Psychopharmacology in pregnancy and lactation

Examiners test whether you can counsel in absolute risks, name the landmark signals (Huybrechts, Patorno, EURAP/NEAD, Grigoriadis, Viguera), and run a continue / switch / stop / dose-adjust algorithm without ideology. This is the drug spine for every perinatal mood, bipolar, psychosis and CASC medication station.^[18][20][22]

Meet the patient — the corridor question that decides the viva

A 28-year-old with bipolar I sits in your clinic, white-faced, holding a positive pregnancy test. She is six weeks gone. She is on valproate 1000 mg and quetiapine 300 mg, well for two years since her last mania — and she has already stopped both tablets this morning because a search result told her to.^[2][11]

Every registrar's reflex on that ward round: panic. Every examiner's first question: "What do you do in the next ten minutes — and what do you not do?" This whole topic is the structured answer to that one stem.^[2][9]

The classic trap: panic-stopping everything on the positive test. Untreated bipolar illness in pregnancy is not the "safe default" the search result implied — it is a relapse risk with suicide, obstetric and infant-attachment consequences. The first move is always to reframe the question away from "stop or continue the tablet" toward "what does this mother need across the whole reproductive arc?"^[1][2][3]

References22ShowHide

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2. [2]Viguera AC, Whitfield T, Baldessarini RJ, et al. Risk of recurrence in women with bipolar disorder during pregnancy: prospective study of mood stabilizer discontinuation Am J Psychiatry, 2007.PMID 18056236
3. [3]Viguera AC, Nonacs R, Cohen LS, et al. Risk of recurrence of bipolar disorder in pregnant and nonpregnant women after discontinuing lithium maintenance Am J Psychiatry, 2000.PMID 10671384
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9. [9]Tomson T, Battino D, Bonizzoni E, et al. Dose-dependent risk of malformations with antiepileptic drugs: an analysis of data from the EURAP epilepsy and pregnancy registry Lancet Neurol, 2011.PMID 21652013
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11. [11]Meador KJ, Baker GA, Browning N, et al. Cognitive function at 3 years of age after fetal exposure to antiepileptic drugs N Engl J Med, 2009.PMID 19369666
12. [12]Meador KJ, Baker GA, Browning N, et al. Fetal antiepileptic drug exposure and cognitive outcomes at age 6 years (NEAD study): a prospective observational study Lancet Neurol, 2013.PMID 23352199
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17. [17]Grigoriadis S, Graves L, Peer M, et al. Pregnancy and Delivery Outcomes Following Benzodiazepine Exposure: A Systematic Review and Meta-analysis Can J Psychiatry, 2020.PMID 32148076
18. [18]Yonkers KA, Wisner KL, Stewart DE, et al. The management of depression during pregnancy: a report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists Gen Hosp Psychiatry, 2009.PMID 19703633
19. [19]ACOG Treatment and Management of Mental Health Conditions During Pregnancy and Postpartum: ACOG Clinical Practice Guideline No. 5 Obstet Gynecol, 2023.PMID 37486661
20. [20]Vigod SN, Frey BN, Clark CT, et al. Canadian Network for Mood and Anxiety Treatments 2024 Clinical Practice Guideline for the Management of Perinatal Mood, Anxiety, and Related Disorders Can J Psychiatry, 2025.PMID 39936923
21. [21]Bergink V, Rasgon N, Wisner KL Postpartum Psychosis: Madness, Mania, and Melancholia in Motherhood Am J Psychiatry, 2016.PMID 27609245
22. [22]Betcher HK, Wisner KL Psychotropic Treatment During Pregnancy: Research Synthesis and Clinical Care Principles J Womens Health (Larchmt), 2020.PMID 31800350