APA Practice Guidelines

cont. from

2. Bipolar Patients During Pregnancy

Because many medications used to treat bipolar disorder are associated with a higher risk of birth defects, the psychiatrist should encourage effective contraceptive practices for all female patients of childbearing age who are receiving pharmacological treatment (85,86). Since carbamazepine, oxcarbazepine, and topiramate increase the metabolism of oral contraceptives, women taking these medications should not rely on oral contraceptives for birth control (87-89). This effect does not occur with other medications used to treat bipolar disorder.

Multiple clinical issues arise in relationship to pregnancy in bipolar disorder patients. In order to permit discussion of the risks and benefits of therapeutic options, a pregnancy should be planned in consultation with the psychiatrist whenever possible. Because of the higher genetic risk for bipolar disorder (90-92), patients with bipolar disorder who are considering having children may also benefit from genetic counseling

a) Continuing/discontinuing medications.

 Around the time of pregnancy, the risks and benefits of continuing versus discontinuing treatment require the most thoughtful judgment and discussion among the patient, the psychiatrist, the obstetrician, and the father. Specific options include continuing medication throughout pregnancy, discontinuing medications at the beginning of pregnancy or before conception, and discontinuing the medication only for the first trimester.

In clinical decision making, the potential teratogenic risks of psychotropic medications must be balanced against the risk of no prophylactic treatment, with the attendant risks of illness. Although the course of bipolar disorder during pregnancy is still unclear, some evidence suggests that pregnancy does not alter the rate of mood episodes compared with other times. However, in patients who have been stable on a regimen of lithium, the rate of recurrent mood episodes is clearly increased by lithium discontinuation, particularly when discontinuation is abrupt. Should the decision be made to discontinue medication, the woman should be advised about the potentially greater risk of mood episode recurrence with rapid discontinuation of lithium (and possibly other maintenance agents) compared with a slower taper over many weeks.

Although direct evidence of a negative effect of untreated psychiatric disorders on fetal development is lacking, antenatal stress, depression, and anxiety are linked with a variety of abnormalities in newborns. Additionally, during a manic episode, women are at risk of increasing their consumption of alcohol and other drugs, thus conferring additional dangers to the fetus.

b) Prenatal exposure to medications.

First-trimester exposure to lithium, valproate, or carbamazepine is associated with a greater risk of birth defects. With lithium exposure the absolute risk for Ebstein's anomaly, a cardiovascular defect, is 1-2 per 1,000. This is approximately 10-20 times greater than the risk in the general population. Exposure to carbamazepine and valproate during the first trimester is associated with neural tube defects at rates of up to 1% and 3%-5%, respectively. Both carbamazepine and valproate exposure have also been associated with craniofacial abnormalities. Other congenital defects that have been observed with valproate include limb malformations and cardiac defects. Little is known about the potential teratogenicity of lamotrigine, gabapentin, or other newer anticonvulsants.

No teratogenic effects have been demonstrated with tricyclic antidepressants. Near term, however, their use has been associated with side effects in the neonate. The SSRIs seem to be relatively benign in their risks to exposed fetuses, with safety data being strongest for fluoxetine and citalopram. Although data with bupropion, mirtazapine, nefazodone, trazodone, and venlafaxine are limited, none of the newer antidepressants has been shown to be teratogenic. Nonetheless, caution must be exercised if they are prescribed to treat bipolar depression in pregnant women.

Antipsychotic agents may be needed to treat psychotic features of bipolar disorder during pregnancy, but they may also represent an alternative to lithium for treating symptoms of mania. High-potency antipsychotic medications are preferred during pregnancy, since they are less likely to have associated anticholinergic, antihistaminergic, or hypotensive effects. In addition, there is no evidence of teratogenicity with exposure to haloperidol, perphenazine, thiothixene, or trifluoperazine. When high-potency antipsychotic medications are used near term, neonates may show extrapyramidal side effects, but these are generally short-lived. To limit the duration of such effects, however, long-acting depot preparations of antipsychotic medications are not recommended during pregnancy. For newer antipsychotic agents such as risperidone, olanzapine, clozapine, quetiapine, and ziprasidone, little is known about the potential risks of teratogenicity or the potential effects in the neonate.

ECT is also a potential treatment for severe mania or depression during pregnancy. In terms of teratogenicity, the short-term administration of anesthetic agents with ECT may present less risk to the fetus than pharmacological treatment options. The APA Task Force Report on ECT contains additional details on the use of ECT during pregnancy

continue: Prenatal and Postpartum Treatment Issues

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Written 4/02. Reviewed: 03/2006