I want to get pregnant but take medication for bipolar disorder.  What can I do?

Because bipolar disorder has its average onset in late adolescense and early adulthood, many women with bipolar disorder are faced with decisions about their treatment in the midst of their reproductive years.  The best first step is to plan the steps to take before becoming pregnant.  You need to familiarize yourself with the data that are available regarding medication use and its potential effect on a fetus.  You also need to be aware of the risks associated with stopping medication treatment.  First off, know that there is controversy in the literature as to whether or not bipolar disorder improves during pregnancy, but that even if it does for some, it does not for others.  Also, it is important to know that there is a high risk for symptom recurrence in the immediate postpartum period.

The risk of use of mood-stabilizing agents during pregnancy appears to be greatest in the first trimester, although there are teratogenic effects that can occur later as well.  A review of the literature on various medications was done by Yonkers et al. (Am J Psychiatry 161:4, April 2004) and noted the following:

Lithium
There is an association with cardiovascular malformations.  Ebstein's anomaly occurs in 0.1% to 0.2% of the offspring of lithium users in contrast to 0.005% in the general population.  While the risk is increased several-fold, the absolute risk remains small.  Lithium-exposed infaants have been found to weigh more than nonexposed infants.  In two studies of behavior and development, there were no differences in milestone development or behavior.  Exposure to lithium during labor has been associated with "floppy baby syndrome," so close monitoring of levels is part of routine obstetrical care.

Depakote (valproate)
Use during the first trimester is associated with high rates of neural tube defects of 5% to 9% with the risk being dose related.  Craniofacial abnormalities, growth retardation, small head circumference, and heart defects are at a twofold increased risk from the use of anticonvulsants.  Depakote (valproate) has neonatal complications associated with it as well such as heart rate decelerations, irritibility, jitterness, feeding problems, and abnormal tone.  Some experts recommend Depakote (valproate) be switched to another mood stabilizer before pregnancy.  Teratogenic risk also higher with the use of more than one anticonvulsant agent.

Equetro (carbamazepine)
Craniofacial defects, fingernail hypoplasia, and developmental delay have been found at high rates.  Neural tube defects range between 0.5% and 1% Reduced birth weight and head circumference are associated with Equetro (carbamazepine) use.  Equetro (carbamazepine) is not recommended by by most experts for use during pregnancy unless there are no other options.

Lamicral (lamotrigine)
In 2004, rates of major malformations appeared to be similar to those in the general population, but new information suggests an increased risk for cleft lip and palate with first trimester exposure.

Typical Antipsychotics
There have been mixed findings on whether there is an increased rate of malformations, with many studies conducted on clorpromazine.  One study on rates between those on chlorpromazine for psychosis and those who were psychotic but not on chlorpromazine showed similar rates of malformations that were higher than in the general population, suggesting that something else about the illness was contributory.  Case reports have suggested a link between Haldol (halo-peridol) and limb reductions, but larger case series have not supported this.  The risk from typical antipsychotics is considered by many experts to be less than the risk from some mood stabilizers, and thus during pregnancy, a switch from a mood stabilizer to an antipsychotic is often made.

Atypical Antisychotics
There are limited data on the use of atypical antipsychotics in pregnancy.

Keeping the data in mind, it is possible to manage both pregnancy and bipolar disorder safely, but again the planning should ideally occur before getting pregnant.  With careful planning and monitoring, outcomes can be improved for both mother and offspring.  Communication with both psychiatrist and obstetrician are critical.