Bipolar Disorder, Pregnancy and Postpartum

Many people with bipolar disorder have healthy pregnancies and babies. Doing it well takes planning, ideally before conception, because the biggest danger is often not the medication but a relapse, especially in the weeks after birth. Stopping treatment abruptly when a pregnancy test turns positive is a common, understandable reaction, and it carries real risk. This page covers the planning side: preconception steps, the numbers on postpartum relapse, a sleep-protection plan, and what to know about valproate and lithium. Drug-by-drug detail lives on our psychiatric medication in pregnancy and breastfeeding guide.

First: do not stop your medication on your own

The evidence behind that advice is striking. A 2016 meta-analysis in the American Journal of Psychiatry pooled 37 studies covering 5,700 deliveries. Among women with bipolar disorder, postpartum relapse occurred in 66% of those who were medication-free during pregnancy, compared with 23% of those who used preventive medication. The authors concluded that continuing prophylactic medication during pregnancy "appears highly protective."

That does not mean every medication is right for every pregnancy. It means the decision should be a deliberate one, made with the people who know your history, rather than a sudden stop.

Why the postpartum period is the high-risk window

Pregnancy is not uniformly protective or uniformly dangerous, but the weeks after delivery stand out. In a UK study of more than 1,200 women with bipolar disorder, those with bipolar I had about a 50% risk of a major mood episode per pregnancy and postpartum period, and those with bipolar II about 40%. Episodes were more common after birth than during pregnancy, and most began within the first postpartum month. Mania and psychosis tended to start earliest.

In the 2016 meta-analysis, about 17% of women with bipolar disorder had a severe postpartum episode, such as mania or psychosis. A personal history of postpartum psychosis raises the risk further. Read the warning signs on our postpartum psychosis page so you and your support people can act fast if they appear.

A preconception checklist

Because many pregnancies are unplanned, the planning conversation is worth having whenever pregnancy is possible, not only when you are actively trying.

• Your history. How many episodes you have had, how severe, and what happened the last time medication was stopped or changed.
• Your current medication. Whether it is one you would want to stay on if pregnancy happened. If a switch is needed, making it months ahead, while you are well, is safer than switching in the first trimester.
• Contraception that actually works with your medication. Carbamazepine can make hormonal birth control fail, and birth control pills lower lamotrigine levels (see bipolar disorder in women).
• Stability first. Many clinicians prefer a stretch of stable mood before conception.
• Your team. Who prescribes, who provides obstetric care, and how they will share information.
• Partners and family. Who will know the warning signs and help with nights after delivery.

Valproate: the medication to plan around

Valproate (divalproex, Depakote) is the clearest case for planning ahead. Its FDA boxed warning describes major birth defects, especially neural tube defects such as spina bifida, and decreased IQ scores and neurodevelopmental disorders after exposure in the womb. The label says it should not be used to treat bipolar disorder in people who are pregnant or planning pregnancy unless other medications have failed or are otherwise unacceptable, and that anyone of childbearing potential who does take it should use effective contraception.

The 2023 VA/DoD bipolar guideline goes further, recommending against valproate, carbamazepine and topiramate for people of childbearing potential. In the U.K., NICE and the MHRA also advise precautions for men taking valproate around the time of conception; the current U.S. label does not include that warning, but regulators outside the U.S. advise caution. If you take valproate and could become pregnant, or are a man planning to father a child while taking it, raise it with your prescriber now, before a pregnancy.

Lithium and the Ebstein's question

Lithium's reputation in pregnancy comes from early registry reports linking it to Ebstein's anomaly, a heart defect. A 2017 study in the New England Journal of Medicine of more than 1.3 million pregnancies gave a clearer picture of the absolute numbers:

The risk was higher than in unexposed pregnancies and rose with dose, but the authors called it "smaller than had been previously postulated." For context, the general U.S. background risk of a major birth defect is 2% to 4%. The lithium label suggests fetal echocardiography at 16 to 20 weeks after first-trimester exposure. The VA/DoD guideline suggests that people stable on lithium who are or may become pregnant continue it at the lowest effective dose, with education and shared decision-making. No medication in pregnancy is risk-free; the comparison is always with the risk of relapse. Lamotrigine and other options are covered on the medication-by-medication guide.

Lamotrigine levels change in pregnancy

The lamotrigine label notes that physiological changes during pregnancy can lower lamotrigine levels, which return to pre-pregnancy levels after delivery. That means a dose that worked before pregnancy may need review during it, and again after the birth. This is a reason for regular contact with your prescriber in pregnancy, never a reason to change the dose yourself.

Build a sleep-protection plan before the birth

Sleep loss is a well-known trigger for mania, and Postpartum Support International lists prolonged lack of sleep among the risk factors for postpartum psychosis. Researchers also point to circadian disruption after birth as one likely trigger in women who are genetically vulnerable. Planning for sleep is therefore part of treatment, not a luxury. Decide these things before your due date:

1. Night coverage. Who takes at least one overnight feed so you get one protected block of sleep, ideally several hours in a row.
2. Feeding plan. If you are breastfeeding, whether pumped milk or formula will cover a night feed; discuss options with your OB, pediatrician and lactation support.
3. Visitors and hospital nights. Limits on late visitors, and a quiet plan for the first nights home.
4. Warning signs list. Your personal early signs (for example, not sleeping even when the baby sleeps, racing thoughts, unusual energy), shared with your partner or support person.
5. Early check-in. When your first postpartum mental health contact will be, and who calls whom if signs appear.

See sleep and bipolar disorder for routines that help outside the newborn period too.

Breastfeeding and postpartum depression

Whether a medication fits with breastfeeding depends on the specific drug, your baby's age and health, and your goals. That detail, including the free LactMed database, is on the pregnancy and breastfeeding medication guide. Depression after birth is more common than psychosis and is also treatable; see postpartum depression treatment.

At Willow & Stone

Willow & Stone provides outpatient, scheduled care and is not an emergency service. If you have bipolar disorder and are pregnant or thinking about pregnancy, care plans are discussed at your evaluation with Dr. Stacey Forbes, a board-certified psychiatric-mental health nurse practitioner. Talk with your prescriber and OB before making any change. The first visit is a 90-minute evaluation; insurance is accepted for Texas patients (coverage depends on the plan), and care outside Texas is direct-pay with a superbill. Learn about bipolar disorder treatment at Willow & Stone or read the complete bipolar disorder guide.

Common Questions

Sources & Further Reading

• Wesseloo R et al. Risk of postpartum relapse in bipolar disorder and postpartum psychosis: meta-analysis. Am J Psychiatry 2016
• Di Florio A et al. Perinatal episodes across the mood disorder spectrum. JAMA Psychiatry 2013
• Patorno E et al. Lithium use in pregnancy and the risk of cardiac malformations. N Engl J Med 2017
• DailyMed: Depakote (divalproex sodium) prescribing information, boxed warning
• DailyMed: Lithium carbonate prescribing information (2026)
• VA/DoD Clinical Practice Guideline: Management of Bipolar Disorder (2023)
• NICE CG185: Bipolar disorder: assessment and management (updated 2 Sept 2025)
• Postpartum Support International: Postpartum Psychosis

This article is general education, not a diagnosis or advice for your situation. Do not start, stop, or change a medication without talking to the clinician who prescribes it; stopping a mood stabilizer suddenly can trigger relapse.