Relapse of Bipolar Disorder During Pregnancy Increases Risk of Postpartum Illness

In scheduling for pregnancy, women of all ages with bipolar ailment and their treatment vendors are forced to make hard alternatives.  In the environment of treatment discontinuation, relapse charges are significant, and there is evidence that untreated psychiatric sickness in the mother is linked with even worse maternal and fetal results.  On the other hand, many of the medicines generally made use of to take care of bipolar condition, specially lithium, carry a modest but measurable raise in chance of teratogenesis.  The reproductive safety of other remedies, including atypical antipsychotic medicines, is not properly characterised. These choices are additional complicated by the paucity of info concerning the course of bipolar disease for the duration of pregnancy.

A current research from the United Kingdom appears specially at recurrence of sickness through being pregnant and the postpartum time period in a team of women of all ages with bipolar condition.  This research involved 128 females with DSM-5 bipolar problem (BD) who had been recruited to the Bipolar Disorder Investigate Community Pregnancy Examine and have been followed from 12 weeks of gestation to 12 weeks postpartum. Semi-structured questionnaires, supplemented with clinician interviews and assessment of the health-related record, ended up used to assess for life span psychiatric heritage and psychiatric illness for the duration of pregnancy and the postpartum follow-up.  

In this cohort, 98 females experienced bipolar I problem/schizoaffective-BD (BD-I group) and 26 bipolar II disorder/other specified BD and linked condition (BD-II team).   The two teams have been similar, though the ladies in the BD-II team experienced earlier onset of health issues and experienced far more recurrent depressive episodes than women of all ages with BD-I.  Data concerning the use of remedies for the duration of being pregnant was not claimed.  About 40% of the women in each and every group utilized a mood stabilizer throughout the postpartum interval.   

• Perinatal recurrence of ailment was common in both groups: 57% (BD-I) and 62% (BD-II) skilled a temper episode throughout pregnancy. 
• Ladies with BD-I were far more most likely to encounter mania/psychosis in the course of being pregnant than women with BD-II (13.5% vs. %).
• Women with BD-I were being a lot more likely to experience mania/psychosis inside of 6 months postpartum (23%) as opposed to gals with BD-II (4%). 
• In girls with BD-I, mania/psychosis during pregnancy was linked with a sevenfold enhanced chance 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.