Yes, many people with bipolar disorder can and do take medication during pregnancy. In most cases, staying on treatment is safer than stopping it. Women who discontinue mood stabilizers during pregnancy have a 71% chance of experiencing a mood episode, compared to 24% for those who remain on maintenance therapy. The key is not whether to treat bipolar disorder during pregnancy, but which medications carry the least risk and how to manage them carefully throughout each trimester.
Not all bipolar medications are equally safe during pregnancy. Some are considered reasonable options with close monitoring, while one in particular should be avoided entirely. The best time to think through your options is before conception, but even if you’re already pregnant, there are clear paths forward.
Why Stopping All Medication Is Risky
Bipolar disorder doesn’t pause during pregnancy. Hormonal shifts, sleep disruption, and the stress of pregnancy can actually trigger episodes. The 71% relapse rate for women off medication is a striking number, and those relapses carry their own risks to the pregnancy: manic or depressive episodes can lead to poor nutrition, missed prenatal care, risky behavior, substance use, and in severe cases, hospitalization. A depressive episode during pregnancy is also linked to preterm birth and low birth weight.
The postpartum period adds another layer of risk. Women with bipolar disorder face a significantly elevated chance of postpartum psychosis, a psychiatric emergency that typically requires inpatient treatment. Staying on a well-chosen medication through pregnancy and into the postpartum weeks is one of the most effective ways to prevent that outcome.
Medications to Avoid
Valproate (sold under brand names like Depakote) is the one bipolar medication that should not be used during pregnancy. The FDA has issued specific warnings based on evidence that children exposed to valproate in the womb scored 8 to 11 IQ points lower at age 6 compared to children exposed to other mood stabilizers. Valproate also substantially increases the risk of serious structural birth defects, particularly neural tube defects like spina bifida. If you’re currently taking valproate and planning a pregnancy, switching to a safer alternative well before conception is the standard approach.
Lithium: Lower Risk Than Once Thought
Lithium was long considered dangerous during pregnancy because of early reports linking it to a rare heart defect called Ebstein’s anomaly. More recent and rigorous research has put that risk in better perspective. A large study published in the New England Journal of Medicine found that cardiac malformations occurred in about 2.4% of lithium-exposed infants, compared to a baseline rate in the general population of roughly 1%. That’s a real increase, but far smaller than older estimates suggested.
The specific concern is with right ventricular outflow tract defects, which occurred in about 0.6% of lithium-exposed infants versus 0.18% of unexposed infants. To screen for these, a fetal echocardiogram is recommended for anyone who took lithium during the first trimester, when the heart is forming. For women whose bipolar disorder has been well controlled on lithium, continuing it through pregnancy is often the most stable choice, with the understanding that closer monitoring is needed.
Lithium levels also need careful tracking during pregnancy because blood volume increases substantially, which can dilute the drug’s concentration. Your prescriber will likely check levels more frequently and adjust your dose as needed, then reduce it back to your pre-pregnancy dose shortly after delivery.
Lamotrigine: A Common Choice
Lamotrigine is one of the most widely used mood stabilizers during pregnancy, particularly for women whose bipolar disorder involves more depressive episodes. It has not been associated with an increased risk of neural tube defects or major birth defects at the rates seen with valproate.
The challenge with lamotrigine is that pregnancy dramatically changes how your body processes it. In about 77% of women, the body clears lamotrigine up to 250% faster by the third trimester. That means the same dose you took before pregnancy may produce much lower blood levels as the months progress, potentially leaving you unprotected against a mood episode. The remaining 23% of women experience only a modest increase in clearance, so the effect varies.
Because of this variability, blood level monitoring is important. Most prescribers check lamotrigine levels at least monthly during pregnancy to decide whether a dose increase is needed. After delivery, clearance drops back to pre-pregnancy levels within about three weeks, so the dose typically needs to be tapered back down quickly to avoid toxicity. This postpartum adjustment is something to plan for in advance with your prescriber.
Women taking lamotrigine or any anticonvulsant mood stabilizer are advised to take 4 to 5 mg of folic acid daily, starting before conception and continuing through early pregnancy. This is roughly ten times the standard prenatal vitamin dose of folic acid and is intended to reduce the risk of neural tube defects associated with anticonvulsant medications as a class.
Antipsychotics During Pregnancy
Second-generation antipsychotics are commonly used in bipolar disorder, either alone or alongside a mood stabilizer. Their safety profiles during pregnancy vary depending on which one you take.
Olanzapine, clozapine, and quetiapine are grouped together as “high metabolic risk” antipsychotics. A large Swedish registry study found that women taking these medications during pregnancy had roughly 1.8 times the risk of developing gestational diabetes compared to untreated women, even after adjusting for body weight. Their infants were also more likely to be born large for gestational age, which can complicate delivery.
Other antipsychotics, particularly aripiprazole and risperidone, did not show the same increase in metabolic complications. If you’re taking one of the higher-risk antipsychotics and planning a pregnancy, it’s worth discussing whether a switch makes sense. If your condition is well controlled on quetiapine or olanzapine and switching feels risky, more frequent glucose monitoring during pregnancy can help catch gestational diabetes early.
Planning Before Conception
The ideal time to evaluate your medication is before you become pregnant. A preconception plan gives you and your prescriber time to make any switches, confirm that you’re stable on the new regimen, and establish a baseline that can guide dosing decisions throughout pregnancy.
Several factors shape the plan: how severe your episodes have been, how quickly you’ve relapsed after stopping medication in the past, how long you’ve been stable, and which medications have worked for you. For some people with milder illness and long periods of stability, a slow taper off medication before conception is reasonable, with a plan to restart at the first sign of relapse. For others, especially those with a history of severe mania or psychosis, staying on medication continuously is the safer path.
If a medication change is needed, it should be done gradually. Abrupt discontinuation of mood stabilizers is itself a relapse trigger. A slow taper also gives you time to see how you respond before the added vulnerability of pregnancy begins. Because conception timing is unpredictable, some women end up off medication longer than expected while trying to conceive, which increases their exposure to relapse risk.
Breastfeeding After Delivery
The postpartum period is the highest-risk window for mood episodes in bipolar disorder, so continuing medication after delivery is typically a priority. For many medications, breastfeeding is still possible with monitoring.
Lithium passes into breast milk at roughly 40 to 45% of the mother’s blood level. While it appears on some older lists of contraindicated drugs during breastfeeding, current guidance does not consider it an absolute contraindication for healthy, full-term infants, particularly those older than two months. The main caution is that anything causing dehydration in the infant (illness, hot weather, poor feeding) can impair the baby’s ability to clear lithium, so parents need to watch for signs of lethargy or poor feeding. Premature or medically fragile infants are at higher risk.
Lamotrigine also transfers into breast milk, but serious adverse effects in breastfed infants are rare at therapeutic maternal doses. Antipsychotics generally transfer at low levels. The decision to breastfeed while on bipolar medication is individual, balancing the benefits of breastfeeding and continued treatment against the specific drug’s transfer rate and the infant’s health.