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Pregnancy and bipolar


Bipolar Disorder in Pregnancy

Written by Annie Stuart

In this Article

  • Complications of Bipolar Disorder in Pregnancy
  • Bipolar Medications During Pregnancy
  • Electroconvulsive Therapy (ECT) During Pregnancy
  • Other Steps You Can Take

Do you have bipolar disorder and want to become pregnant or are pregnant already? Perhaps you have bipolar disorder and do not want a pregnancy. Be sure to talk with both your obstetrician and psychiatrist about the risks and benefits of bipolar medications and forms of birth control. For some women, a contraceptive injection that is only needed every few months is best.

If you have bipolar disorder and become pregnant unexpectedly, take note: Stopping your medications suddenly may cause harm to you and your unborn child.

Complications of Bipolar Disorder in Pregnancy

Few studies have been done on bipolar disorder and pregnancy, so not enough is known about the risks of untreated bipolar disorder or the risks and benefits of medications during pregnancy. And the factors that lead to relapse during pregnancy are not clear.

Bipolar disorder, however, can worsen during pregnancy. Pregnant women or new mothers with bipolar disorder have seven times the risk of hospital admissions compared to pregnant women who do not have bipolar disorder.

At least one study has called into question the common belief that pregnancy may have a protective effect for women with bipolar disorder. The study followed 89 women through pregnancy and the year after delivery. When stopping bipolar medications for the period from six months before conception to12 weeks after, the women had:

  • Twice the risk of relapse
  • A 50% risk of recurrence within just two weeks, if they stopped suddenly
  • Bipolar symptoms throughout 40% of the pregnancy -- or more than four times that of women who continued their bipolar medications

Bipolar Medications During Pregnancy

Some women continue taking bipolar medications and have healthy babies. But a few bipolar medications have an increased risk of birth defects in the first trimester. That includes defects such as:

  • Neural tube defects
  • Heart defects
  • Developmental delay or neurobehavioral problems

However, you must weigh these risks against the risks of untreated bipolar disorder.

Untreated depression, for example, has been linked in some studies with low birth weight, or possible negative effects on developing brain structures in the baby. Mood symptoms can also lead to behaviors like these, which can harm a baby:

  • Poor prenatal care
  • Poor nutrition
  • A rise in alcohol or tobacco use
  • Stress and trouble with attachment

Your doctor may suggest stopping some medicines but continuing others, because, for some women, the mental health risks of stopping a medication are greater than the possible (or unknown) risks -- if any -- of continuing it. Psychiatrists with expertise in women's health often advise continuing certain psychiatric medicines during pregnancy along with regular tests to check on the health of your baby. But whatever you do, don't stop taking medications without first talking with your doctor.

Was your pregnancy unplanned? If so, know that stopping medications suddenly may do more harm than good.

Mood stabilizers. Taking multiple mood-stabilizing drugs can carry more risks than taking just one. Because of the rare risk for a particular kind of heart defect, lithium is sometimes not recommended during the first three months of pregnancy unless its benefits clearly outweigh the risks. Lithium may, though, be a safer choice than some anticonvulsants. And when lithium is continued after childbirth, it can reduce the rate of relapse from 50% to 10%.

To reduce its risks to you and your child:

  • Drink plenty of water and maintain normal salt intake to prevent lithium toxicity.
  • Have your lithium levels checked regularly.
  • If you choose to breastfeed while taking lithium, make sure your pediatrician is checking your baby's levels of lithium, thyroid hormone, and kidney function after delivery, at 4-6 weeks of age, and then every 8-12 weeks.

Both valproate (Depakote) and carbamazepine (Tegretol) during the first trimester may lead to birth defects such as neural tube defects, affecting the formation of the brain and spinal cord (for this reason, it is crucial to take the proper prenatal vitamins, including folic acid).And most experts say it is a good idea to stop them at least during the first trimester of pregnancy. You may need to switch to another drug.

