59 - MDedge

Current PsychiatryVol. 10, No. 9 59

Mytilee Vemuri, MD, MBA Assistant Clinical Professor of Psychiatry

Katherine Williams, MD Associate Clinical Professor of Psychiatry

• • • •

Stanford UniversityStanford, CA

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Ms. M, age 31, has bipolar I disorder and takes lamotrigine, 200 mg/d, and aripiprazole, 10 mg/d. She was first hospitalized at age 20 for a manic episode and was discharged on lithium, 1,200

mg/d. She was hospitalized again at age 25 for a depressive episode that occurred after she stopped taking lithium because of undesirable side effects. She was switched to lamotrigine, 200 mg/d, which she tolerated well. Aripiprazole, 10 mg/d, was added 1 year later to address emergence of mild mood elevation symptoms.

During a recent follow-up appointment, Ms. M expresses interest in get-ting pregnant in the next 6 months. Her mood has been stable for 5 years and she asks if she should stop taking her medications in preparation for pregnancy. What would you recommend?

Because the typical age of onset for bipolar disorder (BD) is late ado-lescence or early adulthood, women are at risk for new onset or recur-rence of mood episodes throughout their peak reproductive years. This article updates practitioners on the treatment of BD during pregnancy, including preconception planning and the risks and benefits of medi-cation use during pregnancy. We also cover treatment considerations during the postpartum period, such as prophylaxis of mood episodes and mood stabilizer treatment for women who breast-feed.

Prenatal planning Ideally, “prenatal planning” should begin long before women with BD prepare to have children. Because one-half of pregnancies in the United States are unplanned1 and manic episodes may result in impulsivity


Optimal outcomes require careful preconception planning, medication risk/benefit analysis

Bipolar disorder in pregnancy

Current PsychiatrySeptember 201160

and increased sexual activity, all women of reproductive age with BD should be counseled about birth control and risks of unplanned pregnancies. Discussions about risks of in utero exposure to psycho-tropics should occur when medications are first prescribed. Because certain mood stabilizers, (eg, carbamazepine) may de-crease efficacy of oral contraceptives by inducing cytochrome P450 (CYP450) en-zymes, women taking these medications also should be counseled about additional methods of birth control.2

Oral contraceptives also may affect mood stabilizer levels through similar mechanisms. Because of CYP450 induc-tion, lamotrigine serum levels are lower during the 3 “active” weeks of exposure to exogenous estrogen. During the “pill-free” last week, lamotrigine levels may increase up to 54%.3

Because mood stabilizers such as valpro-ate are associated with teratogenic risks, women with BD should be asked about

contraception at every visit.4 Valproate also has been associated with an increased risk of menstrual cycle irregularity. Some studies have shown that even before ini-tiating mood stabilizers, women with BD have a higher incidence of menstrual cy-cle irregularity than women without BD, which suggests the link between polycys-tic ovarian syndrome (PCOS) and BD may be independent of medications and part of the endophenotype.5

The importance of prenatal vitamins should be discussed. The recommended folate dosage for women planning to be-come pregnant is 0.4 to 1 mg/d and 0.8 to 5 mg/d for women with either a previ-ous pregnancy with neural tube defects or those taking an antiepileptic medication.6

Table 17 summarizes recommendations to improve prenatal planning in women with BD. Goals include:

• meeting with the patient at least 3 months before conception to review current menstrual cycle functioning. If your patient exhibits any signs or symptoms of PCOS, consider referral to a gynecologist

• meeting with patient and partner/significant supports to discuss treatment decisions

• optimizing the patient’s mood before conception, preferably for at least 3 to 6 months

• prescribing monotherapy at the lowest therapeutic dose if clinically feasible

• assessing the patient’s personal prefer-ences and beliefs regarding medication use during pregnancy and breast-feeding

• assessing the patient’s capacity to un-derstand the risks and benefits of medica-tion continuation/discontinuation during pregnancy, including risk for relapse, cur-rent literature on teratogenicity, perinatal complications, and neurodevelopmental studies. Document that the patient provides informed consent.

