Pregnancy and Bipolar Disorder: Expert Interview With Leena Mittal, MD
Many psychiatrists avoid these discussions because they do not feel it is their role or that they are not sufficiently educated to broach them.
Psychiatry Advisor: How should postpartum psychosis be managed?
Dr Mittal: Postpartum psychosis remains a relatively rare complication of bipolar disorder, but it carries great risk. Its onset can be rapid, within days to weeks after delivery. Prominent symptoms can be confusion, delusions, paranoia, and sometimes hallucinations. This condition carries a risk for the woman harming herself or her baby and is a psychiatric emergency.
Postpartum psychosis poses a serious risk to the mother and to the baby. It is essential for women to be closely monitored and families should be educated about this possibility and be aware of potential signs and symptoms. The MCPAP for Moms includes assessment tools regarding thought of harming the baby, degree of suicidal risk, when medication is necessary, risk factors for postpartum depression, and suggestions for initiating a discussion with the mother (https://www.mcpapformoms.org/About/ReportsandPublications.aspx).
Psychiatry Advisor: What is involved in helping patients plan for pregnancy?
Dr Mittal: First and foremost, women should be encouraged to call their psychiatric and obstetrician/gynecologist providers when they are planning pregnancy or if they find out about pregnancy unexpectedly. Women should be discouraged from stopping their medications on their own without input from their providers.
Beyond encouraging the woman to begin to address her physical health together with her primary care physician or obstetrician/gynecologist, it is important to help her begin thinking about her plan for the pregnancy itself and the delivery and postpartum period.
Clinicians should not focus exclusively on psychotropic medication but should also address other risk factors for poor perinatal outcome, such as obesity, smoking, and the use of alcohol or other substances of abuse. Healthy behavior, including adherence to a prenatal vitamin regimen and a schedule of prenatal care visits, maintenance of a healthy diet, and attendance at childbirth preparation classes, should be encouraged.
Some helpful tips would include considering what medications have been most effective and whether a regimen can be simplified; considering which nonpharmacologic treatments have been most effective; taking into account the patient's preference for treatment; helping the patient plan a support system; and educating the patient regarding the risks of illness, medication, and ongoing psychiatric treatment.
Psychiatry Advisor: What is the impact of medication on lactation?
Dr Mittal: When counseling a woman with BPD who is taking medications about lactation, there are 2 major considerations. One is how much medication enters the milk and the other is what the impact of the medication is on the baby. For example, in antidepressants, the exposure is low but different for each agent. According to the American Academy of Pediatricians, anything less than 10% of maternal weight-adjusted dose is a reasonably low exposure.20
For the mood stabilizers, it is more complicated, although lactation is not absolutely contraindicated. For example, with lithium and lamotrigine, variable amounts pass into breast milk. Thus decisions about breastfeeding while taking these medications should involve collaboration between a woman, her psychiatrist, and her child's pediatrician to balance the potential risks along with the benefits of treatment and the alternatives.
Psychiatry Advisor: What considerations should psychiatrists bring to mothers when looking toward delivery and the postpartum period?
Dr Mittal: It is important to plan for preservation of sleep, because caring for a newborn can interfere with consolidated sleep at night. Breastfeeding can have an impact on a woman's ability to sleep in consolidated periods, and it may be necessary to encourage some women to seek help with nighttime care. Women can consider expressing milk or replacing nighttime feedings with supplemental formula so that someone else can bottle feed the baby.
In addition, women and their families should be informed about the potential for postpartum mood complications and a plan should be developed for close monitoring and accessing care if symptoms of depression, mania, or psychosis arise.
Being a new mother is typically overwhelming for most women, even those without BPD, so it is especially important to make sure an adequate support system is in place.
Psychiatry Advisor: What other suggestions do you have for psychiatrists treating this population?
Dr Mittal: I recommend that the psychiatrist should collaborate closely with the woman's obstetrician/gynecologist and other healthcare providers, if relevant, to maximize consistency of care and encourage psychosocial support when appropriate.
