Table 5 List of frequently asked questions and management options to support shared decision-making regarding valproate use for bipolar disorder before or during pregnancy
Frequently asked questions | Continuing the current dose of valproate | Lowering the dose of valproate | Discontinuing valproate | Changing to another medication |
|---|---|---|---|---|
What does it involve? | No change to medication or dose | Over a period of weeks to months, decreasing the amount of valproate | Over a period of weeks to months, gradually stopping valproate | Switching to a different medication (e.g. lamotrigine or an antipsychotic) |
What are the risks to me? | Usual side effects of valproate | Usual side effects of valproate, potential for relapse | Higher risk of relapse (depends on a variety of factors – discuss with your clinician), increased risk of puerperal psychosis | Risk of relapse if the other medication is not as effective as valproate; risk of new side effects |
What are the risks to my baby? | Congenital malformations (see Table 4) long-term developmental disorders (estimated one in 3) | Reduced risk of congenital malformations and developmental disorders (risk depends on the dose, discuss with your clinician) | Indirect risks, e.g. disinhibition from poorly controlled bipolar disorder (discuss with your clinician) | Some medications are much safer for your unborn baby (specifically lamotrigine, some antipsychotics) |
What are the benefits? | You are less likely to relapse or suffer from puerperal psychosis | Your unborn baby will have a lower risk of malformations than if you continue the full dose | Your unborn baby will have the same risk of malformations as the general population | If you can tolerate the new drug, you are less likely to relapse or suffer from puerperal psychosis; the other medication could have adverse effects |
Who would benefit most from this? | People with unstable bipolar disorder and frequent relapses who are not controlled on other medication or lower doses of valproate | People with bipolar disorder who are not controlled on other medication | People who have been stable off valproate and do not wish to take other medications during pregnancy | People who are stable on alternatives to valproate |