Case Continued

Medication decisionsMs. M’s first question is, “Should I stop taking my medications?” Ms. M and her psychiatrist review the risks and benefits of medication exposure during pregnancy (Table 2) and decide against discontinuing all medications

Clinical Point

Because mood stabilizers are associated with teratogenic risks, ask women with BD about contraception at every visit

Discuss this article at www.facebook.com/ CurrentPsychiatry

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comprehensive prenatal counseling should begin at least 3 months before pregnancy. Folate supplementation is advised

medication should be avoided if clinically feasible (particularly during the first trimester). Avoid abrupt discontinuation. Increase psychosocial and clinical supports

if medication is pursued:• Use minimum effective dose• Monotherapy is preferable• Avoid changing effective medications

unless there is significant safety or clinical advantage

• Increase frequency of clinical monitoring as indicated

comprehensive postpartum counseling should begin before and be reinforced throughout pregnancy, emphasizing:

• importance of sleep• postpartum prophylaxis• risks/benefits of breast-feeding• importance of social support and

identification of support structure, including psychoeducation session with support team

BD: bipolar disorder

Source: Adapted from reference 7

Pregnancy and Bd: Medication management guidelines

Table 1


because of her history of relapse when she stopped lithium. Because Ms. M’s mood has been stable for 5 years, she and her psychia-trist decide to limit her medications to la-motrigine monotherapy at her current dose, and agree to slowly taper aripiprazole. One week later, Ms. M calls and states she has a positive pregnancy test and is wondering if she should stop aripiprazole all at once. Ms. M is advised to continue with the original plan to slowly taper aripiprazole.

Medication risks/benefits Women with BD have a high rate of relapse associated with abrupt discontinuation of pharmacotherapy during pregnancy. As such, patients and their partners and families should be cautioned against rapid discontinuation of medications.8 The risk to mother and fetus is particularly high for women with a history of recurrent, se-vere mood episodes. These patients face not only a high risk of recurrence of mood episodes, but also the inherent danger of impulsivity, poor self-care, and suicidal-ity associated with mania, depression, and mixed states. In these cases, continuing a medication (other than known teratogens such as valproate) that has effectively sta-bilized mood may be preferred to discon-tinuation; these decisions are made after careful risk/benefit assessment.

Carefully reviewing the patient’s history is essential to assessing the risks and bene-fits of tapering medications before pregnan-cy. Consider the frequency and severity of your patient’s mood episodes, and whether a switch in mood state was rapid or had a prodromal phase. If a patient currently has

a stable mood, a history of mild to moder-ate mood episodes, a history of prodromal symptoms (eg, gradually increasing sleep disturbances and mood deterioration), and no history of rapid switches, gradually dis-continuing medications before or during pregnancy may be considered. However, encourage women to enlist their partners and family members to monitor for warn-ing symptoms and advocate for early medi-cation intervention. Because insomnia is a sign of relapse for many patients, educate women and their families about the impor-tance of maintaining a regular sleep/wake cycle and alerting care providers if this cy-cle changes.

Mood stabilizers with the greatest risk for teratogenicity are valproate, carbamaze-pine, and lithium.9 Valproate is associated with a 6% to 13% risk of congenital mal-formation, including neural tube defects (1% to 2%) and cardiac or craniofacial de-fects.3 Risks increase at doses >800 mg/d.10 Potential perinatal complications associ-ated with valproate include heart rate deceleration, abnormal tone (hypotonia or hypertonia), and growth retardation.11 Neurobehavioral sequelae include lower IQ scores and increased risk of autism.12

Carbamazepine is associated with a 2% to 5% risk of congenital malformation, in-cluding neural tube defects and cardiac or craniofacial defects.4 Perinatal compli-cations associated with carbamazepine include vitamin K deficiency.4 The neu-robehavioral sequelae of carbamazepine are controversial; most prospective stud-ies do not suggest long-term cognitive deficits.13 It is strongly recommended that

Clinical Point

Advise patients with BD that abruptly discontinuing pharmacotherapy during pregnancy will increase their risk of relapse

risks of discontinuing risks of continuing

Mood relapse during pregnancy or postpartum

Risks of alternative treatment(s):

• failure to respond to different emergency treatment

• potential exposure to polypharmacy

Medication-specific risks:

• congenital malformation (carbamazepine, lithium, valproate)

• neurodevelopmental risks (valproate)

BD: bipolar disorder

Potential risks of continuing or discontinuing medications for Bd during pregnancy

Table 2



valproate and carbamazepine be avoided, if possible, in women with BD who plan to become pregnant in the near future.

