A Delicate Balance: Pregnancy with Bipolar Disorder

Learn why the mental health condition presents pregnant people with unique challenges, and why it's critical to keep an open dialogue with a healthcare provider.

pregnant woman taking pill

Updated on January 11, 2023.

Pregnancy can be a time of excitement and joy. But for pregnant people with bipolar disorder, it can also present unique, potentially dangerous challenges, such as the risk of recurrence, as well as adverse effects from medication.

One 2018 study published in the British Journal of Psychiatry examined relapse, interviewing 887 women with bipolar disease who had children. Researchers found that 55 percent of those who had bipolar episodes during their first pregnancy relapsed during their second pregnancy. Another 31 percent relapsed during their second pregnancy, even though they didn’t have any episodes during the first pregnancy.

And, as recently as 2000, healthcare providers (HCPs) actually warned people with bipolar disorder not to have children at all.  

There are reasons to be cautious, but compared to just 20 years ago, medical experts understand much more today in terms of which bipolar medications may be affected by pregnancy, how to adjust dosing, and how to monitor your mental health during pregnancy and after birth. 

Medication levels and pregnancy

The physiological changes a pregnant person experiences may reduce the effectiveness of their bipolar medication. One 2018 study published in the Obstetrics and Gynecology Clinics in North America looked at the blood concentrations of mood-stabilizing drugs. Researchers found that lamotrigine (Lamictal) levels dropped due to the increased metabolism that comes with pregnancy, noting that the dosage may need to be doubled or even tripled to maintain proper levels. Similarly, they found that doses of lithium and some second-generation antipsychotics may also need to be increased during pregnancy.

Inadequate medication levels put people at higher risk of manic and depressive episodes while they’re pregnant, and especially during postpartum. In fact, childbirth itself can lead to relapse, due to hormone shifts and other bodily changes that take place. Complications during birth and may be a factor, as well. One 2022 review of nearly 4,000 women across 16 studies in the Journal of Clinical Medicine found that almost 37 percent of those diagnosed with bipolar disease relapsed after giving birth.

The implications here are vast. People with bipolar disorder who become pregnant and have depressive episodes may not be able to care for themselves at the level required to have a healthy baby. They are likely to have poorer nutrition and could be less likely to comply with prenatal care. They may isolate themselves from the support of friends and family. And depression in pregnant people has also been linked to lower birth weights and poorer birth outcomes overall.

A delicate balancing act

Pregnant people on medication for bipolar disorder also have to consider the health of their fetus, as some medications can pose risks.

Valproate (Depakote) increases the risk for neural tube defects like spina bifida and impaired cognitive development. Sedatives such as lorazepam (Ativan), sometimes used to treat anxiety or insomnia in bipolar patients, have been linked to withdrawal symptoms such as hypothermia, respiratory depression, and hypotonia (floppy infant syndrome). Both of these medicines are passed through breast milk, as well.

Even though other medications are safer in pregnancy—lithium, for example—some people might be tempted to stop their treatment altogether. But that's also risky. The same 2018 study in Obstetrics and Gynecology Clinics in North America showed that people who discontinue their bipolar meds before and during pregnancy have a 71 percent risk of recurrence. They also contend with bipolar symptoms through a much larger part of their pregnancy, and those who quit their medications suddenly are especially vulnerable to relapse.

Healthy parent, healthy family

So, is it possible to have a safe pregnancy with bipolar disorder?

Yes, but the most important thing for people who are pregnant—as well as new parents—to do is continue working with your HCP. Keep the dialogue open. Tell your provider as soon as you become pregnant—or, even better, before—so that you can work together on adjusting your medications and dosages, if necessary. And, most importantly, never take yourself off of your treatment program without the recommendations of your obstetrician and mental health provider.

Article sources open article sources

Di Florio A, Gordon-Smith K, et al. Stratification of the risk of bipolar disorder recurrences in pregnancy and postpartum. Br J Psychiatry. 2018;213(3):542-547. 
Clark CT, Wisner KL. Treatment of Peripartum Bipolar Disorder. Obstet Gynecol Clin North Am. 2018;45(3):403-417. 
Prakash C, Hatters-Friedman S, Moller-Olsen C, North A. Maternal and Fetal Outcomes After Lamotrigine Use in Pregnancy: A Retrospective Analysis from an Urban Maternal Mental Health Centre in New Zealand. Psychopharmacol Bull. 2016 Aug 15;46(2):63-69.
Conejo-Galindo J, Sanz-Giancola A, et al. Postpartum relapse in patients with bipolar disorder. J Clin Med. 2022;11(14):3979. 
U.S. Food & Drug Administration. FDA drug safety communication: children born to mothers who took Valproate products while pregnant may have impaired cognitive development. Published June 30, 2011. Last reviewed February 8, 2018.
U.S. Food & Drug Administration. Ativan. 2016. Accessed December 19, 2022.
U.S. Food & Drug Administration. Depakote. 2011. Accessed December 20, 2022.

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