Prescription of Sodium Valproate as a Mood Stabiliser in Pregnancy

This essay was submitted for the Royal College of Psychiatry's perinatal psychiatry medical student essay prize in 2017. The essay considers the choices available to women with bipolar disorder who become pregnant while taking sodium valproate to treat mania or for mood stabilisation. The implications of three options are considered: to stop all treatment, to switch to a different mood stabiliser or to continue on sodium valproate. The implications for the fetus, on the mother's wellbeing and the ethics of patient choice are discussed.

Pregnancy can be especially challenging for women with bipolar disorder, predominantly because of the heightened probability of relapse, potential fetal harm caused by bipolar medication, and a 250-fold risk of puerperal psychosis compared to the general population. Sodium valproate is a known teratogen, and is discouraged in pregnancy, but what choice is open to women who rely on this medication to stabilise their mood?

The large majority of women of childbearing age with bipolar disorder should not be prescribed sodium valproate as the risks to the unborn fetus far outweigh the benefits of the medication, as other drugs have similar if not better efficacy to stabilize the mother's mood, with lower risks to the fetus. In the small minority of women for whom valproate may be the only effective treatment, she must be fully informed of the teratogenic and neurodevelopmental risks, as well as the ways in which the pregnancy can be managed to reduce such risks.