Prospective studies of lithium have shown a 2.8% rate of congenital malfor-mations, which is much lower than the 11% rate found in retrospective studies.14 Ebstein’s anomaly—downward displace-ment of the tricuspid valve—is estimated to occur in .05% to 0.1% of infants exposed to lithium, which is 10 to 20 times the base rate, but a low absolute risk.11

It is recommended women taking lithium during pregnancy complete a fe-tal high resolution ultrasound and echo-cardiogram at 16 to 18 weeks.11 Perinatal complications associated with lithium include prematurity, hypotonia, hypothy-roidism, hepatic abnormalities, respira-tory distress, and nephrogenic diabetes insipidus.15 When prescribing lithium, divided doses are recommended to main-tain a stable serum level. Serum lithium levels should be monitored frequently, and higher doses may be needed because of increased glomerular filtration rate and plasma volume throughout pregnancy.10 Because of fluid shifts at delivery—in-cluding blood loss during delivery and postpartum diuresis and diaphoresis—there is a risk of lithium toxicity at this time. Some researchers have suggested suspending lithium treatment during la-bor or 24 to 48 hours before planned in-duction or Caesarean section may lower this risk, with re-administration after de-livery when medically stable.16 Women should be followed closely for signs of lithium toxicity and have lithium lev-

els monitored as clinically indicated.16 There is insufficient data to support any neurobehavioral sequelae of in utero ex-posure to lithium; however, there are few long-term follow up studies using stan-dardized measures.17

Lamotrigine is associated with a 1.9% to 4.6% rate of congenital malformations, including cleft lip/palate (8.9/1,000 vs 0.5 to 1.2/1,000 baseline).4 Studies sug-gest that rates of malformations (cardiac, genitourinary, gastrointestinal, neural tube defect) are dose-dependent: 1.3% at dos-ages <100 mg/d, 1.9% at 100 to 200 mg/d, and 5.4% at >200 mg/d.18 Because cleft lip and palate are formed by late second tri-mester, it is recommended to attempt to keep the lamotrigine dose <200 mg/d dur-ing the first and second trimesters. Higher doses of lamotrigine may be needed in the third trimester because of increased renal clearance.19 There is insufficient data to support any lamotrigine-associated neurobehavioral effects, and unlike stud-ies of valproate, follow-up evaluations of lamotrigine-exposed children have not shown lower IQs.20

Evidence about the reproductive safe-ty of other mood stabilizers used in BD is limited. A recent population-based co-hort study did not show increased risk of major malformations in children ex-posed to topiramate, gabapentin, or ox-carbazepine during the first trimester of pregnancy.21 Topiramate often is used in combination with other mood stabilizers for weight control, and studies suggest that polypharmacy with topiramate, es-pecially at higher doses and with valpro-ate, increases the risk of major congenital malformations, especially cleft lip and cleft palate.22 Consequently, topiramate is not recommended for women planning to conceive.

antipsychotics. Although there is increas-ing information about outcomes of neo-nates exposed to atypical antipsychotics during pregnancy, the literature still is lim-ited. The greatest number of studies have evaluated olanzapine, risperidone, and quetiapine and show the rate of congeni-tal malformations is 0.9% to 4.1%, which

Clinical Point

The mood stabilizers with the greatest risk for teratogenicity are valproate, carbamazepine, and lithium

Suicide/infanticide

Reckless behavior/substance abuse

Poor self-care/care of infant

Difficulty with mother-infant bonding

Mood relapse more severe and difficult to treat than prior episodes

Possible hospitalization

Consequences of postpartum mood relapse

Table 3

is consistent with general population rates.23-26 Perinatal complications associ-ated with these atypical antipsychotics in-clude neonatal extrapyramidal syndrome (EPS), possible neonatal adaptation/with-drawal syndrome, and an increased risk of the infant being either large or small for gestational age. Because atypical antipsy-chotics may increase the risk of metabolic syndrome, women should be counseled about the possible increased risk for ges-tational diabetes with these medications. None of these drugs have been associated with neurobehavioral sequelae, but long-term follow-up studies of exposed infants are lacking.

