Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Bipolar disorder in women: Preconception and prenatal maintenance pharmacotherapy

Victoria Hendrick, MD
Section Editor
Paul Keck, MD
Deputy Editor
David Solomon, MD


Euthymic bipolar patients often receive maintenance pharmacotherapy prior to conception and during pregnancy [1,2]. Onset of bipolar disorder in women typically occurs during childbearing years [3], and most patients are at risk for recurrent mood episodes [1].

This topic reviews preconception and prenatal maintenance pharmacotherapy for bipolar patients. Indications for maintenance pharmacotherapy during pregnancy, the teratogenic risks of medications used for bipolar disorder, preconception counseling and care for bipolar disorder, and the general maintenance treatment of bipolar disorder are discussed separately.

(See "Bipolar disorder in women: Indications for preconception and prenatal maintenance pharmacotherapy".)

(See "Teratogenicity, pregnancy complications, and postnatal risks of antipsychotics, benzodiazepines, lithium, and electroconvulsive therapy".)

(See "Bipolar disorder in women: Contraception and preconception assessment and counseling".)


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Sep 2016. | This topic last updated: Jan 12, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
  1. Yonkers KA, Wisner KL, Stowe Z, et al. Management of bipolar disorder during pregnancy and the postpartum period. Am J Psychiatry 2004; 161:608.
  2. 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; 164:1817.
  3. Merikangas KR, Akiskal HS, Angst J, et al. Lifetime and 12-month prevalence of bipolar spectrum disorder in the National Comorbidity Survey replication. Arch Gen Psychiatry 2007; 64:543.
  4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington, VA 2013.
  5. ACOG Committee on Practice Bulletins--Obstetrics. ACOG Practice Bulletin: Clinical management guidelines for obstetrician-gynecologists number 92, April 2008 (replaces practice bulletin number 87, November 2007). Use of psychiatric medications during pregnancy and lactation. Obstet Gynecol 2008; 111:1001.
  6. Jones I, Craddock N. Bipolar disorder and childbirth: the importance of recognising risk. Br J Psychiatry 2005; 186:453.
  7. Galbally M, Snellen M, Lewis AJ. A review of the use of psychotropic medication in pregnancy. Curr Opin Obstet Gynecol 2011; 23:408.
  8. Burt VK, Bernstein C, Rosenstein WS, Altshuler LL. Bipolar disorder and pregnancy: maintaining psychiatric stability in the real world of obstetric and psychiatric complications. Am J Psychiatry 2010; 167:892.
  9. National Institute for Health and Clinical Excellence. Bipolar disorder: The management of bipolar disorder in adults, children and adolescents, in primary and secondary care. National Clinical Practice Guideline Number 38 http://www.nice.org.uk/ (Accessed on December 30, 2011).
  10. Newport DJ, Stowe ZN, Viguera AC, et al. Lamotrigine in bipolar disorder: efficacy during pregnancy. Bipolar Disord 2008; 10:432.
  11. Cohen LS. Treatment of bipolar disorder during pregnancy. J Clin Psychiatry 2007; 68 Suppl 9:4.
  12. Burt VK, Rasgon N. Special considerations in treating bipolar disorder in women. Bipolar Disord 2004; 6:2.
  13. Viguera AC, Cohen LS, Baldessarini RJ, Nonacs R. Managing bipolar disorder during pregnancy: weighing the risks and benefits. Can J Psychiatry 2002; 47:426.
  14. Gentile S. Bipolar disorder in pregnancy: to treat or not to treat? BMJ 2012; 345:e7367.
