Maternal And Fetal Outcomes in Bipolar Disorder the Impact of Continuing Vs. Discontinuing Mood Stabilizers During Pregnancy
DOI:
https://doi.org/10.69980/ajpr.v29i1.888Keywords:
Bipolar disorder, pregnancy, mood stabilizers, lithium, recurrence, relapse, prospective cohort, Pakistan.Abstract
ABSTRACT
Background: The perinatal period presents a major clinical challenge for women with bipolar disorder (BD). Concerns about teratogenic risk often lead to the discontinuation of mood-stabilizing medications, potentially increasing vulnerability to severe mood episodes. However, prospective data on this risk-benefit trade-off, particularly in non-Western health care settings, remain limited.
Objective: To prospectively quantify the risk of mood episode recurrence during pregnancy in women with BD, comparing those who continued mood stabilizers with those who discontinued them around conception or in early pregnancy.
Methods: This prospective observational cohort study was conducted at Ayub Teaching Hospital, Abbottabad, Pakistan, from July 1, 2025, to November 30, 2025. Euthymic pregnant women aged 18–45 years with a DSM-5-confirmed diagnosis of Bipolar I or II disorder and gestational age ≤24 weeks were enrolled. Consecutive sampling was used to recruit 86 women, who were categorized according to treatment status at conception or during early pregnancy: 38 in the continuation group and 48 in the discontinuation group. The primary outcome was the first recurrence of a DSM-5-defined mood episode (depressive, manic, hypomanic, or mixed). Group comparisons were performed using chi-square and Fisher’s exact tests. Time to recurrence was analyzed using Kaplan-Meier survival curves and the log-rank test. Multivariable Cox regression was planned to identify independent predictors of recurrence.
Results: The discontinuation group had a significantly higher rate of unplanned pregnancies (64.6% vs 42.1%; p = 0.04) and greater baseline illness severity, characterized by a higher proportion of Bipolar II subtype (56.3% vs 31.6%; p = 0.02), longer illness duration (≥5 years: 66.7% vs 44.7%; p = 0.03), a history of rapid cycling (39.6% vs 18.4%; p = 0.03), and prior suicide attempts (33.3% vs 15.8%; p = 0.04). Lithium use was more common in continuers (52.6% vs 12.5%; p < 0.001). The cumulative incidence of any mood episode recurrence during pregnancy was significantly higher in the discontinuation group (62.5% vs 31.6%; p = 0.004), with the excess risk most pronounced in the first trimester (33.3% vs 7.9%). Kaplan-Meier analysis demonstrated a significantly shorter time to recurrence in the discontinuation group (log-rank test, p < 0.01).
Conclusion: Discontinuation of mood-stabilizing medication in early pregnancy is associated with a significantly higher and earlier risk of mood episode recurrence. These findings from a Pakistani cohort underscore the need for individualized preconception risk-benefit counseling and integrated perinatal psychiatric care, particularly for women with markers of greater illness severity.
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