Bipolar disorder presents special challenges to women of childbearing age as well as to their families and clinicians. Problems include lower fertility rates, strong genetic loading, and potential fetal teratogenic risks as well as high risks of illness recurrence if treatment is discontinued abruptly (1–10). It is noteworthy, however, that family planning issues for women with bipolar disorder have received scant research consideration (1, 4). Pregnancy poses several clinical dilemmas, and evidence-based guidelines for the clinical care of this population remain very sparse. Extensive clinical experience suggests that women with bipolar disorder are often counseled to avoid or terminate pregnancy in order to avoid risks of potential fetal exposure to psychiatric medications or risk of recurrent illness.
Mood stabilizers, including valproate, carbamazepine, and lithium, are associated with teratogenic risks (2, 7). First-trimester exposure to lithium probably increases the risk of cardiac malformations, notably Ebstein’s anomaly, by several-fold, from a baseline risk of 0.005% (1 in 20,000 live births) to a risk ranging from 0.05% to 0.1% (1 in 2,000 to 1 in 1,000 live births) (2). Compared with lithium, anticonvulsants such as carbamazepine and valproic acid may pose even greater risks, including high rates (1%–5%) of neural-tube defects such as spina bifida as well as craniofacial anomalies, cardiac anomalies, microcephaly, and growth retardation (3, 10). Reproductive safety information about other, newer agents used to treat bipolar disorder remains very limited, leaving lithium as a plausible first-line option, especially during mid-to-late pregnancy (3, 10). Concern about teratogenic risks associated with the standard mood stabilizers can lead to incomplete consideration of the major risks associated with recurrences of bipolar disorder illness during pregnancy. These risks include not only the particularly high risk of early relapse after interruption of ongoing treatment but also the higher risk for postpartum recurrence as well as the impact of untreated psychiatric illness on the development of the fetus (1, 3, 6, 7, 10).
Although there are no empirically based treatment guidelines for the management of bipolar disorder during pregnancy, substantial progress has been made with improved information on the reproductive safety of psychotropic drugs used to treat bipolar disorder and a better understanding of the course of the disorder and the risks of recurrence during pregnancy and the postpartum period. Increasingly, women with bipolar disorder who wish to conceive seek preconception consultation to better understand the risks and benefits of treatment options (10). This report describes the family planning decisions made by patients with bipolar disorder after preconception consultation by a reproductive psychiatry subspecialty service in a major medical center.