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Table 2 Foetal and maternal risks associated with selected mood stabilisers. Compiled from various sources [50, 53, 78, 79, 101,102,103,104,105,106]

From: Sodium valproate in pregnancy: what are the risks and should we use a shared decision-making approach?

Medication Risks to offspring associated with use in pregnancy Maternal risks associated with use in pregnancy
Lithium Severe toxicity in newborn. There are limited and conflicting data regarding the risk of cardiovascular malformations (including Ebstein’s anomaly) following lithium exposure in utero. A large cohort study in 2017 showed that the relative risk was still elevated (1.7), and also dose dependent, but lower than previously thought. Absolute risk remains low (< 1/1500).
Non-teratogenic associations include low birth weight, cyanosis, bradycardia, GI bleeding, polyhydramnios, seizures.
Renal lithium clearance rises during pregnancy, so levels need to be monitored regularly to maintain therapeutic levels.
Valproate Significantly elevates the risk of major defects (7 times higher). These include spina bifida, atrial septal defect, cleft palate, hypospadias, polydactyly and craniosynostosis. See Table 4 and main text for further details.
Non-teratogenic associations include case reports of intra-uterine growth restriction, infant hepatic toxicity and foetal distress during labour.
Neurodevelopmental associations – foetal exposure to valproate in utero is associated with 1.7 times risk of autism spectrum disorder.
Increased hepatic clearance of valproate and increased apparent volume of distribution cause lower maternal levels of the drug.
Carbamazepine Risk of major congenital abnormalities increased 1.8 times, including malformations of neural tube, urinary tract and cardiovascular system, and cleft palate. Crosses placenta and lowers maternal serum levels, so doses may need to be increased.
Lamotrigine Conflicting evidence on the risk of malformations, especially regarding dose response.
Evidence emerging that it appears to be a relatively safe drug in pregnancy.
Crosses placenta and lowers maternal serum levels, so dose may need to be increased. Dizziness, diplopia and ataxia have been reported following these dose increases in pregnant women.
Atypical antipsychotics Most do not appear to significantly increase malformation rate. Risperidone requires additional study. Crosses placenta and lowers maternal serum levels, so doses may need to be increased.