Treating bipolar disorder during pregnancy
Optimal outcomes require careful preconception planning, medication risk/benefit analysis
Lamotrigine concentrations in breast milk are highly variable.30 Lamotrigine is processed through glucuronidation, a process that is immature in neonates. One study found serum lamotrigine levels in infants were 23% to 33% of maternal serum levels and milk/plasma ratios were highly variable, ranging from 6% to 147%.30 Infants exposed to lamotrigine in breast milk should be monitored for rash and signs of thrombocytosis, and if clinically indicated, lamotrigine levels should be checked.30 Valproate has a low infant serum/maternal serum ratio; there are rare case reports of hepatotoxicity and thrombocytopenia. Although valproate can be reinitiated because of its lower breast milk concentration, it is not a drug of choice in reproductive-age women because of the many issues described above, including risks during pregnancy, PCOS, and effect on oral contraceptives.
Carbamazepine serum levels in breast-feeding infants range from 6% to 65%; hepatic dysfunction, sedation, and poor feeding have been reported in infants in rare instances.31
Historically, lithium has been considered incompatible with breast-feeding, but recent reports suggest with careful monitoring it may not be contraindicated. In 10 mother/infant pairs, lithium levels in breast milk and infant serum diminished over time, with no adverse neonatal effects.32 However, if an infant does breast-feed, it may be important to monitor thyroid-stimulating hormone, blood urea nitrogen-to-creatinine ratio, and ECG in both mother and infant, especially if the mother is taking high doses of lithium.
The safety of breast-feeding while treated with atypical antipsychotics is largely unknown. Case reports indicate low transmission of these medications into breast milk.28
CASE CONTINUED
Ms. M is admitted for psychiatric hospitalization because of worsening psychotic symptoms, poor self-care, and persistent thoughts of harming her baby. She agrees to restart aripiprazole, which is titrated to 20 mg/d. Breast-feeding is not pursued. She is discharged in 10 days after she no longer has thoughts of harming her baby, delusions, or psychotic or suicidal ideation. She and her family agree to close supervision by her family and outpatient follow-up.
Related Resources
- The Hospital for Sick Children. Pregnancy and breastfeeding resources. www.motherisk.org/women/pregnancyResources.jsp.
- U.S. National Library of Medicine. TOXNET toxicology data network. https://toxnet.nlm.nih.gov.
Drug Brand Names
- Aripiprazole • Abilify
- Asenapine • Saphris
- Carbamazepine • Equetro, Tegretol
- Gabapentin • Neurontin
- Iloperidone • Fanapt
- Lamotrigine • Lamictal
- Lithium • Eskalith, Lithobid
- Lurasidone • Latuda
- Olanzapine • Zyprexa
- Oxcarbazepine • Trileptal
- Quetiapine • Seroquel
- Risperidone • Risperdal
- Topiramate • Topamax
- Valproate • Depacon
- Ziprasidone • Geodon
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Acknowledgement
The authors would like to thank Natasha Barthel, BS, for her assistance with this article.