There is less information on the safety of newer anticonvulsants. However, lamotrigine (Lamictal) may be a useful alternative for some women.

Antipsychotic medications. Antipsychotic medications can be used during acute treatment of mania, especially to manage delusions or hallucinations. Some medicines in this family also have become standard first-line treatments for acute bipolar depression. Examples of newer antipsychotics include:

  • Aripiprazole (Abilify)
  • Cariprazine (Vraylar)
  • Lurasidone (Latuda)
  • Olanzapine (Zyprexa)
  • Olanzapine/samidorphan (Lybalvi)
  • Quetiapine (Seroquel)
  • Risperidone (Risperdal)
  • Ziprasidone (Geodon)

Your doctor may suggest that you switch during pregnancy to an older-generation antipsychotic such as haloperidol (Haldol). This may also be a good idea if you've stopped taking a mood stabilizer but symptoms came back.

Antidepressants. There is less information about the effects of antidepressants on bipolar disorder and pregnancy. If you are on antidepressants, your doctors will watch you closely for mood switches or multiple episodes over time. Also, know that these drugs may increase the risk of mania. This is thought to be especially true if mood stabilizers have been stopped.

Electroconvulsive Therapy (ECT) During Pregnancy

Also known as electroshock, this therapy is among the safest treatment options during pregnancy and can have a therapeutic effect for mood disorders. During pregnancy, this type of therapy causes few complications. But to reduce the risks, your doctor may:

  • Have the baby's heart rate and oxygen levels monitored during ECT.
  • Suggest antacids or placement of an airway tube (intubation) to reduce the risk of gastric regurgitation or lung inflammation during ECT.
  • Encourage you to eat well and drink plenty of water to help prevent premature contractions.

Other Steps You Can Take

Do what you can to exercise and manage stress. And maintain structure in your day. These steps can help you get good sleep and reduce rapid shifts in moods. As always, psychotherapy can also be a big help.

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Therapy for Bipolar Disorder

Bipolar Disorder Guide

  1. Overview
  2. Symptoms & Types
  3. Treatment & Prevention
  4. Living & Support

Treatment of bipolar disorders during pregnancy: maternal and fetal safety and challenges

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Pregnancy and bipolar disorder. - Bipolar.su

Many girls ask themselves: Is it possible to have children if you have a mental disorder? What difficulties will I face? Is it possible that the disease is inherited? Is it possible to take drugs during pregnancy and if so, which ones?

In each case, of course, this issue is decided individually, taking into account all the risks.

I scanned the pregnancy chapter from Bipolar for Dummies. It provides detailed answers to all these questions.

All women of childbearing age who are being treated for bipolar disorder should discuss contraception and pregnancy with their doctors and have a contingency plan in place in case of an unexpected pregnancy.

These discussions should cover various aspects of reproductive health, both in terms of how bipolar disorder affects pregnancy and how pregnancy affects bipolar disorder.

After all, half of all pregnancies are accidental, and this figure may be higher for women with bipolar disorder because they are at higher risk for irregular menstrual cycles and impulsive sexual behavior.

Deciding whether to get pregnant

Being bipolar doesn't mean you can't have children. Many parents with bipolar disorder raise healthy, well-adjusted children. When you are thinking about having children, ask yourself the following questions and discuss them with someone in your support group who may be involved in or influence your decision.

• What are the chances that my child will develop bipolar disorder?

If only one of the parents has bipolar disorder, then the child has a 5-10% chance of developing the disease. If both parents have it, the risk can be as high as 25%.

• How will drugs affect the development of the fetus?

Many medicines used to treat bipolar disorder can be harmful to the developing fetus. You can choose drugs that have the lowest risk or discuss with your doctor the possibility of stopping drugs during pregnancy.

• How will pregnancy affect my mood?

Pregnancy and the postpartum period is a time of high risk for mood swings. Careful monitoring during pregnancy and for at least 30 days postpartum can help you and your doctors spot early warning signs.

