A delicate balance: pregnancy with bipolar disorder

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. In fact, 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 25 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 changes a pregnant person experiences in their body may reduce the effectiveness of their bipolar medication. To maintain effectiveness, the dosage may need to be increased, perhaps significantly.

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 may be a factor, as well.

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 post-traumatic stress disorder (PTSD), 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 and should be avoided during pregnancy. 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.

Other medications, such as lithium, may be safer for some pregnant people. Still, lithium dosing should be monitored throughout pregnancy. Additionally, a fetal ultrasound is recommended between weeks 18 and 22 for all pregnant people. This can help provide parents and healthcare providers with information about the developing fetus.

Despite the availability of safer medications, some people might be tempted to stop their bipolar treatment altogether. But that's also risky, as there is a high risk of recurrence, as well as experiencing symptoms throughout pregnancy.

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—is to 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.