For aripiprazole, asenapine, ziprasi-done, iloperidone, and lurasidone there is insufficient data about rate of congenital malformations, obstetric complications, and neurobehavioral sequelae. However, perinatal complications associated with these medications include risk of EPS and withdrawal symptoms.25,26

Case Continued

Worsening mood symptomsDuring pregnancy, Ms. M’s mood is stable on lamotrigine, 200 mg/d, and she partici-pates in individual interpersonally oriented psychotherapy to address anxieties related to becoming a mother. However, late in her third trimester, Ms. M reports worsening symptoms, including depressed mood, in-somnia, fatigue, and poor motivation. She also learns her mother had an episode of postpartum depression. Ms. M and her doc-tor discuss the risks of postpartum relapse, but she declines additional medication for prophylaxis because she is concerned about its impact on breast-feeding.

Two days after delivery, Ms. M complains of increased insomnia and depressed mood, and her husband reports she is not getting out of bed. She describes thoughts and im-ages of throwing her baby out the window, and feels her thoughts are controlled by something outside of herself. Ms. M suspects her husband is having an affair.

Clinical Point

Some researchers have suggested suspending lithium during labor may lower the risk of lithium toxicity

Available at CurrentPsyChiatry.com

Click on CME

Effective Strategies for Patients WithComplex Depression in Psychiatric PracticeSwitch or augment? Lessons from STAR*D

◾ Andrew A. Nierenberg, MD, Associate Director, Depression Clinical and Research Program, Co-Director, Bipolar Clinic and Research Program, Massachusetts General Hospital; Professor of Psychiatry, Harvard Medical School, Boston, Massachusetts

Switching, combination, and augmentation strategies for major depressive disorder

◾ George I. Papakostas, MD, Director, Treatment-Resistant Depression Studies, Massachusetts General Hospital; Associate Professor of Psychiatry, Harvard Medical School, Boston, Massachusetts

Major depressive disorder and other medical illness: A two-way street

◾ Philip R. Muskin, MD, Professor of Clinical Psychiatry, Columbia University; Chief of Service: Consultation-Liaison Psychiatry, Department of Psychiatry, Columbia University Medical Center; Research Psychiatrist, New York State Psychiatric Institute, New York, New York

This supplement was sponsored by SciMed and supported by an educational grant from AstraZeneca. It was peer reviewed by Current PsyChiatry.

Available Online

FRee2.0 CMecredits

continued



Postpartum risksAll women with BD should be counseled regarding prophylaxis with mood stabiliz-ers during the postpartum period. Women with BD are at high risk of mania and psy-chosis postpartum, particularly those with a personal or family history of postpartum psychosis. Postpartum psychosis frequent-ly presents with an abrupt onset, shortly after delivery (Table 3, page 62). Although it may present with the classic symptoms of mania or psychotic depression, it also may have features of delirium.27

Clinicians should immediately imple-ment treatment with mood stabilizers and antipsychotics to manage acute psychotic symptoms, while also ruling out medical causes or comorbidities. Hospitalization should be considered. Aggressive treat-ment of insomnia will help stabilize mood. Electroconvulsive therapy can be used in treatment-refractory or urgent cases.10 Lastly, because approximately 4% of wom-en with postpartum psychosis commit infanticide, all mother/child interactions should be closely supervised.27

In small prospective studies, use of lithium within 48 hours of delivery de-creased the risk of relapse of postpartum psychosis within the first 3 months.28,29 In lower-risk patients who have discontin-ued pharmacotherapy during pregnancy, restarting medication before or immedi-ately after delivery should be considered. At the same time, it is important to mini-mize sleep disruption, particularly post-partum. Psychoeducation—ideally begun in the preconception counseling visit—is extremely important for emphasizing the need for postpartum sleep.

