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Is it safe to conceive while on treatment for bipolar disorder?

Q: My 30 years old wife suffered from a state of depression seven years back when our daughter was born. I took her to a psychiatrist who prescribed medicines to control depression. She was diagnosed with bipolar disorder. She took the medication for a period of two years. After that the doctor told us to stop taking the medication. After stopping the medication, she was feeling alright for a few years. But the episode of depression recurred when her father died three years back. Then, we again consulted the doctor who asked her to continue the medication. Now, we are planning for another child. The doctor told us that she can stop the medication. Presently, my wife is taking Lamitor DT 100; Zipsydon 20 and Lithosun SR 400.

A:Please note that in patients suffering from bipolar mood disorder, risk of relapse after delivery is high. For women who have had long periods without relapse, the possibility of withdrawing treatment before conception and for at least the first 3 months (first trimester) of pregnancy should be considered. Also note that the mental health of the mother influences the fetal well being, obstetric outcome and child development. The challenge lies in balancing risks versus benefits. Please note that Lithium is associated with fetal heart risk and is secreted in high levels in breast milk, and is better avoided during pregnancy (particularly during first 3 months of pregnancy, a period when organs of the fetus are getting formed) and lactation. Lamotrigine may be associated with risk of cleft palate (9 in 1000 risk) in the fetus and in dermatological problems (S-J syndrome in infants if taken while breastfeeding). Zyprasidon may be associated with increase in the level of Prolactin hormone and thereby may reduce chance of conception. Zyprasidon has been assigned to pregnancy category C by FDA and animal studies have shown developmental risks and fetal structural abnormality.

However there are also case reports where Zyprasidon use during pregnancy in human has not been associated with any major risks. Guidelines suggest that mood stabilizers (including Lithium and anticonvulsant drugs including lamotrigine) should better be avoided. The guidelines also suggest that w.r.t pregnancy there is most experience with certain antidopaminergic drugs like trifluperazine, chlorpromazine. There is no clear evidence that olanzapine has teratogenic potential but the data are limited. If on Olanzapine, one needs to keep an eye on weight gain and blood sugar levels. Overall, medicines should be avoided in the first trimester of pregnancy. Sleep hygiene and peaceful environment help. In case of planning pregnancy, regular reviews with obstetrician as well as psychiatrist shall help. Prior to planning pregnancy, if a decision is arrived at in terms of stopping medication, then a careful taper is suggested rather than an abrupt withdrawal.

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