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Treating Bipolar Disorder during and following pregnancy, including Postpartum Psychosis

The following treatment guidelines are meant as a reference tool, but are not intended as treatment advice or to replace the clinical decision-making process of psychiatrists or other health professionals who administer these treatments. In clinical practice there are often good reasons why treatment approaches differ from what is described here.

Safety information regarding the use of medications during pregnancy is a topic that tends to change rapidly. The Motherisk program is an online resource that provides up-to-date information on the safety of medications in pregnancy.

Planning for Pregnancy in Bipolar Disorder

Women with Bipolar Disorder who wish to become pregnant need to plan this carefully.  Many of the medications commonly used to treat Bipolar Disorder, such as Lithium, Valproic Acid and Carbamazepine, can cause serious congenital malformations to the developing fetus, and should be used only with extreme caution during the first trimester of pregnancy. The safety of other commonly used medications, like the Atypical Antipsychotics, remains largely unknown.

However, stopping one's medications, especially if this is done abruptly, can lead to a relapse of a Bipolar mood episode (Hypomania, Mania, Depressive or Mixed). Experiencing high levels of stress or a Major Depression during pregnancy also carries risks for the fetus, such as delivery complications and increased chances of developing mood disorders and metabolic disorders later in life (see here for further information).

Therefore, pregnancies in these cases need to be planned carefully so that any medications that are potentially harmful to a fetus can be stopped gradually, and choices can be made about what other treatments could be tried.

Planning a pregnancy also involves using effective birth-control methods at times when a pregnancy is not desired. This is especially important when medications with potential for serious harm to a fetus are being used, such as the ones mentioned above. In this regard, it is important to note that Carbamazepine, Topiramate and Lamotrigine may all interfere the with the effectiveness of oral contraceptive pills.

Treatment Options for Bipolar Disorder during Pregnancy

On the one hand, it is best to use the minimum amount of medication during the first trimester when the fetus organs are forming and there is the greatest risk that birth defects could occur. This is especially true regarding medications that are known to present serious risks to a developing fetus, namely Lithium, Valproic Acid and Carbamazepine.

On the other hand, women with Bipolar Disorder are at high risk of having a Bipolar mood episode (Hypomania, Mania, Depressive or Mixed) during the pregnancy, and having a Bipolar mood episode during pregnancy then increases significantly a woman's changes of having a Postpartum Psychosis following the delivery (see here for further information). For these reasons, it is often recommended for women with Bipolar Disorder to be on some form of medication treatment during the pregnancy [ref].

Medications that would seem to be somewhat safer in pregnancy would be the Atypical Antipsychotics and Lamotrigine. These medications are all classified as Category C, meaning that no controlled human pregnancy studies have been done but that these medications may have caused some adverse effects when used in very high doses in animal pregnancies [ref].

Keeping in mind these considerations, the treatment for a Bipolar mood episode (Hypomania, Mania, Depressive or Mixed) during pregnancy would follow the same guidelines as for regular cases [ref].

Treatment Options for Bipolar Disorder following Pregnancy

In the first few weeks following delivery, women with Bipolar Disorder are at risk for having a mood episode (Hypomania, Mania, Depressive or Mixed), which can include a Postpartum Psychosis. These are treated according to the standard guidelines for Bipolar Disorder [ref].

In women who have experienced past episodes of Postpartum Psychosis, but who have never experienced Bipolar mood episodes (Hypomania, Mania, Depressive or Mixed) at other times in their lives (other than during the postpartum period), the recommendation is to initiate prophylactic treatment with a mood stablizer such as Lithium immediately after delivery [ref].

Breastfeeding needs to be done with caution with most of the medications used for Bipolar Disorder. Olanzapine, Quetiapine, Valproic Acid and Carbamazepine may be safe for use in breastfeeding [ref].

 

Unless otherwise indicated, the above treatments strategies are based on the CANMAT Guidelines for the Management of Patients with Bipolar Disorder [ref, ref, ref].

 

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