Bipolar Disorder in Pregnancy

Why bipolar disorder gets a different level of planning

NICE guideline CG192 on antenatal and postnatal mental health singles out bipolar disorder repeatedly. Recommendation 1.4.7 asks clinicians discussing treatment to take account of "the possibility of the sudden onset of symptoms of mental health problems in pregnancy and the postnatal period, particularly in the first few weeks after childbirth (for example, in bipolar disorder)".

That sentence is doing a lot of work. The risk profile in bipolar disorder is not evenly spread across pregnancy; it is concentrated in the days and weeks immediately after birth, when relapse can be rapid and severe. Everything else in the care plan follows from that fact.

The Royal College of Psychiatrists says the same in its patient information on planning a pregnancy: referral to a perinatal mental health service to see a perinatal psychiatrist is particularly important if you have had bipolar disorder, schizophrenia, postpartum psychosis or another psychotic illness. That is a named referral, not general advice to talk to someone.

Valproate: the clearest instruction in the guideline

NICE CG192 recommendation 1.2.3 and 1.4.27: do not offer valproate for acute or long-term treatment of a mental health problem in women or girls of childbearing potential, "unless other options are ineffective or not tolerated and the pregnancy prevention programme is in place".

Recommendation 1.4.28: if a woman is already taking valproate and is planning a pregnancy, advise her to stop the drug gradually "because of the risk of fetal malformations and adverse neurodevelopment outcomes after any exposure in pregnancy".

Recommendation 1.4.29: if a woman taking valproate becomes pregnant, stop the drug, for the same reasons.

NICE points to the MHRA safety advice on valproate throughout. This is the most restrictive medicines recommendation in the whole guideline and it is not a matter of clinician preference.

Lithium: not banned, but conditional

Lithium is treated differently, and more carefully, than valproate.

CG192 recommendation 1.4.33: "do not offer lithium to women who are planning a pregnancy or pregnant, unless antipsychotic medication has not been effective."

Recommendation 1.4.34: if lithium is nevertheless offered, the woman should know "there is a risk of fetal heart malformations when lithium is taken in the first trimester, but the size of the risk is uncertain", should know that lithium levels may be high in breast milk with a risk of toxicity for the baby, and should have lithium levels monitored more frequently throughout pregnancy and after birth.

NICE's own words, "the size of the risk is uncertain", are worth quoting to anyone who gives you a confident percentage.

Recommendation 1.4.35: if a woman taking lithium becomes pregnant, consider stopping the drug gradually over 4 weeks if she is well, while explaining that stopping "may not remove the risk of fetal heart malformations" and that there is a risk of relapse, "particularly in the postnatal period, if she has bipolar disorder". Both halves of that sentence matter. Stopping is not a risk-free choice.

Antipsychotics

CG192 recommendation 1.4.23 is comparatively straightforward: "if a pregnant woman is stable on an antipsychotic and likely to relapse without medication, advise her to continue the antipsychotic." Recommendation 1.4.26 says not to offer depot antipsychotics to a woman planning a pregnancy, pregnant or considering breastfeeding, unless she is responding well to a depot and has a history of non-adherence with oral medication.

Where medication is started in pregnancy, recommendation 1.4.12 asks clinicians to seek advice, preferably from a perinatal mental health specialist, and to "choose the drug with the lowest risk profile for the woman, fetus and baby, taking into account a woman's previous response to medication". No doses appear on this page; all of these are specialist prescribing decisions.

What a good plan actually contains

A perinatal mental health plan for bipolar disorder should be written down and should name:

• your medication decision and who reviews it, and when
• your early warning signs, in your own words, and who to contact
• what happens in the first two weeks after birth, including whether sleep will be actively protected in hospital and at home
• whether a mother and baby unit admission would be the plan if you became unwell, and which one
• who is watching for postpartum psychosis, which is a medical emergency

Sleep is not a soft factor here. Loss of sleep is a recognised relapse trigger in bipolar disorder, and a newborn guarantees it. A plan that does not mention sleep is incomplete.

Screening and follow-through

NICE guideline NG201 places mental health enquiry within routine antenatal care, and CG192 recommendation 1.4.2 asks for referral to a secondary mental health service, preferably a specialist perinatal service, for preconception counselling if you have a current or past severe mental health problem and are planning a pregnancy.

ACOG's 2023 clinical practice guideline on screening and diagnosis of mental health conditions in pregnancy and postpartum sets out the US equivalent, with structured screening at defined points. The underlying logic in both countries is the same: severe perinatal mental illness is detectable and treatable, and the failures are usually failures of follow-up rather than of diagnosis.

The NHS pages on bipolar disorder describe the condition and its usual treatments outside pregnancy, and are a reasonable thing to share with a partner or family member who will be part of your plan. They should be, because the people around you are often the first to notice a change.

If you are already pregnant and have stopped your medication

A significant number of people reach a page like this having stopped treatment on discovering a pregnancy, without telling anyone. If that is you, the useful action is not guilt but a same-week appointment. CG192 asks for advice to be sought from a perinatal mental health specialist when psychotropic medication decisions are being made in pregnancy, and the earlier that happens the more options remain open. Stopping abruptly is itself a relapse risk, which NICE names directly in its lithium recommendation, so an unplanned stop is a reason to be seen rather than a decision to defend.