There was a time when women with bipolar disorder were advised not to get pregnant. If you have bipolar disorder, I do not need to tell you it is a difficult disorder to live with. Pregnancy and caring for a baby will not make it any easier. But, pregnancy is no longer out of the question. Bipolar disorder peaks from age 12 to 36, prime years of pregnancy. Many women with bipolar disorder do get pregnant and have safe pregnancies. [1,2]
The key to a safe pregnancy is balancing the risk of taking medications against the risk of untreated bipolar disorder wreaking havoc on your pregnancy. To manage this balancing act, you need help from your pregnancy care provider and your psychiatrist. [1-4] If you can find one, a perinatal psychiatrist is a great doctor to have on your team. 
The Risk of Bipolar Medications During Pregnancy
Bipolar disorder cannot be cured or controlled with psychotherapy alone, although it can help. You need medications to control the disease. The big problem is the risk of birth defects. Bipolar medications include mood stabilizers, antidepressants, and antipsychotics. The goal of treatment is to control acute episodes of mania or depression and prevent relapse. All these medications have been linked to birth defects, but the evidence is sparse. Some are much safer than others. The risk is still there, but it is small. [1-4]
The Risk of Untreated Bipolar Disorder During Pregnancy
Some studies suggest untreated bipolar disorder may increase the risk of having a premature baby or a small, underweight bay. More importantly, there is strong evidence that women who stop medication during pregnancy are much more likely to suffer a relapse during pregnancy. An acute bipolar episode increases the risk for substance abuse, smoking, lack of prenatal care, and a host of risky behaviors that could be devastating during pregnancy. [1-4]
Untreated bipolar disorder in the period after birth is even more risky than during pregnancy. The risk is for postpartum depression and post-partum psychosis. These conditions could put a woman in a situation where she is a danger to herself and her baby. [1-2]
How to Balance the Risks
The best time to start is before pregnancy. Make a plan with your psychiatrist and your primary care doctor. There is no one-size-fits-all plan. Bipolar disorder affects each woman differently. If you are stable, but need to be on medications, your doctors may suggest changing to medications that have the lowest risk of birth defects. That way you don’t have to stop your medication suddenly when you get pregnant. [1,2]
If you have had a recent relapse, you may want to delay pregnancy until you are more stable.
If you are very stable, your doctors may decide to let you go off medications for a while to see how you do. The first trimester of pregnancy is the time for highest risk of a birth defect. They may try to keep you off medication during this time. 
Here are some other basics to keep in mind: [1,2]
- Lithium is a mood stabilizer that has been linked to heart defects in babies, but recent evidence suggests that this risk is much smaller than once though. This is an effective drug with very low risk.
- Lamotrigine is an antiseizure drug that has a good safety profile in pregnancy and can work as a mood stabilizer.
- If you have depression, SSRI anti-depressants are often used during pregnancy with a good safety record.
- Atypical antipsychotic medications are another bipolar drug used in pregnancy.
- If you find out you are pregnant and you are on any bipolar medication, do not stop the drug suddenly on your own. This can causes a quick relapse. Talk to your doctors and start a plan.
- Your doctors may suggest higher than normal doses of the pregnancy vitamin folic acid. This vitamin may help protect against birth defects if you need to be on a bipolar medication.
- Even if you do not have a diagnosis of bipolar disorder, let your doctor know if there is a history of bipolar disorder in your family. Bipolar runs in families, especially if your mother or father were bipolar. Pregnancy may be a trigger for a new diagnosis. Let your doctor know about symptoms like moodiness, sadness, loss of interest, trouble sleeping, irritability, unusually high energy, racing thoughts, or risky behaviors.
- If your doctors let you go off medications, let your doctors know right away if you have any symptoms of a relapse.
- Be aware of the dangers of post-partum depression or psychosis after pregnancy. Let your doctors know about symptoms like fear of harming your baby, fear of other people harming your baby, confusion, delusions, or paranoia. Let your health care providers know any time you feel you may be a danger to yourself or your baby.
- Two non-medication options may be used as last resorts in the unlikely event that bipolar disorder gets out of control during pregnancy. Electroshock therapy can be effective. It can also be done safely during pregnancy. If you are really struggling, a hospital admission to get you into a safe place where your symptoms can be managed might be considered.
After pregnancy, you need to weight the risks and befits of breastfeeding. The danger of birth defects from medications is over, but all the bipolar medications pass through breast milk and the effects on your baby are unpredictable. You should consider that breastfeeding on demand is exhausting. Stress and lack of sleep are known triggers for bipolar episodes. Breast-feeding is possible, but you may consider the option of bottle-feeding. 
Finally, although psychotherapy does not prevent bipolar symptoms, it can help you manage them. Working with a therapist with or without medications is a good idea. Pregnancy and bipolar are challenging enough alone. Get as much help as you can from friends and loved ones. Use your support system. You can have a healthy pregnancy and a healthy baby, but don’t try to do it alone. [3,4]
- Drug, Healthcare and Patient Safety, Treatment of bipolar disorders during pregnancy: maternal and fetal safety and challenges.
- Psychiatry Advisor, Pregnancy and Bipolar Disorder.
- Black Dog Institute, Bipolar disorder treatments during pregnancy and the postnatal period.
- MGH Center for Women’s Mental Health, Worse Pregnancy Outcomes in Women with Bipolar Disorder.
- MGH Center for Women’s mental Health, Breastfeeding and Psychiatric Medications.