What antipsychotic (anti-psychotic) medications are safe for bipolar disorder during pregnancy?

Safest Antipsychotics for Bipolar Disorder During Pregnancy

Atypical antipsychotics, particularly quetiapine, olanzapine, and lurasidone, are the safest options for treating bipolar disorder during pregnancy, with lamotrigine also showing a favorable safety profile. These medications have better safety profiles compared to traditional mood stabilizers like valproate and carbamazepine, which should be avoided due to known teratogenic effects.

First-Line Options for Bipolar Disorder During Pregnancy

Atypical Antipsychotics

• Quetiapine: Limited published data on quetiapine use during pregnancy shows no major malformations in exposed infants 1. In a prospective observational study, 21 women exposed to quetiapine during pregnancy delivered infants with no major malformations, and among 42 other reported cases, no major malformations were observed.

• Olanzapine: FDA pregnancy registry data indicates that olanzapine has not established a drug-associated risk of major birth defects, miscarriage, or adverse maternal or fetal outcomes 2. However, there is some evidence suggesting an association with metabolic complications in pregnant women 3.

• Lurasidone: Recent studies have shown lurasidone to have a favorable safety profile during pregnancy, with better neonatal outcomes compared to untreated bipolar disorder 4.

Other Options

• Lamotrigine: Shows a favorable safety profile with no clear increase in teratogenicity 3, 4. Women treated with lamotrigine during pregnancy had significantly lower rates of premature delivery and low birth weight compared to untreated women with bipolar disorder 4.

Medications to Avoid During Pregnancy

• Valproate and Carbamazepine: Should be avoided in reproductive-aged women due to known teratogenic effects 5.
• Risperidone: May have a possible association with malformations and is not considered a first-line agent for use during pregnancy 6.

Important Considerations

Risks of Untreated Bipolar Disorder

Untreated bipolar disorder during pregnancy is associated with:

• Higher rates of premature delivery
• Low birth weight infants
• Increased risk of maternal psychiatric decompensation
• Potential for postpartum psychosis

A study comparing women with untreated bipolar disorder to those on mood stabilizers found significantly higher rates of premature delivery and low birth weight in the untreated group 4.

Monitoring During Pregnancy

When using antipsychotics during pregnancy:

1. Metabolic Monitoring:

   • Monitor for gestational diabetes, particularly with atypical antipsychotics
   • Regular blood glucose screening
   • Weight monitoring

2. Fetal Monitoring:

   • Additional ultrasounds every 3-4 weeks to document adequate fetal growth 7
   • Fetal umbilical artery Doppler exams if growth restriction is present
   • Consider measurements of peak systolic velocity of the fetal middle cerebral artery when administering medications 7

3. Neonatal Monitoring:

   • Be aware of potential neonatal effects including extrapyramidal symptoms and withdrawal symptoms
   • Monitor for respiratory distress, agitation, hypertonia, hypotonia, tremor, and somnolence 1, 2

Dosing Considerations

• Use the lowest effective dose to control symptoms
• Metabolic changes during pregnancy may necessitate dose adjustments 6
• Single medication at an effective dose is preferable to multiple medications at lower doses 5

Clinical Decision Algorithm

1. Assess Severity: Determine if medication is necessary based on symptom severity and risk of relapse
2. Select Medication:
   • For newly diagnosed patients: Start with quetiapine or lurasidone
   • For stable patients already on medication: Continue current effective medication unless it's valproate or carbamazepine
3. Monitor Closely:
   • Maternal symptoms and medication efficacy
   • Metabolic parameters (glucose, weight)
   • Fetal growth and development
4. Prepare for Delivery:
   • Be aware of potential neonatal effects
   • Have pediatric team informed of maternal medication use

Common Pitfalls to Avoid

• Discontinuing medication: Abrupt discontinuation can lead to relapse and worse outcomes than continuing medication
• Underestimating untreated illness: The risks of untreated bipolar disorder often outweigh the risks of medication exposure
• Polypharmacy: Using multiple medications increases exposure risk; aim for monotherapy when possible
• Inadequate monitoring: Regular maternal and fetal monitoring is essential to detect and address any complications early

Remember that the decision to use antipsychotics during pregnancy should balance the risks of untreated bipolar disorder against the potential risks of medication exposure, with the goal of maintaining maternal stability while minimizing fetal exposure to both psychiatric symptoms and medication risks.