A woman with bipolar I disorder is 8 weeks pregnant and was on lithium. Lithium was discontinued at 6 weeks due to teratogenicity concerns. She is now manic. Regarding restarting a mood stabiliser, which statement is most accurate?
- A Quetiapine (atypical antipsychotic) is a reasonable option for acute mania in pregnancy ✓
- B Valproate is the safest mood stabiliser to use in first trimester
- C Lithium can be resumed after the first trimester with careful folic acid supplementation
- D Carbamazepine is preferred over lithium in the second trimester
Explanation
Atypical antipsychotics, particularly quetiapine and olanzapine, are considered the safest treatment options for acute mania in pregnancy and are often used across all trimesters when a mood stabiliser is needed. Valproate is strongly contraindicated in pregnancy due to neural tube defects (up to 9% risk), neurodevelopmental toxicity (IQ reduction of ~7–10 points), and autism spectrum disorder risk. Lithium's Ebstein's anomaly risk is lower than previously estimated (~0.05% with first-trimester exposure) and it can be used in the second/third trimester with monitoring, but resumption after stopping during organogenesis requires careful risk-benefit assessment. Carbamazepine carries neural tube defect risk similar to valproate.
Reference: Kaplan & Sadock's Synopsis of Psychiatry, 11th ed.
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