Relapse of Bipolar Disorder During Pregnancy Increases Risk of Postpartum Illness

In arranging for being pregnant, females with bipolar problem and their care vendors are pressured to make difficult alternatives.  In the environment of medicine discontinuation, relapse prices are significant, and there is evidence that untreated psychiatric illness in the mother is linked with even worse maternal and fetal outcomes.  However, a lot of of the medicines generally utilized to treat bipolar problem, specially lithium, have a smaller but measurable increase in hazard of teratogenesis.  The reproductive protection of other remedies, such as atypical antipsychotic remedies, is not well characterized. These choices are further difficult by the paucity of details about the program of bipolar sickness all through being pregnant.

A new examine from the United Kingdom appears to be especially at recurrence of disease for the duration of pregnancy and the postpartum period of time in a group of girls with bipolar ailment.  This examine bundled 128 females with DSM-5 bipolar problem (BD) who have been recruited to the Bipolar Dysfunction Exploration Community Being pregnant Examine and were being adopted from 12 weeks of gestation to 12 months postpartum. Semi-structured questionnaires, supplemented with clinician interviews and review of the medical record, ended up utilised to evaluate for life span psychiatric background and psychiatric ailment for the duration of being pregnant and the postpartum adhere to-up.  

In this cohort, 98 girls experienced bipolar I ailment/schizoaffective-BD (BD-I team) and 26 bipolar II problem/other specified BD and relevant condition (BD-II group).   The two teams ended up related, although the women in the BD-II team experienced before onset of health issues and experienced more repeated depressive episodes than gals with BD-I.  Details relating to the use of medications for the duration of pregnancy was not described.  About 40% of the females in every single group utilized a mood stabilizer through the postpartum interval.   

• Perinatal recurrence of disease was common in each groups: 57% (BD-I) and 62% (BD-II) knowledgeable a temper episode throughout pregnancy. 
• Women with BD-I have been far more most likely to knowledge mania/psychosis throughout pregnancy than females with BD-II (13.5% vs. %).
• Girls with BD-I had been far more probable to practical experience mania/psychosis in 6 months postpartum (23%) in comparison to ladies with BD-II (4%). 
• In ladies with BD-I, mania/psychosis all through pregnancy was linked with a sevenfold amplified 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.