The treatment of bipolar disorder during pregnancy or in those women who wish to conceive poses a unique set of dilemmas with which clinicians should be familiar. Given the teratogenicity of some psychotropic medications used to treat bipolar disorder and incomplete reproductive safety data for agents frequently employed to manage the illness, patients and clinicians should collaborate as they weigh options regarding appropriate pharmacologic therapy during pregnancy. Ultimately, risk-benefit decisions are made that must factor in the risk of relapse of psychiatric illness during pregnancy and its attendant morbidity versus the risk of fetal exposure to these agents. No clinical decision is risk-free, and patients with comparable information about risks and benefits of treatment options may make different decisions. However, awareness of the latest reproductive safety data across the family of compounds used to treat bipolar disorder, including antipsychotics, antidepressants, mood stabilizers, and anticonvulsants, allows for the most informed decisions. This article (1) describes the treatment dilemmas faced by bipolar women who are either pregnant or who wish to conceive, (2) reviews the teratogenic risks associated with commonly used psychotropic medications used to treat the illness, and (3) provides some clinical guidelines for treating this population during pregnancy.