Treatment for Bipolar Disorder in Pregnant Women

[BillrothI]

Hey Everybody -

Quick question regarding the psychiatry shelf:

What is the first-line treatment for women with bipolar I/II who plan on getting pregnant? I thought I remembered reading that it was haloperidol somewhere, but I can't find anything online that confirms that this is the first-line treatment.

If, for example, a woman is stable on lithium but plans on getting pregnant, do you taper her for a couple of weeks and then start another drug (haloperidol, atypical, etc.)? Or do you keep her on the lithium since Ebstein anomaly is relatively unlikely?

Thanks!

-Bill

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[KVBane]

According to up to date the first line treatment for bipolar pregnant patients is Lamotrigine (an anti-epileptic) or continuing the use of lithium if that is what the patient is currently well controlled on.

 

[Blitz2006]

Bump.

Also am interested in anyone else's views on this.

I read in the literature Haldol as well (since its the oldest). But what about the use of Lithium/Lamictal/Atypicals?

Thx,

 

[jrlob91]

Bump.

Also am interested in anyone else's views on this.

I read in the literature Haldol as well (since its the oldest). But what about the use of Lithium/Lamictal/Atypicals?

Thx,

Absolutely not lithium....

 

[Blitz2006]

Absolutely not lithium....

Well..new literature is showing that Lithium may not be as dangerous congenitally as we once thought..

MMS: Error

Lithium in pregnancy: the need to treat, the duty to ensure safety. - PubMed - NCBI
"Despite such concerns, lithium should still be considered the first-choice agent for treating bipolar disorder in pregnancy."

 

[DocWinter]

Onlinemeded will confirm that the L drugs Lamictal and Lamotrigene are 1st line therapy.
Not lithium and especially not Valproic acid

 

[Amygdarya]

Onlinemeded will confirm that the L drugs Lamictal and Lamotrigene are 1st line therapy.
Not lithium and especially not Valproic acid

Lamictal (brand name) and lamotrigine (generic) are the same drug.

 

[Saxappeal1]

Lamictal (brand name) and lamotrigine (generic) are the same drug.

I think he means Lamotrigine and Levetiracetam.

 

[Ismet]

I think he means Lamotrigine and Levetiracetam.

Keppra has been used off label for bipolar in some cases, it's not an approved treatment for bipolar. That won't be the right answer on the psych shelf.

If, for example, a woman is stable on lithium but plans on getting pregnant, do you taper her for a couple of weeks and then start another drug (haloperidol, atypical, etc.)? Or do you keep her on the lithium since Ebstein anomaly is relatively unlikely?

If their bipolar disorder is not severe, they can be tapered off of lithium prior to conception. It can be restarted after fetal organogenesis (my embryo knowledge is gone so I don't know how many weeks GA that is). ACOG guidelines indicate that if the woman had severe bipolar symptoms that are well controlled with lithium, it can be continued through pregnancy. The risk of the mother having severe mood effects and the consequences that come from that has to be weighed against the risk to the fetus.

The first line in pregnant women would be lamotrigine (Lamictal). If the woman is already stable on lithium and coming off of lithium would mean relapsing to severe mood changes, then continue the lithium after counseling her about the potential risks to baby. She'll need closer monitoring and fetal echos.

I did have a bipolar patient who was on Haldol during pregnancy, but that was because she had already failed Lithium and Lamictal. It wouldn't be the first answer I'd pick.

 

[Saxappeal1]

Ok it may not be right on the shelf but is it ok on the wards @Ismet

 

[Ismet]

Ok it may not be right on the shelf but is it ok on the wards @Ismet

I've never personally seen Keppra being used for Bipolar disorder but I am not in psychiatry.

 

[Amygdarya]

Well, I'm only an MS4 (going into psychiatry), but as far as I know, Keppra is not used for any psychiatric disorders. In fact, this is one of the top meds psychiatrists suggest to discontinue because of its inherent psych side effects (from psychosis to severe suicidality).
Keppra is fairly liberally used for seizure disorders because it's safer in terms of "medical" side effects like severe skin lesions, hepatitis, pancreatitis, thrombocytopenia etc. and in terms of teratogenicity compared to other antiepileptics. But it can produce severe psych side effects, and discontinuation helps.

 

[Saxappeal1]

Thanks

 

[Blitz2006]

Keppra has been used off label for bipolar in some cases, it's not an approved treatment for bipolar. That won't be the right answer on the psych shelf.



If their bipolar disorder is not severe, they can be tapered off of lithium prior to conception. It can be restarted after fetal organogenesis (my embryo knowledge is gone so I don't know how many weeks GA that is). ACOG guidelines indicate that if the woman had severe bipolar symptoms that are well controlled with lithium, it can be continued through pregnancy. The risk of the mother having severe mood effects and the consequences that come from that has to be weighed against the risk to the fetus.

The first line in pregnant women would be lamotrigine (Lamictal). If the woman is already stable on lithium and coming off of lithium would mean relapsing to severe mood changes, then continue the lithium after counseling her about the potential risks to baby. She'll need closer monitoring and fetal echos.

I did have a bipolar patient who was on Haldol during pregnancy, but that was because she had already failed Lithium and Lamictal. It wouldn't be the first answer I'd pick.

So if I have a patient stable on Lamictal, it is ok to continue during pregnancy?

 

[Ismet]

So if I have a patient stable on Lamictal, it is ok to continue during pregnancy?

From my understanding, yes. It's Category C but it doesn't have the risk of birth defects like the other mood stabilizers do. Out of all of them, it's the safest in pregnancy. And women can breastfeed while on Lamictal as well. A psychiatrist or OB/Gyn would be more knowledgeable about this, I just know it's safe to use from a peds/newborn standpoint and having newborn patients whose mothers were well controlled on Lamictal. I've seen an Ebstein's baby whose mom was on Lithium, but I've also seen (more) completely normal babies from moms on Lithium.