Bipolar disorder (types I and II) affect up to 5% of the population in the United States. As the onset of this condition typically occurs during or before the reproductive years, the management of bipolar disorder in women is often complicated by pregnancy. There are concerns regarding fetal exposure to medication, the impact of untreated maternal illness, and data demonstrating that women are at increased risk for relapse during the postpartum period.
After last week’s post, we received several comments regarding the use of mood stabilizers in breastfeeding women, specifically asking which is safer: lithium or lamotrigine.
Women with bipolar disorder are vulnerable to postpartum illness, and it is generally recommended that mothers continue treatment with a mood stabilizer throughout the postpartum period to reduce their risk of relapse; however, this recommendation is complicated by the all mood stabilizers are secreted into the breast milk, although their concentrations appear to vary considerably (Chaudron and Jefferson, 2000).
There are strong parallels between the clinical management of bipolar disorder and epilepsy, and women with these disorders face significant challenges while pregnant or planning to conceive. In this setting, treatment decisions must balance the risks of recurrence of severe illness with the risks of potential harm to the fetus when certain medicines are taken during pregnancy.
A clinician asks: “I am a psychiatrist treating a patient with Bipolar Disorder on Seroquel and Topamax. I would like to know what information is available regarding the safety of these medications to the infant if used during breastfeeding.”
While anticonvulsants, such as lamotrigine (Lamictal), topiramate (Topamax), and gabapentin (Neurontin), are being used with increasing regularity for the treatment of women with bipolar disorder, we have limited information with respect to the reproductive safety of the newer anticonvulsant agents. In 2006, we reported on preliminary data indicating an increased risk of oral clefts among infants exposed to lamotrigine during the first trimester of pregnancy.
Women with bipolar disorder are at increased risk for recurrence of illness during pregnancy. Therefore, many women with bipolar disorder elect to continue treatment with medications during pregnancy after weighing the risks and benefits of various treatment options with their physicians. Lamotrigine (Lamictal) is an anticonvulsant used to treat bipolar disorder. While the safety data on this relatively new anticonvulsant in pregnancy is limited, pregnancy registry data suggests that lamotrigine may pose less of a risk to the developing fetus than with older anticonvulsants, such as valproate (Depakote). With lamotrigine emerging as an effective and relatively safe treatment for pregnant women with bipolar disorder, more attention is now being paid to the effects of pregnancy on lamotrigine levels.
There have long been concerns regarding the use of the anticonvulsant valproate (Depakote) during pregnancy. First trimester use of valproate has been associated with a 3-5% risk of neural tube defects, as well as an increased risk of other malformations affecting the heart, limbs, and genitals. A recent report published in the New England Journal of Medicine indicates that in utero exposure to valproate may also result in lower IQ.
Given recent discussions within our group and with our colleague, Lewis Holmes, MD, chief of the Genetics and Teratology Unit at Massachusetts General Hospital for Children and director of the North American AED (Antiepileptic Drug) Pregnancy Registry, I wanted to expand upon a previous blog post. In the initial post, I wrote that women who take certain medications, like mood stabilizers or antiepileptic drugs, are advised to take increased doses of folic acid before pregnancy and throughout pregnancy.
As many of the traditional mood stabilizers used to treat bipolar disorder, including lithium and valproic acid, carry some teratogenic risk and the reproductive safety of other medications, including the atypical antipsychotic agents, has not been well-characterized, many women with bipolar disorder decide to discontinue their treatment during pregnancy. A new study from Dr. Adele Viguera and her colleagues at the Massachusetts General Hospital and the Emory University School of Medicine helps to better define the risks associated with discontinuing treatment during pregnancy.
