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Bipolar with Kids

Q. I have been diagnosed with bipolar disorder for almost 10 years now. I am currently using Depakote. I have a child who is now 7 years old. When I got pregnant, I was told to stop the lithium that I was on and that I needed to have ultrasounds up to the first 3 months to make sure my baby's heart was okay. I was told that I could go back on lithium after that time period.

The doctor I was seeing at the time didn't think I needed to be medicated for the duration of my pregnancy, only to find out that was a HUGE mistake. By the time I gave birth I was full blown into some type of mania.

In thinking back all along the pregnancy there were sure signs of a high. I never went back on any medications after I had my daughter again--another big mistake. I went through the usual cycle of feeling high and then the big crash. I was totally helpless and couldn't care for my daughter without the help of my family. I finally got back on my medications and have not had an episode since.

We are thinking about having a second child but I need to know how this can be avoided. Is there anything that can be done different? I'm scared to go off my medications. It's a huge risk and I don't want to feel that way again. On the other hand, my daughter had a traumatic birth and was in ICU for a while. I feel like I missed out on the best months of being a mother and a parent because of my illness. I don't want to jeopardize anything or anyone due to this illness. It would be better if I could stay on my medications for the whole pregnancy but I'm just not up to date on that. Can you offer any advice?

A. The situation you describe is a difficult one for many thousands of mothers with bipolar disorder. Of course, I can't tell you what you should do with your treatment--that's a matter for you and your doctor to discuss in detail. But I can give you some information that may put this in some perspective.

Maternal exposure to carbamazepine [Tegretol] and valproate [Depakote] in the first trimester (months 1-3 of pregnancy) is associated with markedly increased risk of neural tube (spinal cord) defects. Thus, with valproate, there is a 15-fold increase in the risk of spina bifida (split spinal cord), vis--vis rates in the general population (Burt & Hendrick, 1997). Folic acid supplementation may reduce, but does not eliminate, this risk.

Also, children exposed in utero to anti-epileptic drugs may exhibit long-term developmental problems. For these reasons, whenever possible, these drugs should be avoided during the first trimester. Defects in the heart (e.g., Ebstein's anomaly) are associated with first-trimester maternal use of lithium. The risk of Ebstein's anomaly is about 30 times higher than in the general public, but the absolute numbers are not that large-about 1 in 700 lithium-exposed infants, versus about 1 in 20,000 in the general population.

The risk of Ebstein's anomaly is greatly decreased after the first trimester, since the developing fetus's organs have already formed by then (though the brain is still developing). The condition of the fetus's heart can be monitored periodically using ultrasound, as you know. In patients with known bipolar disorder already receiving mood stabilizers, a slow tapering of mood stabilizers upon first learning of the pregnancy, with restoration of the medication in the latter stages of pregnancy, appear to reduce the risk of mood disorder recurrence.

Burt & Hendrick (1997) note that for bipolar women with a history of severe decompensation (psychological "break down") when not on mood stabilizers, medication may be needed throughout pregnancy. Indeed, a relapse of mania or major depression may pose a graver danger than the medication to both the mother and the fetus-for example, if the mother is unable to care for the infant or herself, becomes suicidal, etc.

In addition to traditional options such as lithium and divalproex, newer treatment options are becoming increasingly available, such as the atypical antipsychotic olanzapine for acute mania and the anticonvulsant lamotrigine for bipolar depression. These might represent alternatives to lithium or divalproex for the pregnant bipolar patient, and may not pose as high a risk of birth defects--however, our experience with these agents during pregnancy is still very limited. Hence, there are no guarantees.

Given the complexities of clinical management and the difficult risk-benefit issues that must be weighed, it's important for your psychiatrist to work closely with your primary care physician and/or obstetrician. Getting adequate psychotherapy both during and after any pregnancy would also be very important. If you would feel better getting a second opinion, don't be afraid to raise this with your psychiatrist. He or she could refer you to a specialist in this area, for a consultation. One such specialty consultation service is provided by the Perinatal and Reproductive Psychiatry Service, Massachusetts General Hospital, Harvard Medical School, Boston 02114, USA. They may also be able to refer you to experts in your area.

Finally, the National Depressive and Manic-Depressive Association (NDMDA) may be a good source of information and support, if you are not yet involved with this group. They can be reached at 800-826-3632. I hope things go well with your plans!

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July 2002

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