The management and treatment of psychotic exacerbations of manic-depressive illness during the last six months of pregnancy are discussed and guidelines are given. The author notes that such concerns are covered only superficially in most standard references. The acutely psychotic pregnant patient presents a therapeutic dilemma that has been overshadowed by the attention to teratogenic effects of psychotropic drugs. To date there are no controlled studies on the efficacy of different therapeutic modalities during pregnancy. Citing a case example, the author says second- and third-trimester treatment designs must primarily consider the perinatal aspects of pharmacotherapy in the mother and fetus rather than teratogenicity.