Breast-feeding concernsData on risks of infant exposure to medi-cations through breast milk are largely limited to case reports and case series. All mood-stabilizing medications have been found to pass into breast milk at varying concentrations.28 If a patient chooses to breast-feed, she should inform her pedia-trician of this decision, and she and her support system should be educated about signs of neonatal toxicity. Ideally, the psy-

chiatrist should liaise with the patient’s pediatrician, especially when infants are premature, because the child’s liver metab-olism may be immature, leading to higher serum drug levels and in some cases drug accumulation. Encourage patients to con-sider bottle feeding, either their own breast milk, pumped and stored, or formula. This will allow others to assist with feedings and the patient to have more consistent sleep, which could stabilize mood.

Lamotrigine concentrations in breast milk are highly variable.30 Lamotrigine is processed through glucuronidation, a process that is immature in neonates. One study found serum lamotrigine lev-els in infants were 23% to 33% of mater-nal serum levels and milk/plasma ratios were highly variable, ranging from 6% to 147%.30 Infants exposed to lamotrigine in breast milk should be monitored for rash and signs of thrombocytosis, and if clini-cally indicated, lamotrigine levels should be checked.30 Valproate has a low infant se-rum/maternal serum ratio; there are rare case reports of hepatotoxicity and throm-bocytopenia. Although valproate can be reinitiated because of its lower breast milk concentration, it is not a drug of choice in reproductive-age women because of the many issues described above, including risks during pregnancy, PCOS, and effect on oral contraceptives.

Carbamazepine serum levels in breast-feeding infants range from 6% to 65%; hepatic dysfunction, sedation, and poor feeding have been reported in infants in rare instances.31

Historically, lithium has been consid-ered incompatible with breast-feeding, but recent reports suggest with careful moni-toring it may not be contraindicated. In 10 mother/infant pairs, lithium levels in breast milk and infant serum diminished over time, with no adverse neonatal ef-fects.32 However, if an infant does breast-feed, it may be important to monitor thyroid-stimulating hormone, blood urea nitrogen-to-creatinine ratio, and ECG in both mother and infant, especially if the mother is taking high doses of lithium.

The safety of breast-feeding while treated with atypical antipsychotics is largely un-

Clinical Point

In the postpartum, women with BD are at high risk of mania; psychosis may present with an abrupt onset shortly after delivery

known. Case reports indicate low transmis-sion of these medications into breast milk.28

Case Continued

Ms. M is admitted for psychiatric hospitaliza-tion because of worsening psychotic symp-toms, poor self-care, and persistent thoughts of harming her baby. She agrees to restart aripiprazole, which is titrated to 20 mg/d. Breast-feeding is not pursued. She is dis-charged in 10 days after she no longer has thoughts of harming her baby, delusions, or psychotic or suicidal ideation. She and her family agree to close supervision by her family and outpatient follow-up.

References 1. Finer LB, Henshaw SK. Disparities in rates of unintended

pregnancy in the United States, 1994 and 2001. Perspect Sex Reprod Health. 2006;38(2):90-96.

2. ACOG Committee on Practice Bulletins-Gynecology. ACOG practice bulletin. No. 73: use of hormonal contraception in women with coexisting medical conditions. Obstet Gynecol. 2006;107(6):1453-1472.

3. Wegner I, Edelbroek PM, Bulk S, et al. Lamotrigine kinetics within the menstrual cycle, after menopause, and with oral contraceptives. Neurology. 2009;73(17):1388-1393.

4. Tomson T, Battino D. Teratogenic effects of antiepileptic medications. Neurol Clin. 2009;27(4):993-1002.

5. Reynolds MF, Sisk EC, Rasgon NL. Valproate and neuroendocrine changes in relation to women treated for epilepsy and bipolar disorder: a review. Curr Med Chem. 2007;14(26):2799-2812.