• Can I deal with stress?

Pregnancy, the birth of a child, its upbringing and the child itself will undoubtedly disrupt the usual life, change relationships and increase stress. However, with careful planning, you will be able to resist the chaos and delegate some of the responsibility to those close to you.

You might be interested: Antidepressants and pregnancy

Planning and preparing for pregnancy

If you are a woman with bipolar disorder and you decide to try to get pregnant, work with your doctor to come up with a plan that can make pregnancy easier , minimize risks to the fetus and prevent mood cycles. Your planning and preparation should focus on the following tasks.

- Stabilize your mood a few months before conception.

Getting pregnant with a stable mood improves your chances of maintaining mood stability throughout your pregnancy.

- Monitor your mood more closely. Involve a few trusted friends or relatives—ideally those you see several times a week or more—to control your mood. Make sure these volunteers are aware of your first signs and know what to do if they notice a problem.

- Use the smallest amount of medication at the lowest effective dose. If there is a need for drugs, the goal is monotherapy (single drug).

- Avoid drugs that have a high risk of fetal developmental problems. This usually means stopping valproate, carbamazepine, lithium, and paroxetine and switching to other prophylactic drugs if possible.

- Increase non-drug treatment and support. Proper nutrition (which includes prenatal vitamins with folic acid), regular and adequate sleep, psychotherapy and family support alleviate the burden of pregnancy and help compensate for reductions in medication or dosage.

Therapy for Bipolar Disorder in Pregnancy

If you suspect you are pregnant, confirm as soon as possible and schedule an appointment with a psychiatrist and OB/GYN to develop a plan of action that is best for you and your pregnancy. As parts of your plan, consider the following actions.

1. Increase your doctor and psychotherapist visits.

2. Talk to your doctor about making adjustments to your medications.

3. If you are taking lithium and decide to continue taking it during pregnancy, do the following:

• Discuss with your doctor the possibility of stopping lithium in the first trimester, when it is more likely to affect the development of the fetus, and starting it again admission in the second trimester.

• Talk to your doctor about spreading your daily dose throughout the day to keep your lithium levels constant.

• Ask your OB/GYN to schedule regular ultrasounds or other tests to monitor your baby's heart development.

• Watch your fluid intake carefully. Be especially alert to dehydration, which can increase lithium levels.

• Talk to your doctor about gradually and temporarily reducing your lithium intake by at least 50% during the week before delivery to avoid lithium toxicity that can result from fluid loss during childbirth.

• Check your blood lithium levels more frequently—every four weeks until week 36, and then weekly until delivery. Check it again within 24 hours of delivery.

• Talk to your doctor about restoring your full maintenance dose of lithium after you have a baby and discuss dosage regimens if you're breastfeeding.

4. If you are taking atypical antipsychotics, ask your doctor about the need to monitor your weight and glucose levels throughout your pregnancy.

Doctors monitor these levels for all pregnancies, but your doctor may be more vigilant if you are taking atypical antipsychotics.

5. As always, if you notice the first signs of a change in mood, contact your psychiatrist immediately.

If your mood begins to change towards mania or depression, you and your doctor may consider drug or non-drug alternatives such as electroconvulsive therapy (ECT).

ECT is considered a relatively safe option for pregnant women who experience severe mania or depression that does not respond to medication. ECT does not appear to be associated with significant fetal malformations, the problems arising are mainly related to the possibility of cardiac complications in the fetus due to the use of anesthetics. In rare cases, ECT can also cause uterine contractions. ECT remains the second or third choice after medication, even during pregnancy, simply because it is a more invasive and complicated procedure.

See also: Pregnancy and childbirth with bipolar disorder

Medication choices before, during, and after pregnancy

If you are pregnant or could become pregnant, you and your doctor should carefully consider the benefits and risks of taking your medications during pregnancy. The following sections highlight important considerations to discuss with your doctor at various reproductive stages.

