Relapse of Bipolar Disorder During Pregnancy Increases Risk of Postpartum Illness

In planning for being pregnant, gals with bipolar dysfunction and their care companies are forced to make challenging options.  In the environment of medicine discontinuation, relapse charges are important, and there is proof that untreated psychiatric sickness in the mother is linked with even worse maternal and fetal results.  Having said that, numerous of the prescription drugs normally applied to take care of bipolar ailment, specifically lithium, have a modest but measurable raise in risk of teratogenesis.  The reproductive basic safety of other medicines, including atypical antipsychotic prescription drugs, is not properly characterised. These selections are further sophisticated by the paucity of knowledge regarding the training course of bipolar illness all through pregnancy.

A new examine from the United Kingdom seems to be exclusively at recurrence of illness all through being pregnant and the postpartum period in a group of women with bipolar condition.  This examine involved 128 women with DSM-5 bipolar problem (BD) who were recruited to the Bipolar Condition Investigation Network Being pregnant Study and had been adopted from 12 weeks of gestation to 12 months postpartum. Semi-structured questionnaires, supplemented with clinician interviews and evaluation of the professional medical record, were employed to assess for life time psychiatric historical past and psychiatric sickness all through being pregnant and the postpartum abide by-up.  

In this cohort, 98 gals had bipolar I ailment/schizoaffective-BD (BD-I team) and 26 bipolar II problem/other specified BD and relevant ailment (BD-II group).   The two groups were similar, whilst the gals in the BD-II team had earlier onset of illness and had a lot more recurrent depressive episodes than ladies with BD-I.  Details about the use of drugs through pregnancy was not reported.  About 40% of the women of all ages in every single group utilized a temper stabilizer all through the postpartum interval.   

• Perinatal recurrence of disease was typical in both equally teams: 57% (BD-I) and 62% (BD-II) experienced a temper episode during being pregnant. 
• Ladies with BD-I have been much more very likely to working experience mania/psychosis in the course of pregnancy than gals with BD-II (13.5% vs. %).
• Ladies with BD-I were extra very likely to knowledge mania/psychosis in just 6 weeks postpartum (23%) in contrast to ladies with BD-II (4%). 
• In girls with BD-I, mania/psychosis all through pregnancy was involved with a sevenfold greater risk of postpartum mania/psychosis (RR 7., p<0.001). 

 In women with BD-I, depression during pregnancy was associated with a threefold increase in risk of postpartum depression  (RR 3.18, p=0.023).

This study is consistent with previous reports suggesting that risk for perinatal recurrence of bipolar disorder is high, with approximately 60% of women with bipolar disorder (type I or II) experiencing recurrent illness during pregnancy and/or the postpartum period.  Also consistent with previous reports is the finding that depressive episodes are more common than mania in women with BD-I and BD-II however, mania/psychosis is much more common in women with BD-I than those with BD-II. (In this study, only one of the 26 women with BD-II experienced postpartum mania/psychosis.)

The Importance of Remaining Well During Pregnancy

Of great clinical significance is the observation that women who experience recurrent illness during pregnancy are more likely to experience illness during the postpartum period.  The highest risk was observed in women with BD-I in this study, women who experienced mania/psychosis during pregnancy had a sevenfold increased risk of experiencing postpartum mania/psychosis.  Overall, recurrence of illness during pregnancy (depression or mania) was associated with a twofold increase in risk for postpartum illness.  

It is clear that risk for postpartum psychiatric illness, including postpartum psychosis, is high in women with bipolar disorder.  Previous studies have demonstrated that risk for postpartum illness can be reduced significantly with the use of a mood stabilizer, such as lithium, during the postpartum period.  However, given the risks associated with the use of certain mood stabilizers during pregnancy, many women and their providers elect to discontinue mood stabilizers during pregnancy.  This study confirms previous studies documenting high rates of recurrent illness during pregnancy in women with bipolar disorder, but the findings of this study also suggest that the discontinuation of mood stabilizers during pregnancy may have significant implications for vulnerability to postpartum psychiatric illness.

In women with unipolar depression, relapse during pregnancy is a robust predictor of postpartum depression this study indicates that for women with bipolar disorder, recurrent illness during pregnancy, especially mania or psychosis, is a robust predictor of postpartum psychiatric illness. While certain mood stabilizers, including lithium carry some risk of teratogenesis, we need to weigh the relatively small risk of teratogenesis in mood stabilizers, excluding valproic acid, against the very high risk of recurrent illness during pregnancy in the mother. Avoiding medication during pregnancy and restarting it after delivery may not be the best option.  This study, and others, suggests that keeping the mother well during pregnancy will reduce the risk of postpartum psychiatric illness.

Ruta Nonacs, MD PhD

Perry A, Gordon-Smith K, Di Florio A, Craddock N, Jones L, Jones I. Mood episodes in pregnancy and risk of postpartum recurrence in bipolar disorder: The Bipolar Disorder Research Network Pregnancy Study. J Affect Disord. 2021294:714-722.