Relapse of Bipolar Disorder During Pregnancy Increases Risk of Postpartum Illness

In organizing for pregnancy, ladies with bipolar disorder and their treatment companies are compelled to make hard choices.  In the setting of medication discontinuation, relapse rates are major, and there is evidence that untreated psychiatric health issues in the mom is associated with even worse maternal and fetal results.  However, many of the remedies normally utilized to address bipolar dysfunction, precisely lithium, have a small but measurable improve in danger of teratogenesis.  The reproductive basic safety of other medications, together with atypical antipsychotic prescription drugs, is not effectively characterized. These decisions are even further difficult by the paucity of data with regards to the training course of bipolar disease through pregnancy.

A modern analyze from the United Kingdom appears particularly at recurrence of illness for the duration of pregnancy and the postpartum period of time in a group of ladies with bipolar ailment.  This analyze provided 128 ladies with DSM-5 bipolar condition (BD) who had been recruited to the Bipolar Ailment Research Network Pregnancy Analyze and were followed from 12 months of gestation to 12 weeks postpartum. Semi-structured questionnaires, supplemented with clinician interviews and review of the health-related file, ended up utilized to evaluate for lifetime psychiatric historical past and psychiatric health issues all through being pregnant and the postpartum comply with-up.  

In this cohort, 98 women of all ages had bipolar I disorder/schizoaffective-BD (BD-I team) and 26 bipolar II ailment/other specified BD and associated ailment (BD-II group).   The two teams have been comparable, whilst the gals in the BD-II team had previously onset of health issues and had more frequent depressive episodes than girls with BD-I.  Facts regarding the use of drugs in the course of pregnancy was not documented.  About 40% of the females in just about every team applied a temper stabilizer all through the postpartum time period.   

• Perinatal recurrence of sickness was prevalent in both of those teams: 57% (BD-I) and 62% (BD-II) seasoned a temper episode all through pregnancy. 
• Girls with BD-I ended up additional probable to encounter mania/psychosis in the course of being pregnant than women with BD-II (13.5% vs. %).
• Women with BD-I were being extra possible to working experience mania/psychosis within just 6 weeks postpartum (23%) compared to females with BD-II (4%). 
• In women of all ages with BD-I, mania/psychosis throughout pregnancy was affiliated with a sevenfold enhanced threat 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.