6. Wilson RD, Johnson JA, Wyatt P, et al. Pre-conceptional vitamin/folic acid supplementation 2007: the use of folic acid in combination with a multivitamin supplement for the prevention of neural tube defects and other congenital anomalies. J Obstet Gynaecol Can. 2007;29(12):1003-1026.

7. Burt VK, Rasgon N. Special considerations in treating bipolar disorder in women. Bipolar Disord. 2004;6(1):2-13.

8. Viguera AC, Whitfield T, Baldessarini RJ, et al. Risk of recurrence in women with bipolar disorder during pregnancy: prospective study of mood stabilizer discontinuation. Am J Psychiatry. 2007;164(12):1817-1824.

9. Bowden CL, Singh V. Long-term management of bipolar disorder. In: Ketter T, ed. Advances in the treatment of bipolar disorder. Washington, DC: American Psychiatric Publishing, Inc.; 2005:111.

10. Wyszynski DF, Nambisan M, Surve T, et al. Increased rate of major malformations in offspring exposed to valproate during pregnancy. Neurology. 2005;64(6): 961-965.

11. 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.

12. Meador KJ, Baker GA, Browning N, et al. Effects of breastfeeding in children of women taking antiepileptic drugs. Neurology. 2010;75(22):1954-1960.

13. Gentile S. Prophylactic treatment of bipolar disorder in pregnancy and breastfeeding: focus on emerging mood stabilizers. Bipolar Disord. 2006;8(3):207-220.

14. Iqbal MM, Gundlapalli SP, Ryan WG, et al. Effects of antimanic mood-stabilizing drugs on fetuses, neonates, and nursing infants. South Med J. 2001;94(3):304-322.

15. Kozma C. Neonatal toxicity and transient neurodevelopmental deficits following prenatal exposure to lithium: another clinical report and a review of the literature. Am J Med Genet A. 2005;132(4):441-444.

16. Newport DJ, Viguera AC, Beach AJ, et al. Lithium placental passage and obstetrical outcome: implications for clinical management during late pregnancy. Am J Psychiatry. 2005;162(11):2162-2170.

Mrs. T, age 28, has bipolar I disorder that is successfully treated with carbamazepine, 400 mg/d, and risperidone, 2 mg/d. On a recent visit, she tells you she is pregnant. How would you counsel her?

■ Take a thorough history and review with Mrs. T the risks and benefits of medication exposure during pregnancy

■ Assess her preferences and beliefs regarding medication use during pregnancy and breast-feeding

■ Caution her against rapidly discontinuing her medications■ Meet with Mrs. T, her family, and significant supports to

discuss treatment decisions

instantThis month’s

poll

Mr. K, age 56, has been taking amitriptyline, 150 mg/d, for 7 years to treat depressive symptoms. Recently, he reveals that he is being treated for “heart problems” but can’t remember which drugs his cardiologist prescribed. How would you treat Mr. K?

JULY POll ResulTs

see ‘Treating bipolar disorder during pregnancy’ page 58-66

Visit CurrentPsychiatry.com to answer the Instant Poll and see how your colleagues responded. Click on “Have more to say?” to comment.

1% Schedule another appointment in a few weeks to closely monitor Mr. K

80% After obtaining consent, call the cardiologist to find out which drugs Mr. K is taking

11% Switch Mr. K to another antidepressant, such as a selective serotonin reuptake inhibitor

8% Order ECG monitoring

1%

suggested reading: Casher MI, Bostwick JR, Yu MA. Current PsyChiatry. 2011;10(7):54-64.

▲ Data obtained via CurrentPsychiatry.com, July 2011

continued

80%

11% 8%



17. Schou M. What happened later to the lithium babies? A follow-up study of children born without malformations. Acta Psychiatr Scand. 1976;54(3):193-197.

18. Morrow J, Russell A, Guthrie E, et al. Malformation risks of antiepileptic drugs in pregnancy: a prospective study from the UK Epilepsy and Pregnancy Register. J Neurol Neurosurg Psychiatry. 2006;77(2):193-198.