- Epstein RA, Moore KM, Bobo WV. Treatment of bipolar disorders during pregnancy: maternal and fetal safety and challenges. Drug Health Patient Saf. 2014;7:7-29.
- Mittal L, Wichman CL, Byatt N. Bipolar disorder in pregnancy and breast-feeding: a practical guide for the general psychiatrist. Psychiatr Ann. 2015;45(8):411-416.
- Yonkers KA, Vigod S, Ross LE. Diagnosis, pathophysiology, and management of mood disorders in pregnant and postpartum women. Obstet Gynecol. 2011;117(4):961-977.
- Viguera AC, Tondo L, Koukopoulos AE, Reginaldi D, Lepri B, Baldessarini RJ. Episodes of mood disorders in 2,252 pregnancies and postpartum periods. Am J Psychiatry. 2011;168(11):1179-1185.
- Bipolar Lives. Bipolar Pregnancy. http://www.bipolar-lives.com/bipolar-pregnancy.html. March 5, 2015. Accessed November 20, 2017.
- Dolman C, Jones IR, Howard LM. Women with bipolar disorder and pregnancy: factors influencing their decision-making. BJPsych Open. 2016;2(5):294-300.
- Marengo E, Martino DJ, Igoa A, et al. Unplanned pregnancies and reproductive health among women with bipolar disorder. J Affect Disord. 2015;178:201-205.
- Freeman MP. Bipolar disorder and pregnancy: risks revealed. Am J Psychiatry. 2007;164(12):1771-1773.
- Heffner JL, DelBello MP, Fleck DE, Adler CM, Strakowski SM. Unplanned pregnancies in adolescents with bipolar disorder. Am J Psychiatry. 2012;169(12):1319.
- Main M. One Key Question: Would You Like to Become Pregnant in the Next Year? http://depts.washington.edu/nwbfch/archives/one-key-question-would-you-become-pregnant-next-year. Northwest Bulletin. July 2016. Accessed November 19, 2017.
- Ward RK, Zamorski MA. Benefits and risks of psychiatric medications during pregnancy. Am Fam Physician. 2002;66(4):629-636.
- Tosato S, Albert U, Tomassi S, et al. A systematized review of atypical antipsychotics in pregnant women: balancing between risks of untreated illness and risks of drug-related adverse events. J Clin Psychiatry. 2017;78(5):e477-e489.
- Viguera AC, Nonacs R, Cohen LS, Tondo L, Murray A, Baldessarini RJ. Risk of recurrence of bipolar disorder in pregnant and nonpregnant women after discontinuing lithium maintenance. Am J Psychiatry. 2000;157(2):179-184.
- Yonkers KA, Wisner KL, Stowe Z, et al. Management of bipolar disorder during pregnancy and the postpartum period. Am J Psychiatry. 2004;161(4):608-620.
- Patorno E, Huybrechts KF, Hernandez-Diaz S. Lithium use in pregnancy and the risk of cardiac malformations. N Engl J Med. 2017;377(9):893-894.
- Haskey C, Galbally M. Mood stabilizers in pregnancy and child developmental outcomes: a systematic review. Aust N Z J Psychiatry. 2017;51(11):1087-1097.
- Prady SL, Hanlon I, Fraser LK, Mikocka-Walus A. A systematic review of maternal antidepressant use in pregnancy and short- and long-term offspring's outcomes [published online October 12, 2017]. Arch Womens Ment Health. doi:10.1007/s00737-017-0780-3
- Jefferies AL; Canadian Paediatric Society, Fetus and Newborn Committee. Selective serotonin reuptake inhibitors in pregnancy and infant outcomes. Paediatr Child Health. 2011;16(9):562-563.
- Santucci AK, Singer LT, Wisniewski SR, et al. One-year developmental outcomes for infants of mothers with bipolar disorder. J Clin Psychiatry. 2017;78(8):1083-1090.
- Sach HC; Committee on Drugs. The transfer of drugs and therapeutics into human breast milk: an update on selected topics. Pediatrics. 2013;132(3);e796-e809.