• 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.
• 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.

In depth

• For all women taking medication, immediately contact a psychiatrist to establish if drug treatment should be stopped.
• Refer urgently to a psychiatrist and specialist fetomaternal medicine service, for a risk assessment and further management, those women who are taking medication with a known teratogenic risk at the time of conception or in the first trimester (i.e. lithium, valproate, carbamazepine, lamotrigine, or paroxetine).
• Refer all other women to a psychiatrist for an assessment and a discussion of drug treatment.

In depth

• All pregnant women who have bipolar disorder and experience a depressive episode require referral or possibly admission.
• Admit urgently those women who are considered to be a danger to themselves or others.
• If admission is thought to be necessary but the woman refuses, see Compulsory admission.
• Refer urgently for specialist mental health assessment those women:
• For whom the degree of risk is increasing such that they are likely to become a danger to themselves or others.
• With severe depression.
• In a mixed episode.
• With rapid cycling.
• For all other women, arrange an appointment with a psychiatrist as soon as possible to discuss treatment options.
• Whilst awaiting specialist assessment, do not start or change treatment without specialist advice.

In depth

• All pregnant women with mania need referral or possibly admission. For more detailed management information, see Scenario: Known bipolar, hypomania or manic episode.

In depth

• Advise the woman not to breastfeed if she is taking lithium, a benzodiazepine, or lamotrigine.
• A selective serotonin reuptake inhibitor (SSRI) may be prescribed if an antidepressant is being considered, but not fluoxetine or citalopram.

In depth