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Bipolar Affective Disorder
 
BIPOLAR DISORDER IN PREGNANCY AND POST-PARTUM

The decision whether or not to use medications, particularly mood stabilizers, during pregnancy begins with a risk-benefit exercise in which the patient and her family should be fully involved (Packer, 1992). The risks of teratogenicity, posed by all the mood stabilizers, should be weighed against the risks of an illness recurrence, suicide and inability to look after self and the unborn child. If the patient’s previous course of illness has been good with low severity of and frequency of episodes, a planned pregnancy without mood stabilizers may be considered, with a gradual discontinuation of medication and a four week medication-free

period before conception. Elective use of ECT, neuroleptics and SSRIs in the first trimester can pose a lower relative risk to the fetus compared with mood stabilizers. (Altshuler et al, 1996; Packer 1992; Stowe et al, 1995).

If any mood stabilizer is being used in the first trimester of pregnancy, consider folic acid supplements with anticonvulsants, and also monitor for teratogenicity using appropriate investigations. Mood stabilizer dose may need to be raised to maintain a therapeutic serum level as the blood and fluid volume increases during pregnancy. It is advisable to gradually discontinue medication, if this is appropriate clinically, about four weeks before delivery. If the mood stabilizer is being continued during delivery, the doses need to be reduced drastically in order to avoid the toxicity caused by decreasing blood and fluid volumes immediately following childbirth. The newborn should also be monitored for and protected from toxicity from mood stabilizers.

The immediate post-partum period carries with it a greater than 50% risk of recurrence or exacerbation. (Cohen et al, 1995), hence it is advisable to recommend re-instituting mood stabilizer treatment if this had been discontinued earlier, or ensuring that serum therapeutic levels are achieved and maintained. All mood stabilizers are secreted through breast milk. There is pooled data to suggest that the medication or metabolites secreted through breast milk do not pose a significant immediate risk to the newborn (Stowe et al, 1995). However, there is no long term data available to conclusively rule out any behavioural effects on the developing child exposed to mood stabilizers during the newborn period. Hence, it is common practice to recommend discontinuing breast feeding of the newborn if this is clinically appropriate.

References
Altshuler LL, Cohen LS, Szuba MP, Burt VK, Gitlin M, Mintz J. 1996. Pharmacologic Management of Psychiatric Illness During Pregnancy: Dilemmas and Guidelines. Am J Psychiatry. 153: 5. 592-606.

Cohen LS, Sichel DA, Robertson LM, Heckscher E, Rosenbaum JF. 1995. Post-Partum Prophylaxis for Women with Bipolar Disorder. Am J Psychiatry. 152: 11. 1641-1644.

Packer S. 1992. Family Planning for Women with Bipolar Disorder. Hospital and Community Psychiatry. 43. 5. 479-482.

Stowe ZN, Nemeroff CB. 1995. "Psychopharmacology during Pregnancy and Lactation." In Textbook of Psychopharmacology. Ed. Schaatzberg AF, Nemeroff CB. American Psychiatric Press. Chapter 41: 823-835.


Over one million Canadians suffer from some form of depressive illness.