Before pregnancy

All women of childbearing age should discuss the following factors with their physicians when choosing medications to treat bipolar symptoms, even if they do not plan to become pregnant in the near future.

- Some medicines, including carbamazepine (Tegretol), oxcarbazepine (Trileptal), lamotrigine (lamiktal), and topiramate, can make certain birth control pills less effective.

- Contraceptive drugs can affect the bloodstream concentrations of other drugs, particularly lamotrigine, decreasing estrogen levels during the three weeks of exposure and increasing estrogen levels by up to 50% during the last pill-free week.

- Some antipsychotics can increase prolactin levels and reduce the chance of conception. If you are planning a pregnancy, your doctor may check your prolactin levels and discuss alternative medications.

- Valproic acid (Depakine) increases the risk of polycystic ovaries - an endocrinological disorder that increases testosterone levels in women and disrupts the menstrual cycle, causes acne and hirsutism (excessive male pattern hair in women), increases the risk of type II diabetes, other problems health and can lead to infertility.

During pregnancy

Taking medication during pregnancy requires close cooperation between a woman with bipolar disorder, her psychiatrist, and an ob/gyn. Of course, ideally it is best not to take medication during pregnancy, but studies show that stopping bipolar medication early in pregnancy greatly increases the risk of recurrence of mood swings, especially in women with a history of frequent or severe mood swing symptoms.

Such an episode of mood swings can be dangerous for both the mother and the baby. However, the early stages of pregnancy (the first trimester) are the period of greatest risk for serious fetal malformations due to drug use, so many women consider stopping all medication.

Medicines are classified according to their potential risks during pregnancy. The following lists the drugs prescribed for bipolar disorder that fall into this classification system and describes some of the specific problems associated with each of these categories.

Category D: use in life-threatening emergencies when no safer drugs are available. There is evidence of risk to the fetus.

Lithium: this drug significantly increases the risk of cardiac problems, as well as premature birth, neurological problems, and thyroid and kidney problems in the fetus.

Valproate (Depakine): This medicine is associated with a high risk of serious fetal malformations, especially if used in the first trimester of pregnancy. It also increases the risk of stillbirth and miscarriage.

Carbamazepine (Tegretol): Mothers taking carbamazepine during pregnancy face a significant risk of fetal malformations.

Benzodiazepines: increase the risk of fetal malformations when used in the first trimester of pregnancy. When used late in pregnancy, they can cause muscle hypotension, or flaccid baby syndrome, a neurological condition/related to muscle weakness.

Paroxetine (Paxil): use in the first trimester of pregnancy leads to an increased risk of fetal malformations, especially of the cardiovascular system. Most other antidepressants currently in use fall under category C.

Imipramine and nortriptyline: These tricyclic antidepressants are considered class D drugs, while other tricyclics fall into class C, as indicated below.

Category C: Use with caution if benefits outweigh risks. Animal studies show risk; human studies are not available; either animal or human studies have not been conducted.

Lamotrigine (Lamictal): this drug is associated with a lower risk of major malformations compared to the other anticonvulsants listed above, but there is still a significant risk of some birth defects - possibly higher risk at higher doses.

Atypical antipsychotics: Little information is available on the risk of atypical antipsychotics in pregnancy, but they are thought to pose a lower risk of major malformations than class D drugs (lithium, valproate, and carbamazepine). Fetal development may be affected by drug-induced weight gain and changes in maternal glucose and insulin levels.

SSRIs and SNRIs antidepressants other than paroxetine: Pregnant women should avoid taking antidepressants during the third trimester to reduce serotonin-related problems in the newborn, including nervousness, feeding difficulties, and breathing problems.

Most antidepressants pose a lower risk of serious malformations than class D drugs. A rare problem associated with SNRIs is pulmonary hypertension - problems with the heart and lung system - in a child after long-term use by the mother during pregnancy.

