How to approach bipolar disorder patients who plans pregnancy?

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 from medication to control the condition as well as high rates of premature mortality due largely to suicide but including also the effects of accidents, substance abuse, and general medical disorders. A common misconception is that pregnancy is protective against psychiatric symptoms. The majority of recent studies suggest that pregnancy is a period of substantial risk for recurrence with estimates of recurrence as high as 50%. Identifying and treating women prior to pregnancy might prevent negative outcomes. Illness history and reproductive safety of medications are the most important factors to consider when planning treatment. Factors associated with a higher risk of relapse during pregnancy include abrupt discontinuation of mood stabilizers, a history of four or more prior mood episodes, and prior intrapartum mood episode. Currently, a common clinical practice is to stop ongoing mood stabilizing treatment during pregnancy in order to avoid potential adverse fetal developmental effects and purported associated liability risk. However, some progress has been made lately in applying the limited information available to develop treatment guidelines for the clinical management of women with bipolar disorder during pregnancy. Women with more severe risk of relapse are recommended to continue medications. Medications used to treat BD (including valproate, carbamazepine, and lithium) are associated with increased risk of fetal anomalies and neurobehavioral abnormality. 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. Despite the dearth of data, folic acid supplementation (4 mg daily) is recommended to prevent neural tube defects for patients being treated with anticonvulsants. 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. The American Congress of Obstetricians and Gynecologist (ACOG), in an April 2008 Practice Bulletin, recommend that the use of valproate and carbamazepine during pregnancy should be avoided, when possible, particularly during the first trimester. They further recommend that a fetal echocardiogram should be considered in women exposed to lithium during the first trimester. Atypical antipsychotics are widely used in the treatment of BD; however, there are limited data about their use during pregnancy. High potency antipsychotics could be used if needed. In the other hand, in women with low risk of relapse, medication should be tapered slowly over the course of 6 weeks. It is also important to address the consumption of caffeine, nicotine, illicit drugs, and alcohol, as well as poor nutrition and the general level of stress and sleep deprivation. In conclusion, women of reproductive age with BD should be counseled that pregnancy is a time of substantial risk of relapse, particularly following discontinuation of ongoing mood stabilizing maintenance treatment. A relapse prevention and management strategy for bipolar disorder should be outlined before the patient attempts conception.