Collaborative Management of Women with Bipolar Disorder During Pregnancy and Postpartum: Pharmacologic Considerations

Sheila Ward, CNM, MSN, PMHNP; Katherine L. Wisner, MS, MD

Disclosures

J Midwifery Womens Health. 2007;52(1):3-13. 

In This Article

Abstract and Introduction

Abstract

Bipolar disorder is a chronic condition characterized by periods of mania, depression, or mixed states (co-occurring mania and depression). The postpartum period is associated with a high risk for symptom relapse or intensification, which can be reduced with the use of medications. Abrupt discontinuation of these medications increases the probability of relapse, which is associated with high-risk behaviors, significant family dysfunction, and suicide. Drugs used to treat patients with bipolar disorder vary in teratogenic potential. Although first trimester lithium use is associated with Ebstein's anomaly, the risk was overestimated in the past. Valproate and its derivatives and carbamazepine are human teratogens. Lamotrigine does not negatively impact major reproductive outcomes, but the data are limited. Typical antipsychotic medications are relatively well studied and the data do not identify major morphologic teratogenicity. There are fewer studies of newer atypical antipsychotic medications, and registries have been developed to collect prospective data. Clinical management of bipolar disorder during pregnancy, postpartum, and lactation requires a careful balancing of maternal and fetal risks and benefits. Communication and careful comanagement between the obstetric and psychiatric team is essential when treating women with bipolar disorder during the reproductive years.

Introduction

Bipolar disorder, formerly known as manic depression, is a serious, recurrent psychiatric illness with an estimated lifetime prevalence of up to 4%.[1] Bipolar disorder is typically treated with antimanic agents, such as lithium, antipsychotic medications,[2] and anticonvulsants, all of which have potential risks for the fetus and significant side effects for the mother. Because of its relatively high prevalence during the reproductive years, managing bipolar disorder is a challenge for the woman and her obstetric health care professional who is collaboratively managing the treatment of the pregnant or postpartum woman with a mental health specialist. This paper will review important information for midwives who are comanaging the care of women with bipolar disorder; a discussion of primary management of pharmacologic therapy is beyond the scope of this paper.

Bipolar disorder is a spectrum disorder, with 4 major diagnostic subcategories. Diagnostic criteria are shown in Table 1 . Bipolar I disorder has a similar prevalence in male and female populations,[2] although bipolar II disorder and some subtypes (such as rapid-cycling) are more common in women.[3] Bipolar I disorder is characterized by at least one episode of mania, with or without a history of depression. A manic episode is characterized by at least 1 week of elevated or irritable mood accompanied by at least 3 additional symptoms from a list that includes inflated self-esteem or grandiosity, decreased need for sleep, pressure of speech, flight of ideas, distractibility, increased involvement in goal-directed activities or psychomotor agitation, and excessive involvement in pleasurable activities with a high potential for painful consequences.[3] If the mood is irritable (rather than inflated or expansive), at least 4 of the above symptoms must be present. Marked impairment in function or hospitalization must be associated with the episode. Mania may be associated with psychosis in which the patient experiences delusions (which are often grandiose), and visual and/or auditory hallucinations.[3]

Hypomania is a symptomatically mild form of mania in which a woman may enjoy a sense of well-being and experience optimal functioning and enhanced productivity. The same symptoms as mania are present and are observable by others, but the episode is not enough to disrupt normal functioning. Some women experience unusual irritability during periods of hypomania. Without proper treatment, hypomania can lead to mania or herald a period of ongoing mood instability.[4] Persons who have had only episodes of hypomania that alternate with depression have bipolar II disorder.[3]

Compared to episodes of depression in patients with unipolar disorder, depressive episodes in patients with bipolar disorder are more commonly characterized by psychomotor retardation, extreme lethargy, hypersomnia, and more suicidal ideation.[5] Women with bipolar depression often describe themselves as unable to get out of bed. Women with bipolar depression are more likely to exhibit weight gain, instead of weight loss, as is often seen in unipolar depression. Psychosis is more common in bipolar depression than in unipolar depression.[3]

Mixed episodes occur when manic and depressive symptoms exist together.[3] A woman may feel sad, hopeless, and suicidal while at the same time energized and irritable. Mixed episodes are more common among women,[3] and are often severe and impair daily functioning and relationships. A mixed episode can last from 1 week to several months and is generally followed by a depressive episode.[3]

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