Bipolar and Pregnancy — MRCPsych Paper B MCQ
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Correct answer: A — Arrange specialist preconception review and gradually discontinue valproate before conception
Explanation lettering: C = shown as A · A = shown as B · B = shown as C · E = shown as D · D = shown as E
The correct answer is C. NICE CG192 states that a woman already taking valproate who is planning a pregnancy should be advised to gradually stop the drug because of the risk of fetal malformations and adverse neurodevelopmental outcomes after any exposure, and MHRA advises this must involve her specialist. Discontinuation is gradual and supervised, with any alternative individualised to her illness pattern and prior treatment response — no single replacement is mandated. Option A fails because continuing until pregnancy is confirmed guarantees first-trimester exposure, when malformation risk (about 1 in 9) and neurodevelopmental risk (up to 4 in 10) arise. Options B and E fail because neither lithium nor carbamazepine is a routine automatic substitute; carbamazepine is itself not recommended in pregnancy and lithium requires specific individualised risk counselling and monitoring. Option D fails because abrupt cessation and leaving bipolar I disorder untreated risks relapse, including perinatal mania or psychosis.
Reference: NICE CG192, Antenatal and postnatal mental health: clinical management and service guidance — Recommendations (valproate advice for women planning pregnancy), 2014 (updated 2020). https://www.nice.org.uk/guidance/cg192/chapter/recommendations