What medications for bipolar disorder are safe to use during pregnancy?

Medications for Bipolar Disorder Safe During Pregnancy

Primary Recommendation

Lamotrigine and certain atypical antipsychotics (particularly quetiapine and lurasidone) are the safest mood stabilizers for bipolar disorder during pregnancy, while valproic acid must be avoided due to high teratogenic risk. 1, 2

Medications to AVOID

• Valproic acid is contraindicated - associated with significantly increased odds of neural tube defects and should not be used during pregnancy 1
• Carbamazepine carries teratogenic concerns and should be avoided when alternatives exist 1

Preferred Medication Options

First-Line Agents

Lamotrigine:

• Does not show clear increase in teratogenicity based on available data 3
• Limited evidence suggests acceptable safety profile 1
• One of the most commonly prescribed mood stabilizers during pregnancy 2

Atypical Antipsychotics:

• Lurasidone was the most commonly prescribed mood stabilizer in recent pregnancy cohorts 2
• Quetiapine has mixed evidence but is frequently used with acceptable safety data 1, 3
• Olanzapine can be used but monitor for metabolic complications (gestational diabetes, excessive weight gain) in pregnant women 4, 3
• Risperidone has inconclusive but not alarming data 3

Second-Line Considerations

Lithium:

• Limited data suggest it may be continued during pregnancy when necessary 1
• Requires close monitoring of levels due to physiologic changes in pregnancy 5
• Earlier concerns about cardiac malformations (Ebstein's anomaly) appear less significant than previously thought 5

Critical Management Principles

DO NOT Discontinue Effective Treatment Without Careful Planning

• Continuing effective pharmacotherapy is generally safer than stopping - untreated bipolar disorder during pregnancy is associated with poor prenatal care, decreased fetal growth, relapse risk, and increased postpartum complications including postpartum psychosis 2, 6
• The risks of bipolar relapse (hospitalization, suicide risk, poor self-care) often outweigh medication risks 6, 5

Avoid Antidepressant Monotherapy

• Antidepressants alone are NOT recommended for bipolar disorder during pregnancy - they can increase risk of mania and rapid cycling, especially in bipolar I disorder 2
• Despite this, antidepressant monotherapy persists inappropriately in clinical practice (35.7% at delivery in one cohort) 2

Monitoring Requirements During Pregnancy

• Close psychiatric monitoring throughout pregnancy and postpartum for mood episode emergence 5
• Careful medication dose adjustments as pregnancy progresses due to physiologic changes affecting drug levels 5
• Monitor for metabolic complications if using olanzapine (glucose screening, weight gain) 3
• Lithium levels require frequent monitoring if used 5

Neonatal Considerations

For atypical antipsychotics (including olanzapine):

• Neonates exposed during third trimester are at risk for extrapyramidal and/or withdrawal symptoms after delivery 4
• Monitor newborns for agitation, hypertonia, hypotonia, tremor, somnolence, respiratory distress, and feeding difficulties 4
• These symptoms vary in severity; some resolve within hours to days, others require prolonged hospitalization 4
• Inform pediatric team about maternal medication use for appropriate neonatal monitoring 4

Clinical Algorithm for Decision-Making

1. If patient is stable on lamotrigine or quetiapine/lurasidone → Continue at lowest effective dose 5, 2

2. If patient is on valproic acid → Switch to lamotrigine or atypical antipsychotic before conception or immediately upon pregnancy recognition 1

3. If patient is on lithium and stable → Consider continuing with close monitoring rather than risking relapse from discontinuation 5, 1

4. If patient is on antidepressant monotherapy → Add mood stabilizer (lamotrigine or atypical antipsychotic) to prevent mood destabilization 2

5. If considering medication discontinuation → Only attempt if illness is mild, patient has been stable for extended period, and close monitoring is feasible - recognize this carries significant relapse risk 6, 5

Common Pitfalls to Avoid

• Do not reflexively discontinue all psychiatric medications upon pregnancy recognition - this often leads to relapse and worse outcomes than continued treatment 6, 2
• Do not use valproic acid under any circumstances during pregnancy 1
• Do not treat bipolar disorder with antidepressants alone - this is inappropriate disease management regardless of pregnancy status 2
• Do not assume "no medication" is the safest option - untreated bipolar disorder carries substantial maternal and fetal risks 6, 2