19. Sabers A, Tomson T. Managing antiepileptic drugs during pregnancy and lactation. Curr Opin Neurol. 2009;22(2): 157-161.

20. Cummings C, Stewart M, Stevenson M, et al. Neurodevelopment of children exposed in utero to lamotrigine, sodium valproate and carbamazepine. Arch Dis Child. 2011;96(7):643-647.

21. Mølgaard-Nielsen D, Hviid A. Newer-generation antiepileptic drugs and the risk of major birth defects. JAMA. 2011;305(19):1996-2002.

22. Martínez-Frías ML. Topiramate in pregnancy: preliminary experience from the UK Epilepsy and Pregnancy Register. Neurology. 2009;72(23):2054-2055.

23. McKenna K, Koren G, Tetelbaum M, et al. Pregnancy outcome of women using atypical antipsychotic drugs: a prospective comparative study. J Clin Psychiatry. 2005; 66(4):444-449.

24. Reis M, Källén B. Maternal use of antipsychotics in early pregnancy and delivery outcome. J Clin Psychopharmacol. 2008;28(3):279-288.

25. Coppola D, Russo LJ, Kwarta RF Jr, et al. Evaluating the postmarketing experience of risperidone use during pregnancy: pregnancy and neonatal outcomes. Drug Saf. 2007;30(3):247-264.

26. Einarson A, Boskovic R. Use and safety of antipsychotic drugs during pregnancy. J Psychiatr Pract. 2009;15(3): 183-192.

27. Spinelli MG. Postpartum psychosis: detection of risk and management. Am J Psychiatry. 2009;166(4):405-408.

28. Yonkers KA, Vigod S, Ross LE. Diagnosis, pathophysiology, and management of mood disorders in pregnant and postpartum women. Obstet Gynecol. 2011;117(4):961-977.

29. Doucet S, Jones I, Letourneau N, et al. Interventions for the prevention and treatment of postpartum psychosis: a systematic review. Arch Womens Ment Health. 2011;14(2): 89-98.

30. Newport DJ, Pennell PB, Calamaras MR, et al. Lamotrigine in breast milk and nursing infants: determination of exposure. Pediatrics. 2008;122(1):e223-231.

31. Gentile S. Prophylactic treatment of bipolar disorder in pregnancy and breastfeeding: focus on emerging mood stabilizers. Bipolar Disord. 2006;8(3):207-220.

32. Viguera AC, Newport DJ, Ritchie J, et al. Lithium in breast milk and nursing infants: clinical implications. Am J Psychiatry. 2007;164(2):342-345.

Clinical Point

Women with BD who choose to breast-feed should be taught to identify signs of neonatal toxicity

Bottom LineAll women of child-bearing age with bipolar disorder should be counseled about reproductive issues. Medication management should begin with counseling before pregnancy, with the goal of minimizing medications and doses during pregnancy if feasible. Medications with lower risks of teratogenicity include lamotrigine, atypical antipsychotics, and based on newer, prospective studies, lithium. Valproate and carbamazepine should be avoided during pregnancy if clinically feasible.

Related Resources• The Hospital for Sick Children. Pregnancy and breastfeeding

resources. www.motherisk.org/women/pregnancyResources.jsp.

• U.S. National Library of Medicine. TOXNET toxicology data network. http://toxnet.nlm.nih.gov.

drug Brand names

Aripiprazole • Abilify Lurasidone • LatudaAsenapine • Saphris Olanzapine • ZyprexaCarbamazepine • Equetro, Oxcarbazepine • Trileptal Tegretol Quetiapine • SeroquelGabapentin • Neurontin Risperidone • RisperdalIloperidone • Fanapt Topiramate • TopamaxLamotrigine • Lamictal Valproate • Depacon Lithium • Eskalith, Lithobid Ziprasidone • Geodon

disclosure

The authors report no financial relationship with any com-pany whose products are mentioned in this article or with manufacturers of competing products.

acknowledgement

The authors would like to thank Natasha Barthel, BS, for her assistance with this article.

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59 - MDedge