Treatment of bipolar disorder during and after pregnancy

Abstract

The treatment of bipolar disorder (BPD) in women is complicated by reproductive life events such as pregnancy and breastfeeding. This presents a clinical challenge to clinicians and patients who must balance risk of recurrent mood episodes against risks of potential teratogenic and adverse side effects of medications. It is important for the clinician and patient to develop an individualized plan of care during conception, pregnancy, delivery and postpartum to ensure maximum safety and minimal risks. Pregnant women with BPD have the same risk of mood episodes as women who are not pregnant. There is clearly an increased risk for the development of mood episodes in the postpartum period — approximately 22—50% of women with BPD will develop postpartum depression (PPD). Risk factors for PPD in women with BPD include having a family history of PPD and depressive symptoms during pregnancy, but this risk can be significantly reduced with prophylactic medications. The risk for postpartum psychosis (PPP) is also significant, and most cases occur in the first 3 days following delivery. Risk factors include a history of an index manic episode, positive family history, and sleep deprivation during delivery. Lithium is the first choice for mood stabilization during pregnancy for women with severe illness. The typical antipsychotics also appear to be relatively safe during pregnancy. Venlafaxine, bupropion, mirtazepine, and the tricyclic antidepressants also all appear to be relatively safe in pregnancy. Patients should be monitored carefully during pregnancy. As the pregnancy progresses physiologic changes occur that alter the excretion of drugs and drug levels may change significantly, necessitating dose adjustments. In addition, factors such as vomiting due to morning sickness must be taken into account. Postpartum, women should be closely monitored, in labor and delivery, and at home. Medication changes made during pregnancy may have to be reversed as physiology changes. If women choose to breastfeed, the pediatrician should be part of the clinical team. It is important to use a team approach when treating BPD during pregnancy. (PsycINFO Database Record (c) 2016 APA, all rights reserved)