Pregnancy and Bipolar Disorder

Many women who are bipolar and of childbearing years have the same questions. Mainly, "Can I be pregnant and still take my medications?" and "Can I pass this disorder to my unborn child?" 

 This article  will attempt to give you  up to date information available, and link you to some personal accounts. All of the personal accounts may not be positive, but you should hear both sides of the story from women who have actually gone through a pregnancy after being diagnosed with bipolar disorder. 

Let's talk about the technical things first.  Most of current articles indicate the same thing, there have not been enough controlled studies in many areas, especially on the effects of medication, on the developing fetus or the effects of being off of medication on the mother. 

In recent studies it has been shown that 1% to 3 % of the general population have bipolar disorder in one form or another. When either parent is bipolar, however, that risk increases to 15%.

 There are ongoing studies being done by the National Institute of Mental Health in Washington, D.C. at John's Hopkins University, Indiana University,  Washington University, and many others.  

In regards to being pregnant and taking medications, there are relatively few studies done on the newer medications that are in use currently, but, the information available suggests strongly that if at all possible, medications should be avoided in the first trimester of pregnancy, that is the first three months. This is the time that the fetus develops their internal organs like the brain, spinal cord, lungs, heart, liver, kidneys, intestines and stomach. For this reason, the following tips have been suggested: 

* Avoid unplanned pregnancies. Use a reliable contraceptive. Most congenital defects occur in weeks 4-10 of development, when the organ development is at a critical point. Medications like Carbamazepine, (tegretol), can also decrease the effects of contraceptive absorption, therefore, higher doses of contraceptive may be needed. 

* Before becoming pregnant, discuss the possibilities thoroughly with your psychiatrist and your gynecologist. They must both have a good understanding of your disorder and the effects of medication at different times of the fetal development, labor and delivery, postpartum and breast feeding issues. 

* If possible your medication can be titrated or slowly decreased until you are off the medication altogether. It is best to wait a one(1) month period as a safety zone between taking your last medication and trying to conceive. 

* Most medications are passed through the breast milk. Because of this, breast feeding issues must also be discussed with both the psychiatrist and neonatal (baby) doctor to weigh the benefits of both the mother and child if the mother is to continue medications or resume them after delivery. 

* Psychosis is the greatest risk of all to both the mother and the fetus. If the risk of returning episodes of extreme mania or depression increases, it is in the best interest of both the mother and the fetus to resume medications. Psychotic illness episodes in unmedicated pregnant women is four (4) times more common. Poor nutrition, hypersexual activity (increased risk of contracting a sexually transmitted disease such as HIV), refusal of prenatal care, impulsive decisions, feticide, and inability to cope with complications of pregnancy are the most common episode induced behaviors. 

In general, the risks of fetal complications have been shown to be lower than once thought, and if it has been deemed that the mother must continue medications for her safety and the safety of the fetus, then it far outweighs the risks of being unmedicated. 

Medications are put into categories as to how they affect the developing fetus.  Below is a list of those categories: (Thanks Dr. Phelps for these!!!)

Category A: Controlled human studies have demonstrated no fetal risk.

Category B: Animal studies indicate no fetal risk, but no human studies OR adverse effects in animals , but not in well-controlled human studies.

Category C: No adequate human or animal studies, OR adverse fetal effects in animal studies, but no available human data.

Category D: Evidence of fetal risk, but benefits outweigh risks.

Category X: Evidence of fetal risk. Risks outweigh any benefits.

Many of the medications taken for mental illness are in "Category C".  Again, however, many of the newer medications have not had complete studies done on human pregnancies.  Check out our medication search engine , towards the bottom of the page, to check on your specific medication questions.

According to Dr. Laura Miller, Assistant Professor of Psychiatry at the University of Illinois, many of the older studies done on pregnancy and psychiatric medications are flawed because they did not take into consideration the following factors: nutritional status of the mother, physical and emotional stresses during the pregnancy, maternal age and environmental factors such as exposure to toxic chemicals and smoking by the mother. 

