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Forum Name: Obstetrics

Question: Pregnancy and Bipolar Medications


 jmw278 - Wed Jul 28, 2010 12:18 pm

I am taking Lamictal and Celexa and I am wanting to have a baby. Is there anything I can take to replace these medications that are safe? I have tried several other medications but this combination is the only one that I've found to be effective. Thank you.
 Debbie Miller, RN - Thu Jul 29, 2010 12:32 pm

User avatar Hello,
Medications for bipolar disorder are some of the most difficult to deal with in pregnancy. As a general rule, we must weigh risks and benefits. It depends on how severe your symptoms are when deciding this ratio. If a woman is well-controlled with Lamictil, it would appear the benefits will outweigh the risks since bipolar can have serious negative consequences on the mother. It is important that her health be good in pregnancy.

We know it is important to treat depression since this is a known risk factor in pregnancy and the chances are very good that the medication will be fine. Celexa appears to be safe, but we can't say for absolute certainty since testing is done differently with pregnant women. Information is gathered and analyzed by teratology risk associations such as otispregnancy.org. We know that major depression is harmful, however.

There is a higher incidence of babies having a little more trouble transitioning after birth when their mothers took SSRI antidepressants but this appears to be something that disappears completely within the first two weeks of life and typically occurs for the first 3-4 days (if at all). These babies may require a little more special care for tremors, irritability and restlessness. We're talking about a pretty small risk to the baby (and only a few will even experience this at all). But, we must weigh this against the risks that come with maternal depression - difficulty bonding with the baby, taking care of herself and her family, substance use which sometimes is employed to try and deal with the bad feelings. If a woman needs an antidepressant, that need outweighs the potential problems to the baby which seem to be temporary and easily treated.

Most of the available information shows that exposure to citalopram (Celexa) during pregnancy does not increase the risk for birth defects over a background risk (all pregnancies have about a 3% birth defect rate).This should be a good choice to control the depressive side of the bipolar, but without a mood stabilizer (Lamictil), the manic side might be a greater problem. There have been conflicting reports about the safety of Lamictil (lamotrigine) but this is in part due to the relatively small numbers of women who have taken it while pregnant. Some reports have indicated an increased risk of oral cleft defects in babies born of mothers who took this during their first trimester but in small numbers it is hard to make an association. Other reports did not show such an increase. Some of the results were complicated by the fact that the mothers were being treated for seizure disorder rather than for bipolar and complications could be the result of the disease itself (seizure disorder in the mother) rather than the treatment (Lamictil).

It is likely that Lamictil is probably a better choice for a mother-to-be who needs it and who is effectively treated with it prior to pregnancy than some of the others such as Depakote (valproic acid) which has been shown to increase birth defect risks.

These are important issues to discuss with your health care provider. It is believed that there is a greater problem with psychiatric conditions not being treated in pregnancy rather than over-treatment since the providers often err on the side of caution (don't take anything in pregnancy just in case). In truth, the risks may be much greater for the mother, the baby and the family relationship when the condition is not treated. For mothers with mild depression, it may be worth it to try tapering off, but serious disorders really can't be left untreated.

Another common practice is to cut a dose in half, the theory being that the risk will be reduced. In fact this might be rendering the treatment useless, thereby exposing the fetus anyway, without therapeutic gain for the mother. If it is to be treated, it should be treated properly.

In your case, examining this before pregnancy, you will be able to decide if it's worth it to try going without your medications but if the results of that are usually serious for you, it just may not be worth it. One option would be to try going off the Lamictil now and possibly through the first trimester without it (with other therapy options in place instead such as seeing a counselor). If you feel you need to resume after the first trimester, you could perhaps do so upon the advice of your doctor with the starting gradual dosing. Typically the control is better when you are taking the therapeutic dose as prescribed on a regular basis and you should not go off your meds without consulting with a doctor to determine the best way to do so. This would probably not be ideal but it is one option you could discuss with your providers (both psych and OB).

Good luck and best wishes.

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