What mood stabilizers are safe to use during pregnancy?

Mood Stabilizers During Pregnancy: Safety and Recommendations

Lamotrigine is the safest mood stabilizer for use during pregnancy, with the lowest risk of congenital malformations and adverse neonatal outcomes compared to other options. 1, 2

Comparative Safety of Mood Stabilizers in Pregnancy

Lamotrigine

• Has the most favorable safety profile among mood stabilizers during pregnancy 1, 2
• Not associated with increased risk of major congenital malformations compared to non-teratogenic exposures 3
• Effective at preventing recurrence of bipolar symptoms during pregnancy (30% recurrence risk vs. 100% when mood stabilizers are discontinued) 4
• Recommended as a first-line option for bipolar disorder requiring mood stabilization during pregnancy 2
• Associated with better neonatal outcomes compared to untreated bipolar disorder 1

Atypical Antipsychotics

• Olanzapine, risperidone, quetiapine, and clozapine can be used for bipolar disorder and schizophrenia during pregnancy 2
• Lurasidone and other atypical antipsychotics show better neonatal outcomes than untreated bipolar disorder 1
• May be considered as alternatives to traditional mood stabilizers when clinically indicated 1, 2

Lithium

• Can be used if an overall assessment indicates a need for mood stabilization during pregnancy 2
• Associated with some risk of congenital malformations and perinatal complications 5
• Requires careful monitoring and dose adjustment during pregnancy and postpartum 2
• Limited data on long-term neurodevelopmental outcomes for children exposed to lithium in utero 5

Contraindicated Mood Stabilizers

• Valproate (sodium valproate) is contraindicated during pregnancy 2, 5
• Associated with higher rates of congenital malformations 5
• Linked to poorer long-term neurodevelopmental outcomes in exposed children 5
• Carbamazepine is also contraindicated during pregnancy 2, 5

Risks of Untreated Bipolar Disorder in Pregnancy

• Untreated bipolar disorder is associated with significantly higher rates of:
  • Premature delivery 1
  • Low birth weight 1
  • Increased risk of spontaneous abortion 6
  • Decreased initiation of breastfeeding 6

Management Recommendations

First-Line Options

• Lamotrigine is the preferred mood stabilizer during pregnancy due to its favorable safety profile and efficacy 3, 4, 1
• Starting dose typically 25-50 mg daily with gradual titration based on clinical response 2
• Monitor serum levels as pregnancy may alter lamotrigine metabolism 4

Second-Line Options

• Atypical antipsychotics (olanzapine, risperidone, quetiapine, lurasidone) when lamotrigine is not suitable 1, 2
• Lithium may be considered when benefits outweigh risks, particularly in women with severe bipolar disorder and history of good response to lithium 2, 5

Breastfeeding Considerations

• Lamotrigine transfers into breast milk but is generally considered compatible with breastfeeding 2
• Monitor breastfed infants for potential drowsiness or feeding difficulties 6
• Sertraline and paroxetine are the most commonly prescribed antidepressants during breastfeeding if adjunctive treatment for depression is needed 6

Important Clinical Considerations

• Discontinuing mood stabilizer treatment during pregnancy carries a very high risk of illness recurrence (100% vs. 30% with lamotrigine) 4
• The risks of exposure to mood stabilizers must be balanced against the risks of untreated maternal bipolar disorder 5
• Pre-conception counseling is ideal to optimize treatment before pregnancy occurs 2
• Regular monitoring of maternal mental health status throughout pregnancy is essential 1
• Collaboration between psychiatrists, obstetricians, and pediatricians is recommended for optimal care 2