Bipolar disorder occurs in childbearing women and onset of symptoms may be during pregnancy or after the birth of a baby.
This may be a first episode or the continuation or relapse from an episode prior to the pregnancy. Symptoms are the same as those that occur with bipolar disorder at other times; however, the treatment required may vary when a woman is pregnant or breastfeeding. The focus of fears and depressive concerns can be the wellbeing of the baby or feelings of inadequacy as a parent.
Women with a history or a family history of bipolar disorder are at increased risk of an episode occurring during pregnancy and after childbirth and they need to be monitored closely for early symptoms. They also have an increased risk of puerperal psychosis*. Once a woman has experienced one episode of bipolar disorder or a puerperal psychosis* the risk of another episode is as high as 50-90%.
Prevention of relapse is an important aspect of the antenatal and postnatal care of women. Relapse is common if a woman discontinues her medication without medical advice. If an episode cannot be prevented then early identification and treatment is desirable to minimize the impact of the disorder on mother and baby.
Bipolar disorder has a genetic component so when one parent has bipolar disorder there is a 10% chance that their child will develop the illness. This possibility rises to 40% if both parents are affected.
*Puerperal (postpartum) psychosis is a very rare, but severe mental health condition that is experienced by one or two in 1,000 women in the weeks after having a baby. Puerperal psychosis is very serious as the mother may be at risk of self-harm and there is risk of potential harm to the baby and/or other children.
TREATMENT ISSUES FOR BIPOLAR DISORDER IN PREGNANCY AND THE POSTNATAL PERIOD
Women who are receiving treatment for bipolar disorder are encouraged to seek a review from their doctor when planning a pregnancy so that ongoing care and a plan regarding medications during the pregnancy and after the birth can be arranged. Women who experience an episode of bipolar disorder during pregnancy or after a birth may require specialist care by a psychiatrist.
Psychologically based therapies play a role in coping with bipolar depression even though the primary causes are biological and may require the use of medication. Practical assistance and increased levels of social support can assist a new mother with the care of her baby when adjusting to, and be undergoing treatment.
The safety and care of mother and baby are of paramount concern and need to be fully assessed on an ongoing basis by all health care professionals involved with ongoing treatment. The availability of family and community supports and local mental health resources will have a bearing on the treatment plan.
USE OF MEDICATION/S
Amongst pregnant and breastfeeding women with bipolar disorder, there are special issues associated with the use of medications and specialist care by a psychiatrist is recommended. The need for effective treatment of the mother using medication has to be balanced against the risk to the fetus and infant. Electroconvulsive therapy is sometimes used when a woman is pregnant and certain types of medications are contra-indicated.
Use of mood stabilizers is a vital aspect of treatment for acute episodes and to prevent relapses. The use of medication in pregnancy is very challenging as these medications can cause malformations when used in the first 3-months of pregnancy. Hence, pregnant women should always be under specialist care at this time and discuss the medication options before pregnancy where possible. High-dose folate should be started before becoming pregnant to reduce the risk of malformations.
There may be an argument for being medication-free in the first trimester; however, this can only be decided in consultation with a psychiatrist. If medication is ceased over this period, there is a need for very regular appointments with the psychiatrist and close communication between the family and the treating team to pre-empt a relapse whenever possible.
- If a woman remains off medication throughout her pregnancy, it should usually be recommended immediately postnatally.
Other things such as minimizing stress, maximizing sleep ( especially in the first 1-2 weeks after baby’s birth ), and where possible staying on the postnatal ward a bit longer to get help in establishing breastfeeding, are very important.
- The close family needs to be aware of the condition and be available to help care for baby especially in the first few weeks postnatally.
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