Medication Management for Pregnancy Planning in GAD and BPD2

Medication Use and Safety

The American Academy of Family Physicians recommends that if mood destabilization occurs during taper of aripiprazole, the medication can be reintroduced, but the goal should be minimizing polypharmacy exposure during pregnancy 1
Bupropion does not appear associated with major congenital malformations or significant adverse obstetrical outcomes, according to the American College of Obstetricians and Gynecologists 2, 3
Small absolute increases in left ventricular outflow tract obstruction and ventricular septal defects have been reported with bupropion use, but confounding by indication cannot be ruled out and other studies have not replicated these findings, as noted by the American College of Obstetricians and Gynecologists 2, 3
Possible increased risk for diaphragmatic hernia exists with bupropion use, though absolute risk remains extremely small given population prevalence, according to the American College of Obstetricians and Gynecologists 3
Two case reports of seizures in breastfed infants exist with bupropion use, but generally no adverse events are reported with breastfeeding, as reported by the American College of Obstetricians and Gynecologists 2, 3

The American Academy of Family Physicians recommends initiating 400 mcg daily of folic acid immediately if not already taking, continuing through first trimester to reduce neural tube defect risk by 75% 1
Higher doses of folic acid (4-5 mg daily) are reserved for women with specific risk factors, according to the American Academy of Family Physicians 1

Abrupt discontinuation of psychiatric medications can precipitate relapse, which poses greater risk to both mother and fetus than continued treatment, as noted by the American College of Obstetricians and Gynecologists 4, 5

The American College of Obstetricians and Gynecologists recommends continuing bupropion and venlafaxine at therapeutic doses rather than attempting discontinuation after pregnancy is established, and monitoring for adequate weight gain, blood pressure, and fetal growth throughout pregnancy 5
Consider intermittent use of medications only if daily functioning would not be severely impacted, though this is generally not recommended for mood disorders requiring continuous treatment, as reported by the American College of Obstetricians and Gynecologists 5

Both bupropion and venlafaxine are compatible with breastfeeding, though bupropion requires monitoring for infant seizures and venlafaxine for irritability or feeding difficulties, according to the American College of Obstetricians and Gynecologists 2, 3

Discontinue lithium at least 2-3 months before attempting conception to allow complete washout and stabilization on alternative mood stabilizers, as recommended by the American Academy of Family Physicians and other guideline societies 6, 7
Achieve optimal disease control before conception with pregnancy-compatible medications, such as those recommended by the American Academy of Family Physicians and other guideline societies 6, 7
Use reliable contraception during the medication transition period to avoid unplanned pregnancy exposure to lithium, as recommended by the Centers for Disease Control and Prevention and other guideline societies 7, 8
Postpone conception if active psychiatric illness is present until remission or low disease activity is achieved, as recommended by the American Academy of Family Physicians and other guideline societies 6, 7

The American Academy of Family Physicians recommends achieving optimal disease control before conception with pregnancy-compatible medications 6, 7
The Centers for Disease Control and Prevention recommends using reliable contraception during the medication transition period to avoid unplanned pregnancy exposure to lithium 7, 8
Perform frequent pregnancy tests once attempting conception to enable early medication adjustments, as recommended by the American College of Chest Physicians 9

Untreated maternal psychiatric illness carries significant risks, including increased risk of adverse pregnancy outcomes, poor prenatal care adherence, substance use, and postpartum complications, as noted by the American Academy of Family Physicians and other guideline societies 6
The risk-benefit analysis must weigh medication risks against the substantial risks of untreated illness, as recommended by the American Academy of Family Physicians and other guideline societies 6
Emphasize the importance of planned pregnancy to optimize medication regimen before conception, as recommended by the American Academy of Family Physicians, the Centers for Disease Control and Prevention, and other guideline societies 6, 7, 8

The National Comprehensive Cancer Network notes that SNRIs like venlafaxine appear to have minimal impact on tamoxifen metabolism, which is relevant context for medication interactions 10