At our clinic we have the opportunity to see patients at various stages of pregnancy. When we evaluate a patient while she is still in the planning stages, we may recommend changing medications to those that have a better studied safety profile during pregnancy and see how she does on those medications prior to conception. If that same patient came into our clinic for an evaluation, but was already pregnant, we may make different recommendations than if she was in the planning stages.

Many clinicians are especially concerned about the first trimester, the time when congenital malformations may occur. Even during this critical period, it is often recommended that the patient continue the medication she has done well on, given the risk of relapse associated with discontinuation of medications and the risk of changing to a medication that she has never taken before. This means that if a patient is already pregnant and is doing well, we often recommend staying on the current medication regiment, even if there is little safety information available during pregnancy on a particular medication.

There are some exceptions to this, of course. For instance, with some medications, such as valproate, there are studies to support a high risk of major malformations during the first trimester as well as data to suggest that valproate may be associated with cognitive and developmental adverse effects. In those cases, it may be best to switch to another mood stabilizer with a better-established safety profile, such as lithium or lamotrigine. In addition, if the patient is currently on a medication with little safety data in pregnancy but has done well on an alternate medication in the past that does have a more established safety profile in pregnancy, it may be recommended that the patient change to the former medication she did well on.

Before making any changes to a medication regiment during pregnancy, it is essential that each patient talk to her treatment provider, as each decision about using psychiatric medications in pregnancy should be made on a case-by case-basis.

Betty Wang, MD

Information on risk of relapse:

Cohen LS, Altshuler LL, Harlow BL, Nonacs R, et al: Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment. JAMA 295(5): 499-507, 2006

Viguera AC, Nonacs R, Cohen LS, et al: Risk of recurrence of bipolar disorder in pregnant and nonpregnant women after discontinuing lithium maintenance, Am J Psychiatry 157 (2): 179-184, 2000

Information on valproate:

Wyszynski D, Nambisan M, Surve T, et al: Increased rate of major malformations in offspring exposed to valproate during pregnancy, Neurology 64 (6): 261-265, 2005

Adab N, Kini U, Vinten J, et al: The longer term outcome of children born to mothers with epilepsy, J Neurol Neurosurg Psychiatry 75(11): 1575-1583, 2004