for those who have previously been pregnant or are on antiepileptic medications.
Not always is medication able to be avoided during pregnancy, and if not, a minimum effective dose should be used of just one stabilizer.1 The treatment decisions should be made with both the mother and significant other, as the significant other should monitor the mother for symptoms of relapse throughout the pregnancy and also to make sure both understand the risks associated with taking mood stabilizing medication while pregnant. Women diagnosed with bipolar disorder may relapse when medication is suddenly discontinued, showing signs of insomnia, impulsivity, suicidal ideations and attempts, and reduced self-care.1 Therefore, in some cases, based upon the severity of the disorder, continuing certain medication is preferred to complete discontinuation.
Mood stabilizers valproate, carbamazepine, and lithium pose the greatest risks for fetus malformation, and are therefore recommended by Viguera, Whitfield, and Baldessarini to be avoided before and during a women’s pregnancy. Valproate, especially with doses over 800 mg/day, poses a six to 13 percent risk of fetus malformation when taken during pregnancy, specifically targeting the neural tubes, cardiac, and facial features.2 Yonkers, Wisner, and Stowe have reported heart rate deceleration, abnormal vocal tone, and growth retardation to be adverse fetal effects, and Meador, Baker, and Browning have found it to cause lower IQ scores, and in some cases, autism. Carbamazepine is also known to cause malformations of the neural tube, cardiac, and facial features, as well as vitamin K deficiencies. Lithium has shown a fetal malformation rate of 2.8 percent, and therefore it is recommended that women who are taking lithium during pregnancy undergo an ultrasound and echocardiogram between 16 and 18 weeks to scan for effects such as prematurity, hypothyroidism, liver abnormalities, respiratory effects, and diabetes. Levels of the medication should be monitored, and due to fluid shifts during delivery, the risk of lithium toxicity becomes present.
Women with bipolar disorder are at risk for postpartum mania and psychosis, which will usually occur soon after delivery.1 Counseling and medication during the postpartum period are imperative to the well being of both the mother and the baby. Because four percent of women diagnosed with postpartum psychosis commit infanticide, monitoring of mother-child interactions is critical.1 Lithium therapy has shown to decrease the risk of postpartum psychosis when given within 48 hours of delivery.1 Also, allowing the mother to receive adequate sleep with minimal disruption has shown to stabilize mood.
However, all mood-stabilizing medications have been discovered to pass into breast milk; therefore, a mother breastfeeding while on such medications needs to be trained to recognize the signs of neonatal toxicity.1 Many processes that breakdown the medications are premature in infants, which can lead to their bodies obtaining high levels of the drugs. It is recommended the mother not breastfeed but instead pump or use formula, which would also allow her to obtain an adequate amount of sleep for mood stabilization as well.1
 Vemuri, M., Williams, K. (2011). Treating bipolar disorder during pregnancy: Optimal outcomes require careful preconception planning, medication risk/benefit analysis. Current Psychiatry, 10(9), 59-67.
 Finer LB, Henshaw SK. Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspect Sex Reprod Health. 2006;38(2):90-96.
 Wegner I, Edelbroek PM, Bulk S, et al. Lamotrigine kinetics within the menstrual cycle, after menopause, and with oral contraceptives. Neurology. 2009;73(17):1388-1393.
 Wilson RD, Johnson JA, Wyatt P, et al. Pre-conceptional vitamin/folic add supplementation 2007: the use of folic add in combination with a multivitamin supplement for
the prevention of neural tube defects and other congenital anomalies. J Obstet Gynaecol Can. 2007;29(12):1003-1026.
 Viguera AC, Whitfield T, Baldessarini RJ, et al. Risk of recurrence in women with bipolar disorder during pregnancy: prospective study of mood stabilizer discontinuation. Am J Psychiatry. 2007;164(12):1817-1824.
 Yonkers KA, Wisner KL, Stowe Z, et at Management of bipolar disorder during pregnancy and the postpartum period. Am J Psychiatry. 2004;161(4):608-620.
 Meador KJ, Baker GA, Browning N, et al. Effects of breastfeeding in children of women taking antiepileptic drugs. Neurology. 2010;75(22):1954-1960.
 Tomson T, Battino D. Teratogenic effects of antiepileptic medications. Neurol Chin. 2009;27(4):993-1002.
 Gentile S. Prophylactic treatment of bipolar disorder in pregnancy and breastfeeding: focus on emerging mood stabilizers. Bipolar Disord. 2006;8(3):207-220.
 Kozma C. Neonatal toxicity and transient neurodevelopmental deficits following prenatal exposure to lithium: another clinical report and a review of the literature. Am J Med Genet A. 2005;132(4):441-444.