Acute mania in pregnancy on valproate
A 29-year-old woman with bipolar I disorder, 16 weeks pregnant, is brought by her husband because of 10 days of decreased sleep, pressured speech, grandiose plans to start a business, irritability, and the belief that her neighbours are recording her. She has been on sodium valproate 1000 mg/day and quetiapine 100 mg at night for 3 years, with good adherence. She had one previous manic episode at age 24 and no suicide attempts. She is not drinking alcohol or using drugs. Blood pressure 118/74, pulse 96, BMI 24. Lithium, renal function, thyroid function and liver enzymes are requested. Obstetric review shows a viable singleton pregnancy with normal findings so far. The patient says she will not stop valproate because 'it is the only thing that works,' and her husband is worried about the pregnancy. She is not imminently suicidal but is increasingly impulsive and has stopped attending work.
1. How do you assess risk and construct an acute medication plan that balances mania, pregnancy and the patient's preferences?
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This is a severe acute manic episode with psychotic features in pregnancy, and the first judgement is that valproate must not be continued. Valproate is associated with a substantial risk of major congenital malformations, including neural tube defects, and with neurodevelopmental harm. The patient's preference is important, but it cannot justify continuing a known teratogen when safer alternatives exist. Document the discussion carefully and involve the obstetric team.
Risk assessment should cover:
- Suicide and self-harm, impulsivity, driving, financial decisions, and risk to the fetus from falls or violence.
- Nutrition, hydration and sleep, because exhaustion worsens mania.
- Psychotic beliefs and the risk of acting on them.
- Safeguarding: the husband is supportive, but the patient should not be left with sole care of the fetus or other children if she is impulsive.
- Capacity for treatment decisions; mania may impair weighing of information, but capacity must be assessed, not assumed.
Medication plan: stop valproate, with obstetric and psychiatric coordination. Cross-taper to quetiapine, titrating to an effective antipsychotic dose, because it is relatively well studied in pregnancy and treats mania and psychosis. Lithium is an alternative or adjunct if quetiapine is insufficient, but requires baseline renal and thyroid tests, levels, hydration advice, and fetal monitoring; the absolute risk of cardiac malformation is small but real. Avoid starting valproate, carbamazepine or lamotrigine as a new mood stabiliser in this acute setting. Give folic acid, avoid abrupt discontinuation without cover, and consider ECT if she deteriorates, refuses medication, or becomes severely psychotic or catatonic. Admit her or provide intensive outpatient care with daily review until sleep and behaviour stabilise.
2. When would you consider electroconvulsive therapy, and what practical safeguards are needed in pregnancy?
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ECT is considered when the illness is severe, life-threatening or refractory to medication, or when medication cannot be used safely. In this case, indications would include worsening mania with psychosis, dangerous impulsivity, refusal of food or fluids, catatonia, or failure of adequately dosed quetiapine and lithium. Pregnancy is not a contraindication. ECT may in fact be safer than prolonged severe mania, dehydration or high-dose polypharmacy.
Before ECT, obtain obstetric and anaesthetic review, confirm gestational age and fetal viability, and document consent or the legal basis for treatment if capacity is impaired. Practical safeguards include:
- Left lateral tilt after 20 weeks to reduce aortocaval compression, with continuous maternal oxygen and monitoring.
- Fetal heart monitoring before and after sessions where feasible, especially after 20 weeks.
- Anaesthetic review for aspiration risk, reflux, airway changes and drug interactions.
- Hydration, antiemetics and thromboprophylaxis as indicated.
- Avoid unnecessary prolonged seizures; use the lowest effective stimulus and monitor seizure duration.
- Post-session obstetric review if there is pain, bleeding, contractions or reduced fetal movement.
The reasoning is that untreated severe mania carries substantial risk to mother and fetus, while ECT has a long safety record in pregnancy. The decision should be made by a multidisciplinary team and recorded with the alternatives considered. If she has capacity and refuses, the legal framework for treatment over objection must be followed rather than proceeding informally.
3. What postpartum plan would you put in place before discharge?
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The postpartum period is the highest-risk time for relapse in bipolar disorder, so planning should begin before delivery, not after it. The plan should include:
- Mood stabiliser strategy: quetiapine or lithium should be continued or restarted promptly after delivery, with doses and monitoring individualised. Valproate should be avoided if breastfeeding is planned because of infant exposure and uncertain long-term effects. If lithium is used, check maternal levels and renal function and discuss infant monitoring with paediatrics.
- Sleep protection: arrange night feeds and childcare support so that she has protected sleep. Sleep loss is a potent trigger for mania.
- Early warning signs: agree a written relapse plan covering reduced sleep, increased activity, irritability, grandiosity and suspiciousness, and identify who will call the team.
- Monitoring frequency: frequent contact in the first weeks, with rapid access to the perinatal team. Screen for postpartum psychosis and depression at each contact.
- Breastfeeding: discuss the risks and benefits of each drug rather than giving a blanket prohibition. Quetiapine is generally considered low-risk; lithium requires infant monitoring and specialist advice.
- Safeguarding: ensure the husband and family know not to leave the baby unsupervised if she becomes acutely unwell, and have a plan for emergency admission.
- Contraception and future pregnancies: discuss effective contraception and preconception planning, because another pregnancy requires a planned switch away from valproate.
The key judgement is that discharge without a perinatal relapse plan would be unsafe even if the acute mania improves.