  15. Bergink V, Bouvy PF, Vervoort JS, et al. Prevention of postpartum psychosis and mania in women at high risk. Am J Psychiatry 2012; 169:609.
  16. Gentile S. Antipsychotic therapy during early and late pregnancy. A systematic review. Schizophr Bull 2010; 36:518.
  17. Burt VK, Stein K. Treatment of women. In: The American Psychiatric Publishing Textbook of Psychiatry, Fifth Edition, Hales RE, Yodofsky SC, Gabbard GO. (Eds), American Psychiatric Publishing, Inc., Washington, DC 2008. p.1489.
  18. Frey BN, Macritchie KA, Soares CN, Steiner M. Bipolar disorder in women. In: Bipolar Disorder: Clinical and Neurobiological Foundations, Yatham LN, Maj M. (Eds), Wiley-Blackwell, West Sussex 2010. p.463.
  19. Newport DJ, Fernandez SV, Juric S, Stowe ZN. Psychopharmacology during pregnancy and lactation. In: The American Psychiatric Publishing Textbook of Psychopharmacology, Fourth Edition, Schatzberg AF, Nemeroff CB. (Eds), American Psychiatric Publishing, Inc., Washington, D.C. 2009. p.1373.
  20. Jain AE, Lacy T. Psychotropic drugs in pregnancy and lactation. J Psychiatr Pract 2005; 11:177.
  21. Deligiannidis KM. Therapeutic drug monitoring in pregnant and postpartum women: recommendations for SSRIs, lamotrigine, and lithium. J Clin Psychiatry 2010; 71:649.
  22. Goodwin FK, Jamison KR. Maintenance medical treatment. In: Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression, 2nd edition, Oxford University Press, New York 2007. p.797.
  23. Wesseloo R, Kamperman AM, Munk-Olsen T, et al. Risk of Postpartum Relapse in Bipolar Disorder and Postpartum Psychosis: A Systematic Review and Meta-Analysis. Am J Psychiatry 2016; 173:117.
  24. Galbally M, Snellen M, Walker S, Permezel M. Management of antipsychotic and mood stabilizer medication in pregnancy: recommendations for antenatal care. Aust N Z J Psychiatry 2010; 44:99.
  25. Gentile S. Drug treatment for mood disorders in pregnancy. Curr Opin Psychiatry 2011; 24:34.
  26. Cohen LS, Wang B, Nonacs R, et al. Treatment of mood disorders during pregnancy and postpartum. Psychiatr Clin North Am 2010; 33:273.
  27. Cummings C, Stewart M, Stevenson M, et al. Neurodevelopment of children exposed in utero to lamotrigine, sodium valproate and carbamazepine. Arch Dis Child 2011; 96:643.
  28. Baker GA, Bromley RL, Briggs M, et al. IQ at 6 years after in utero exposure to antiepileptic drugs: a controlled cohort study. Neurology 2015; 84:382.
  29. Goodwin GM, Consensus Group of the British Association for Psychopharmacology. Evidence-based guidelines for treating bipolar disorder: revised second edition--recommendations from the British Association for Psychopharmacology. J Psychopharmacol 2009; 23:346.
  30. Jentink J, Bakker MK, Nijenhuis CM, et al. Does folic acid use decrease the risk for spina bifida after in utero exposure to valproic acid? Pharmacoepidemiol Drug Saf 2010; 19:803.
  31. Smith LA, Cornelius V, Warnock A, et al. Effectiveness of mood stabilizers and antipsychotics in the maintenance phase of bipolar disorder: a systematic review of randomized controlled trials. Bipolar Disord 2007; 9:394.
  32. Weisler RH, Nolen WA, Neijber A, et al. Continuation of quetiapine versus switching to placebo or lithium for maintenance treatment of bipolar I disorder (Trial 144: a randomized controlled study). J Clin Psychiatry 2011; 72:1452.
  33. Cipriani A, Rendell JM, Geddes J. Olanzapine in long-term treatment for bipolar disorder. Cochrane Database Syst Rev 2009; :CD004367.
  34. Clark CT, Klein AM, Perel JM, et al. Lamotrigine dosing for pregnant patients with bipolar disorder. Am J Psychiatry 2013; 170:1240.
