Preconception Management

• Begin preparation at least six months before conception to ensure stability, switch to safer medications, and manage psychosocial stressors.

Course of Bipolar Disorder During Pregnancy and Postpartum

• Pregnancy: Low risk period with only about 5% relapse rate.
• Postpartum: High risk of relapse; about 1 in 3 women with bipolar disorder (BD) relapse.

Predictors of Relapse

• Early onset of illness, rapid cycling, history of multiple recurrences, and abrupt discontinuation of medications are significant red flags.

Impact on Pregnancy Outcomes

• Increased risks of substance use, low birth weight, preterm birth, and inadequate prenatal care.

Lithium and Pregnancy

• Risks: Mainly cardiac anomalies, including Epstein's anomaly. Risk is dose-dependent:
  • No significant increase in risk with a daily dose of 600 mg or less, but risk increases three-fold with a daily dose of over 900 mg
• Developmental Outcomes in children exposed to lithium in utero appear normal.
• Management: Use the lowest effective dose, obtain a fetal echocardiogram at week 18–24, and adjust doses carefully throughout pregnancy and postpartum.
  • Obtain lithium levels at least monthly
  • Lithium levels drop up to 34% by third trimester
  • Reduce lithium back to pre-pregnancy dose at delivery to avoid lithium toxicity in the mother

Other Mood Stabilizers

• Valproate and carbamazepine: High risk of neural tube defects (NTD); avoid in pregnancy.
  • Risk is linked to these medications' antifolate properties, but even high doses of supplemental folate during pregnancy don't reliably prevent the risk of NTD
• Prenatal valproate is also associated with poor school performance, lower IQ, even autism.
• Lamotrigine: No significant risk of birth defects, but clearance can increase by 250% during pregnancy, requiring dose increases as necessary for symptom control.

Antipsychotics During Pregnancy

• There's some evidence of increased rate of birth defects among antipsychotic-exposed infants, but no specific patterns, suggesting that the underlying illness or unidentified confounds might explain this excess risk of birth defects.
• Risperidone has been linked with an increased risk of cardiac malformations in one study.
• Keep antipsychotic doses at the lowest effective dose during pregnancy to minimize potential adverse sequelae in newborns like sleepiness, jitteriness and extrapyramidal symptoms.
• Haloperidol and olanzapine are reasonable options since there's a lot of information on their use in pregnancy; quetiapine is another good option as it has relatively low placental passage.
• Minimize use of medications for which there's little pregnancy data, like asenapine, paliperidone, lurasidone, clozapine.

ECT

• Safe, rapid, and effective for patients with bipolar disorder
• Main complications are preterm labor and transient fetal arrhythmias, but these are rare
• Produces minimal fetal medication exposure and rapid symptom resolution.

FDA Use in Pregnancy Ratings

• These have been recently revised and the A, B, C, D, X categories are being phased out.
• Don't base your choice of medication use in pregnancy solely on FDA use in pregnancy ratings; information from large numbers of human exposures is far more meaningful.

Prophylactic Treatment for Postpartum Psychosis

• Patients with bipolar disorder should begin prophylactic treatment immediately upon delivery to prevent relapse if they're not already on a mood stabilizer.
• Lamotrigine and lithium are good options, but careful monitoring and dose adjustments are crucial.

Breastfeeding Considerations

• Lithium: Generally not recommended due to the potential for high serum levels in nursing infants, especially if the infant experiences dehydration from conditions like diarrhea or fever.
• Carbamazepine and Valproate: Safe to use in breastfeeding due to their high protein binding.
• Antipsychotics: Generally considered safe; monitor for dose-dependent exposure risks, like sedation in the baby.
• Medications' pharmacokinetics: Highly protein-bound medications with short half-lives tend to produce the least infant exposure through breast milk

Summary