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Perinatal Bipolar Disorder
Communication and Considerations When Managing Pregnant Patients With Bipolar Disorder

Released: August 23, 2023

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Key Takeaways

When managing patients with bipolar disorder who are pregnant or planning to become pregnant:

  • There is no absolute set of instructions; each patient’s risk vs benefit profile should be individually considered.
  • Knowledge of psychotropic medications and their indications for each patient is important to help maintain psychiatric stability while avoiding teratogenic complications.
  • Collaboration with OB/GYNs is essential, as they will be taking the lead on most of the patient’s care.

General Guidance and Overarching Principles
As an overarching rule when treating patients with psychiatric needs, one must consider the patient’s gender assigned at birth and whether there is childbearing potential. If there is childbearing potential, the chance of pregnancy is critical in the medication decision-making process. From the initial visit, psychiatric healthcare professionals (HCPs) should be comfortable discussing birth control options and rationale with patients. As their care continues, HCPs need to be able to appropriately tailor their medication regimens should pregnancy become a consideration. Once pregnancy or family planning enters the picture, it is important to keep a cool head and consider individual risks vs benefits for treatment modifications—no 2 patients will require the same approach.

For this commentary, we will be focusing on pregnancy in the setting of bipolar disorder.

In my experience, upon hearing that a patient is pregnant, many HCPs become nervous about teratogenic effects and stop all medications—but this approach should not be taken without careful consideration for the risks and benefits. In general, we need to focus on stability to get the parent and child safely through the pregnancy. In consideration of the child, studies have shown that babies born to unmanaged patients often are born earlier—sometimes as early as 28-30 weeks—and therefore are more likely to have lower birth weight and additional complications that are compromising to brain development.

When making decisions about the patient’s care and medication regimen during pregnancy, it is important to take into account both the normal mood swings associated with normal hormonal changes in pregnancy and how the pendulum of the patient’s bipolar disorder swings. For example, if a patient swings high (toward mania), then the fetus might be exposed to “risky behaviors” such as alcohol and substance use, decreased rest, and lack of nutrition. If the patient swings low (toward depression), the parent may become suicidal or engage in self-harm, which is also incredibly dangerous to both the parent and fetus. 

Because there is no absolute answer regarding psychotropic medications in pregnancy, we must balance what we know about our patients’ disease history and behaviors against the risk of any medication changes.

Finding Out a Patient Is Pregnant: Initial Steps
If a patient presents with a suspected pregnancy, I send them immediately for testing, especially if a medication that is preferred in pregnancy already is being used. It is important to act quickly: “Stat” results return within a few hours. Having verified lab results can avoid potential unnecessary medication changes or allow HCPs to make medication changes in a more timely manner.

If the patient is indeed pregnant and deciding to proceed with the pregnancy, the ideal scenario would be to cease medication, but this is not an option in a patient with bipolar disorder or psychosis. To facilitate better care for the parent and baby, it is essential to have an open line of communication with the obstetrician or caring HCP. Without collaboration, the OB/GYN may not know the extent of the patient’s psychiatric history and may agree to discontinue medications. It is best to speak directly to OB/GYNs in complex cases; this is key in preventing miscommunication. In my clinical experience, some patients will minimize their psychiatric experiences or presentations to HCPs and agree to stop medications if they feel that would be of benefit to their fetus. Now, sometimes the OB/GYN will not want to follow your recommendations regarding medication; you can provide strong rationale and education with respect to your insight into the patient’s mental status and reasoning behind the recommendations being made. Ultimately, however, this is under the discretion of the OB/GYN team. However, keeping that line of communication open allows OB/GYNs to feel comfortable reaching out to you if they need guidance on medication adjustments.

In addition to collaborating with the OB/GYN, it is important to consider having a therapist or behavior specialist in place for these patients as they proceed through pregnancy. This becomes integral if the decision is made to titrate medications during pregnancy, as this additional support person can help patients manage their mood symptoms with nonpharmacologic strategies to complement and potentially decrease the medication dose.

Now let’s consider a different scenario. Many people do not know they are pregnant for a few months. What should we do if they come into the appointment and tell you they are 3 or 4 months pregnant, and they have been stable on risperidone—a known teratogenic agent—for that entire time period?

Aside from the above overarching principles and necessary collaboration with the OB/GYN, in this scenario it would be important to arrange a fetal echocardiogram or three-dimensional ultrasound as soon as possible to assess for complications such as spina bifida and cardiac abnormalities. Again, when advising patients, it is important to consider individual factors. For example, the prospect of raising a child with spina bifida looks very different to a 14-year-old patient vs a 37-year-old patient. Either way, they need to know what they are facing with this pregnancy, and fetal testing is necessary to inform future decisions.

Considerations for Family Planning
Some patients are aware that bipolar disorder has a genetic component and may ask for advice about family planning before becoming pregnant. The way your answer is presented can really scare a person out of having children, so I do my best to be realistic and rational—staying away from a “doom and gloom” tone about the possibility of passing bipolar disorder on to their child.

Patients may say to me point-blank: “Listen, we want to have kids. Is my kid going to have bipolar disorder?” I typically answer them with a question: “If we were talking about diabetes or attention-deficit/hyperactivity disorder, would you be asking the same question?” Let’s normalize bipolar disorder the same way that any other medical diagnoses are considered. I tell them that just like diabetes is insulin dysregulation, bipolar disorder is dopamine dysregulation. In addition, I tell them that if their child develops bipolar disorder, it can be treated—and treated well—and they can be the advocate to make sure their child is seen and treated earlier.

Your Thoughts?
Managing patients with bipolar disorder throughout pregnancy can be complex, and it is important to weigh the individual risks and benefits of medication changes for each patient. In addition, a strong line of communication with the providing OB/GYN can help promote health and safety for the parent and child. Do you feel comfortable collaborating with OB/GYNs and other HCPs for patients with bipolar disorder during pregnancy? Answer the polling question and let us know why in the comments.

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How comfortable do you feel collaborating with OB/GYNs and other HCPs for patients with bipolar disorder during pregnancy?

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