  35. Marangell LB. Current issues: women and bipolar disorder. Dialogues Clin Neurosci 2008; 10:229.
  36. Quiroz JA, Yatham LN, Palumbo JM, et al. Risperidone long-acting injectable monotherapy in the maintenance treatment of bipolar I disorder. Biol Psychiatry 2010; 68:156.
  37. Einarson A, Boskovic R. Use and safety of antipsychotic drugs during pregnancy. J Psychiatr Pract 2009; 15:183.
  38. McKenna K, Koren G, Tetelbaum M, et al. Pregnancy outcome of women using atypical antipsychotic drugs: a prospective comparative study. J Clin Psychiatry 2005; 66:444.
  39. Newport DJ, Calamaras MR, DeVane CL, et al. Atypical antipsychotic administration during late pregnancy: placental passage and obstetrical outcomes. Am J Psychiatry 2007; 164:1214.
  40. 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; 30:247.
  41. Kloos AL, Dubin-Rhodin A, Sackett JC, et al. The impact of mood disorders and their treatment on the pregnant woman, the fetus, and the infant. Curr Psychiatry Rep 2010; 12:96.
  42. National Institute for Health and Clinical Excellence. NICE clinical guideline 45. Antenatal and postnatal mental health: Clinical management and service guidance. April 2007 http://www.nice.org.uk/CG045 (Accessed on January 01, 2012).
  43. De Hert M, Detraux J, van Winkel R, et al. Metabolic and cardiovascular adverse effects associated with antipsychotic drugs. Nat Rev Endocrinol 2011; 8:114.
  44. Choong E, Bondolfi G, Etter M, et al. Psychotropic drug-induced weight gain and other metabolic complications in a Swiss psychiatric population. J Psychiatr Res 2012; 46:540.
  45. Yonkers KA, Vigod S, Ross LE. Diagnosis, pathophysiology, and management of mood disorders in pregnant and postpartum women. Obstet Gynecol 2011; 117:961.
  46. Bodén R, Lundgren M, Brandt L, et al. Antipsychotics during pregnancy: relation to fetal and maternal metabolic effects. Arch Gen Psychiatry 2012; 69:715.
  47. Gentile S. Pregnancy exposure to second-generation antipsychotics and the risk of gestational diabetes. Expert Opin Drug Saf 2014; 13:1583.
  48. National Institute for Health and Care Excellence (NICE). Antenatal and postnatal mental health: clinical management and service guidance. NICE clinical guideline 192. December 2014. http://www.nice.org.uk/guidance/cg192 (Accessed on August 27, 2015).
  49. Altshuler LL, Cohen L, Szuba MP, et al. Pharmacologic management of psychiatric illness during pregnancy: dilemmas and guidelines. Am J Psychiatry 1996; 153:592.
  50. Diav-Citrin O, Shechtman S, Tahover E, et al. Pregnancy outcome following in utero exposure to lithium: a prospective, comparative, observational study. Am J Psychiatry 2014; 171:785.
  51. Stewart DE, Vigod SN, Stotland NL. Obstetrics and gynecology. In: The American Psychiatric Publishing Textbook of Psychosomatic Medicine: Psychiatric Care of the Medically Ill, Second Edition, Levenson JL. (Ed), American Psychiatric Publishing, Inc, Washington, DC 2011. p.797.
  52. Janicak PG, Marder SR, Pavuluri MN. Principles and Practice of Psychopharmacotherapy, Fifth Edition, Lippincott Williams & Wilkins, Philadelphia 2011. p.367.
  53. 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; 162:2162.
  54. Menon SJ. Psychotropic medication during pregnancy and lactation. Arch Gynecol Obstet 2008; 277:1.
  55. Bulut M, Bez Y, Kaya MC, et al. Electroconvulsive therapy for mood disorders in pregnancy. J ECT 2013; 29:e19.
  56. Freeman MP. Bipolar disorder and pregnancy: risks revealed. Am J Psychiatry 2007; 164:1771.