• Refer the woman to a psychiatrist for an assessment and discussion of drug treatment.
• Explain to the woman that the psychiatrist may advise her to:
• Stop drug treatment prior to trying to conceive, and to remain off it throughout the pregnancy.
• Stop drug treatment prior to conception, and to restart it either after the first trimester or immediately after birth.
• Remain on her current drug treatment throughout conception, pregnancy, and birth.
• Switch to another drug treatment prior to attempting to conceive.
• Explain that the strategy which is chosen will depend on her wishes, and on the advice of the medical team who need to balance the risks of undertreatment (e.g. relapse) with the risk of harming the unborn child by remaining on drug treatment.
• Discuss the likelihood that sleep and routine will be disturbed after the baby is born. Plan for practical support, from organizations such as SureStart and social services, after the baby is born so that the woman gets enough rest and sleep.
• Give general pre-conception advice (e.g. smoking and alcohol consumption), and prescribe folic acid.
• For more detailed information, see the CKS topic on Pre-conception - advice and management.

• The National Institute for Health and Clinical Excellence advises that if a woman with bipolar disorder is planning a pregnancy:
• She should normally be advised to stop taking valproate, carbamazepine, lithium, and lamotrigine, and an alternative prophylactic drug (such as an antipsychotic) considered.
• If she becomes depressed after stopping prophylactic treatment, psychological therapy (cognitive behavioural therapy) should be offered in preference to an antidepressant because of the risk of precipitating mania. If an antidepressant is used, it should usually be a selective serotonin reuptake inhibitor, but not paroxetine.

These recommendations are based on two published guidelines from the National Institute for Health and Clinical Excellence (NICE); Bipolar disorder: the management of bipolar disorder in adults, children and adolescents, primary care and secondary care [National Collaborating Centre for Mental Health, 2006] and Antenatal and postnatal mental health [National Collaborating Centre for Mental Health, 2007].

• Antipsychotics:
• There is some indication of an increased risk of fetal malformation (2.4%, that is 24 per 1,000) [National Collaborating Centre for Mental Health, 2007]. This risk may be related to the underlying illness (information on individual drugs is very limited). One small study (n = 151) found no evidence of increased risk. There is little evidence to distinguish between any first- or second-generation antipsychotics. The risk is thought to be considerably less than with other drugs used in the treatment of bipolar disorder.
• Lithium:
• Lithium is associated with an increased risk of fetal heart defects (risk raised from 8 in 1000 to around 60 in 1000) [National Collaborating Centre for Mental Health, 2007]. Rates of Ebstein’s anomaly in particular are raised from 1 in 20,000 to 10 in 20,000.
• Anticonvulsants:
• Carbamazepine is associated with an increased risk of neural tube defects (risk raised from 6 in 10,000 to around 20–50 in 10,000) and other major fetal malformations, including gastrointestinal tract problems and cardiac abnormalities [National Collaborating Centre for Mental Health, 2007].
• Lamotrigine is associated with an increased risk of oral cleft defect (risk estimated at nearly 9 in 1000).
• Valproate is associated with:
• An increased risk of neural tube defects (spina bifida and anencephaly; risk raised from around 6 in 10,000 to 100–200 in 10,000).
• Adverse effects on the child's intellectual development.
• Antidepressants:
• There are concerns about a possible increase in the risk of congenital malformations associated with prenatal exposure to selective serotonin reuptake inhibitors (SSRIs) in general, and more specifically with paroxetine. SSRIs taken after 20 weeks of gestation may be associated with an increased risk of persistent pulmonary hypertension in the neonate [National Collaborating Centre for Mental Health, 2007].
• Paroxetine should not be used in pregnancy. Two studies have suggested that in women taking paroxetine in the first trimester, the risk of congenital malformation may increase from 3% to around 4%, with an increase in risk from about 1% to 2% for congenital heart malformations [MHRA, 2005].
• Fluoxetine is the SSRI with most evidence of safety in pregnancy, and remains the first-line SSRI for use during pregnancy [NTIS, 2005].
• Tricyclic antidepressants, such as amitriptyline, imipramine, and nortriptyline, have lower known risks during pregnancy than other antidepressants. However they are more likely to be associated with precipitating mania.
• Benzodiazepines:
• Benzodiazepines should not be routinely prescribed for pregnant women, except for the short-term treatment of extreme anxiety and agitation. This is because of the risks to the fetus (e.g. cleft palate) and the neonate (e.g. floppy baby syndrome).
• Folic acid:
• All women should take folic acid prior to conception and during the first 12 weeks of pregnancy to reduce the risk of neural tube defects, but higher doses are recommended for women who are taking valproate or carbamazepine because of the higher risk of neural tube defects.