Common side effects of psychiatric medications on pregnancy include, increase risk of miscarriage, increased risk of premature birth and increase risk of physical and behavioral malformations due to the effect many of the medications can have on the developing neurotransmitters (nerve endings). 

One of the better studied medications is lithium, and although it was once thought to be a significant risk in congenital heat disease, recent studies have shown that risk to be milder now at 4% -12%. 

This medication has also been shown to cause an increased incidence of hypothyroidism (low thyroid output) in the new born. This is usually corrected once the lithium leaves the newborn's system. 

In the fetus  diabetes insipidous has also occurred, which usually clears up when the medication is stopped or after delivery. 

Lithium must be reduced to 50% during labor to prevent fluid retention as well as fetal and maternal toxicity. If the mother develops any respiratory or breathing problems, the medication must be discontinued. 

It is best to monitor serum levels frequently and to keep the therapeutic levels of the medication low. It is also better to take more frequent lower doses of the medication to prevent high peak blood levels and maintain a constant level.

 It is imperative that the mother avoid alcohol consumption of any kind during the pregnancy when taking lithium. 

As stated before it is best for the mother to avoid lithium in the first trimester if possible. It is much safer in the second and third trimesters, in spite of this, if used just prior to delivery, newborns will tend to be lethargic and listless, have shown to have an irregular sucking and startle response and are often cyanotic (blue) due to the poor absorption of oxygen in the blood. 

These conditions improve in the postpartum period (after birth), as the lithium leaves the infant. 

If the mother chooses to breast feed, the newborn must also have lithium levels done on a frequent basis, as it is secreted in the breast milk. Dehydration in the infant must be avoided as the lithium blood levels could reach toxic levels very quickly. 

Depakote (valproic acid) and Carbamazepine (tegretol) have both been shown to cause an increase in neural tube defects by 4-6%, mainly spina bifida, (malformation of the spinal column), and should be avoided in the first trimester, they are safer in the second and third trimester. 

Both have been shown to affect the metabolism or body's use of vitamins as well. It is recommended that if these medications must be given during the second and third trimester that a folate, (Vitamin B group), vitamin supplement be given. 

If Carbamazepine is used then the mother should be given vitamin K in the last month of pregnancy and the newborn given a one time shot of vitamin K at birth.  Both Carbamazepine and Depakote may cause convulsions in the newborn, as a result of withdrawal, on the other hand, if the mother breast feeds, this risk is greatly reduced.  Both have been shown to be safer overall for the newborn  during breast feeding, nonetheless, blood levels on the newborn are necessary.

On a whole, it is very clear that much still needs to be discovered about medications in general and bipolar pregnancies.  Short term and long term effects on animal studies and humans taking certain medications have not been compiled.

In addition to this article, we invite you to read the personal stories of some of our members.  Click here to go to personal stories and site links related to pregnancy and bipolar disorder.

UPDATE:04/02/04;  NIMH has recently published a new medication pamphlet on medications for mental illness.  It includes pregnancy warnings and a comprehensive list of medicines.  Check it out at: 
http://www.nimh.nih.gov/publicat/medicate.cfm 

If you would like to include your pregnancy or post partum story please contact Bipolar World  at bipolarworld@yahoo.com .

Bibliography:

1.  Ed van Gent, Pieternel Kolling, Elise Knoppert-van der Klein  : PREGNANCY, MATERNITY AND THE MANIC DEPRESSIVE DISORDER  http://www.antenna.nl/lithium/englishweb/guidelines/pregnancy_s.html 

2.  Rita A. Suri, MD, Lori L. Altshuler, MD Viven K burt, MD Phd, Victoria Hendrick MD :  MANAGING PSYCHIATRIC MEDICATIONS IN THE BREAST-FEEDING WOMAN
http://www.medscape.com/Medscape.com/Medscape/WomensHealth/journal/1998/
v03.n01/wh3062.suri.html

3.  Dr Valerie Raskin : MEDICATION, PREGNANCY AND LACTATION
http://www.geocities.com/HotSprings/2265/medication.html