Consensus Statement: Managing Bipolar Disorder During and After Pregnancy

A consensus statement published in the American Journal of Psychiatry identifies significant challenges in treating bipolar disorder in women during pregnancy and the postpartum period. The challenges include risks and teratogenic effects associated with some treatments, as well as the difficulty of managing bipolar disorder during unplanned pregnancies.

This consensus statement was the result of an expert review of studies on the treatment of bipolar disorder, as well as mood stabilizers’ effects on pregnancy. The American Psychiatric Association has provided guidelines for treating bipolar disorder. However, most treatment options are not specifically tailored to pregnant women. For example, the mood stabilizers carbamazepine and sodium valproate are teratogens in humans, whereas lithium may be less teratogenic than previously thought.

Researchers stated the effects of the mood stabilizer lithium; anticonvulsants valproate, carbamazepine, and lamotrigine; first- and second-generation antipsychotic agents; calcium channel blockers; benzodiazepines and other sedative hypnotic agents; electroconvulsive therapy; and psychosocial interventions.

For each of these items, the characteristics of organ dysgenesis, intrauterine growth effects, neurobehavioral teratogenicity, neonatal toxicity, and use during pregnancy were described. Although the effects of different treatment options vary, researchers concur that managing maternal bipolar disorder while minimizing teratogenicity is most effective in planned pregnancies. Because bipolar disorder typically sets in during a woman’s reproductive years, cohort and longitudinal studies are needed to understand the risks to pregnant women with the disorder, as well as to their offspring.

In addition, the investigators of the consensus statement provided specific treatment strategies during pregnancy, ranging from preconception to the third trimester. Before pregnancy, the clinician and patient are recommended to discuss possible treatment strategies, including close and frequent psychiatric follow-ups and coordinated care with the obstetrician.

Furthermore, clinicians and patients should discuss whether continuation of medication is required before conception. Concerns that must be taken into consideration include the high possibility for relapse after discontinuation of pharmacotherapy. Clinicians should identify the patient’s history of medication response, time to relapse after medication discontinuation, and time to recovery with pharmacotherapy reintroduction.

In cases where a patient’s medical history indicates incidences of self-harm or impaired mental faculties, the reintroduction of medical therapy after signs of relapse after discontinuation is important for reducing risk to the mother and fetus. In addition, clinicians should emphasize the importance of single-agent psychotherapy vs multiple-agent psychotherapy for improving safety outcomes.

During early conception, the investigators state that the lowest effective medication dose should be used. Agents possessing the least teratogenic potential are preferred over those with higher risk. The first trimester is the period that presents the highest risk for teratogenicity, yet the second and third trimesters also present risks for minor malformations, behavioral effects, low birth weight, and preterm delivery.

The consensus researchers also highlighted the importance of medication prophylaxis during the immediate postpartum period, specifically with lithium, for reducing the relapse rate. Additional mood stabilizers discussed were valproate, carbamazepine, lamotrigine, first-generation antipsychotic agents, and benzodiazepines. Many of these agents are secreted into breast milk, which may pass onward to neonates if the mother decides to breast feed.

Researchers conclude that, “[since] treatment can be managed most effectively if pregnancy is planned, clinicians should discuss the issue of pregnancy and its management with every bipolar disorder patient who has childbearing potential, regardless of future reproductive plans.”

Reference

Yonkers KA, Wisner KL, Stowe Z, et al. Management of bipolar disorder during pregnancy and the postpartum period. Am J Psychiatry. 2004;161(4):608-620.