The Use of Anti-Epileptic Medication in Women with Affective Disorders in Early and Late Pregnancy and During Breastfeeding

Valproate, carbamazepine and lamotrigine are used in psychiatry mainly for the treatment of bipolar disorder. Increasing evidence from studies in women with epilepsy indicate that valproate in higher doses is toxic to the susceptible fetus and can cause anomalies in several organ systems as well as widespread deficits in later cognitive development. This agent should not now be prescribed in psychiatry to women during the entire pregnancy and not to women with childbearing potential unless they use highly reliable contraception. Carbamazepine is associated with a relatively small increase in the risk of neural tube defects and together with the uncertainty about it's antidepressant and preventative efficacy in bipolar disorder it's use in pregnancy should be limited only to special cases who have a history of a particularly favourable therapeutic response to this agent but not others. Whether lamotrigine is associated with a small increase in oral clefts is at present uncertain but the absolute risk is relatively small. Breastfeeding is not contraindicated when women are prescribed valproate or carbamazepine. In contrast, the high serum levels of lamotrigine in breastfed infants and the theoretical risk of severe skin reactions has lead national guidelines to advise against breast feeding during medication with lamotrigine. Pregnancy does not protect from new episodes of bipolar disorder and the early postpartum period is an extremely potent trigger for recurrences. It is therefore essential that reproductive issues are discussed with premenopausal women with affective disorders and that preconception consultations are offered to women who plan a pregnancy. In many countries, advice in these complex situations is available from specialists in perinatal psychiatry.