To minimize risk to mother and child, the best type of conception is a planned conception. Some patients and their clinicians may feel comfortable attempting to taper off of medications prior to attempts to get pregnant and to see if the woman is at a phase of her illness that may be quiescent. Because of the severity of prior episodes, other women may feel that this will not be safe for them and will prefer to be put on the safest medication possible while attempting to get pregnant. Tapering off or transitioning to medications can be done in a thoughtful and conservative way if clinicians and patients are given the time. Often, however, patients will find that they are pregnant while on a medication and feel the need to abruptly discontinue their treatment. It is clear that an abrupt discontinuation of antimanic agents, at least of lithium, rather than a slow taper, is associated with an increased risk for relapse (14,15).
Clearly, the biggest concern is first-trimester exposure because this is the period associated with the highest risk for teratogenicity. Although second- and third-trimester exposure are not associated with teratogenic risks, they are potentially associated with other problems, including minor malformations and behavioral effects. Most of these risks are theoretical because, to our knowledge, there are no controlled data concerning the frequency of such effects in women treated with antimanic medications.
Compared with other antimanic agents, such as the anticonvulsants, lithium appears to be the least teratogenic and, therefore, has the greater relative safety in terms of teratogenicity when compared with divalproex sodium or carbamazepine. Additionally, data regarding lamotrigine suggest low risk for teratogenic effects. However, if a woman has had a poor antimanic response to lithium or lamotrigine in the past, switching to lithium—even though it may be safer from a teratogenic point of view—may actually put the woman at risk for relapse.
If a woman is to remain on carbamazepine or divalproex sodium in the first trimester of pregnancy, her infant will have an increased risk for neural tube defects. Therefore, using the lowest dose that may control her mood might decrease the risk for spina bifida. Lower maternal folic acid levels have been associated with neural tube defects (97). A higher dosage of folic acid (3-4 mg/d) should be prescribed for women on anticonvulsants in pregnancy, and close coordination of care between the psychiatrist and the obstetrician/gynecologist is recommended.
ECT is another option for patients who developed either a mania or depression in pregnancy, but for most patients this is not a first choice. There has been no indication that ECT is associated with any teratogenic effects (96). Therefore, ECT should presently be viewed as a safe and effective treatment for episodes of either mania or depression during pregnancy, especially for severe or life-threatening mood and psychotic episodes. When used in pregnant patients, ECT may pose fewer risks than untreated mood episodes or pharmacotherapy with a teratogenic agent.
Overall, little is known about the direct or indirect effects of nonpharmacological interventions on mania, and no controlled clinical trials have evaluated these strategies during pregnancy. Thus, a purely psychotherapeutic approach for treating mania in pregnancy is not recommended. Cognitive therapies aimed at preventing a manic episode have focused on increasing adherence to treatment with medication (98), improvement of social and occupational functioning, minimizing sleep deprivation (because sleep deprivation can precipitate mania) (3,16), improving other circadian rhythm patterns (99), and preventing relapse.
Cognitive-behavioral strategies may be extremely effective at treating the depressed phase of the illness. In a recent uncontrolled study using a modified version of interpersonal psychotherapy for 13 women with depression and pregnancy, all subjects responded with remission of their depressive symptoms (100). Thus, for bipolar depression in pregnancy, especially if the depression is mild, psychotherapeutic strategies may be an alternative to medication intervention (100).
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