Relapse of Bipolar Disorder During Pregnancy Increases Risk of Postpartum Illness

In arranging for being pregnant, ladies with bipolar problem and their care suppliers are compelled to make challenging decisions.  In the setting of treatment discontinuation, relapse fees are considerable, and there is evidence that untreated psychiatric disease in the mom is related with worse maternal and fetal outcomes.  However, a lot of of the medicines generally utilised to handle bipolar disorder, exclusively lithium, have a small but measurable maximize in risk of teratogenesis.  The reproductive protection of other prescription drugs, such as atypical antipsychotic drugs, is not properly characterized. These selections are further more challenging by the paucity of data regarding the program of bipolar health issues all through pregnancy.

A the latest research from the United Kingdom appears to be like exclusively at recurrence of disease during being pregnant and the postpartum interval in a team of gals with bipolar condition.  This examine incorporated 128 women of all ages with DSM-5 bipolar ailment (BD) who had been recruited to the Bipolar Disorder Investigation Community Pregnancy Study and have been followed from 12 months of gestation to 12 weeks postpartum. Semi-structured questionnaires, supplemented with clinician interviews and review of the health-related history, have been utilized to evaluate for life span psychiatric background and psychiatric sickness for the duration of being pregnant and the postpartum stick to-up.  

In this cohort, 98 women had bipolar I problem/schizoaffective-BD (BD-I group) and 26 bipolar II condition/other specified BD and linked dysfunction (BD-II group).   The two groups had been equivalent, despite the fact that the girls in the BD-II group had earlier onset of disease and had far more regular depressive episodes than gals with BD-I.  Details relating to the use of remedies through pregnancy was not documented.  About 40% of the women of all ages in each and every group applied a temper stabilizer through the postpartum time period.   

• Perinatal recurrence of health issues was prevalent in the two teams: 57% (BD-I) and 62% (BD-II) knowledgeable a mood episode all through being pregnant. 
• Women of all ages with BD-I ended up far more possible to working experience mania/psychosis in the course of pregnancy than girls with BD-II (13.5% vs. %).
• Females with BD-I ended up a lot more probable to encounter mania/psychosis inside 6 months postpartum (23%) compared to women of all ages with BD-II (4%). 
• In gals with BD-I, mania/psychosis throughout being pregnant was related 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.