Other antidepressants: These include bupropion (Wellbutrin), nefazodone (Serzone), vilazodone (Viibryd), desirel (Trazodone), fluvoxamine (Luvox), mirtazapine (Remeron), tricyclics desipramine (Norpramin) and amitriptyline (Elavil) and MAOIs tranylcypromine (Parnate) and phenelzine (Nardil).

Do not change your treatment regimen or stop taking your medication without consulting your doctor. The relapse rate is relatively high during and after pregnancy, when the risk of impulsivity, poor self-care, and suicide is increased. Work with your doctor to develop a treatment plan that balances your well-being (which is as important to your baby as it is to you) with developmental safety. Often such plans include choosing medications that carry less risk during pregnancy, using only one medication if possible, and taking as low doses as possible.

You may be interested in: Bipolar disorder in women

Postnatal period

The postnatal period is known for its high risk of recurrence of mood swings. Many women and their doctors restart their pre-pregnancy medications immediately after delivery to reduce the chance of a mood swing episode. But this has the following potential disadvantages.

- Many medications pass through breast milk, so if you start taking medication immediately after giving birth, you will have to feed your baby formula milk instead of breast milk, which would help restore sleep.

- Fatigue or other side effects from resuming medication are exacerbated by the arrival of a newborn in the house; however, these effects may be a small price to pay for preventing a mood swing episode.

— It can be difficult to achieve your planned medication levels immediately after delivery. when body weight and fluid levels change dramatically.

Similar articles:

Bipolar disorder in women

Pregnancy and antidepressants

Pregnancy and childbirth with bipolar disorder

Summary

Risks for pregnant women and the fetus associated with the use of normothymic drugs

Today, there is a limited evidence base regarding the effect of mood stabilizers on risks for pregnant women and the fetus. Most of the published works demonstrate the relationship between their intake and the development of congenital malformations, premature birth and fetal growth retardation.

Interesting in this regard is the scientific work published in November of this year in the British Medical Journal, in which scientists obtained new data regarding this problem. In this cohort study, Dr. Robert Boden and co-authors from Uppsala University, Sweden, examined 332,137 pregnant women, of whom 874 were diagnosed with bipolar disorder. The rest of the subjects without this disease made up the comparison group. 320 women with bipolar disorder were treated with mood stabilizers.

Pregnancy and childbirth

Newborns of untreated mothers for bipolar disorder had a significantly increased risk of severe prematurity compared with controls (relative risk (RR) 1.96; 95% confidence interval ( CI) 0.93–4.14). In the group of women who received therapy, this indicator was 0. 48 (95% CI 0.07–3.38).

Some intergroup differences in the risk of having a child with low Apgar scores were recorded, but after standardization for the main variables, these differences were not statistically significant.

Other outcomes studied included gestational diabetes mellitus, delivery with forceps or vacuum extractor (instrumented vaginal delivery), non-spontaneous (paced) onset of labor, neonatal hypoglycemia.

Significantly increased risk in untreated and treated women with bipolar disorder compared with controls was reported for instrumental vaginal delivery (RR of 1.52) and induced labor (RR of 1.69) among the listed outcomesand 2.28, respectively). The risk of other adverse outcomes in groups of women with bipolar disorder who took and did not take normothymic drugs was not significantly increased.

Anthropometric measurements

Primary analysis showed an association between untreated bipolar disorder and an increased risk of having a baby with low body weight, height and head circumference for the corresponding gestational age. After standardization, these differences were not statistically significant. In the group of women who received therapy, these indicators were also slightly increased.

A non-statistically significant increase in risk in both groups of women with bipolar disorder was also noted for having a baby with a high birth weight for a given gestational age.

Particular attention should be paid to the high prevalence of microcephaly in women with bipolar disorder. Thus, in the control this pathology was recorded in 2.3% of cases; in the group of women taking normothymic drugs - in 3.3%; in untreated women with bipolar disorder - 3.9%.

Congenital malformations

The prevalence of fetal malformations in women without bipolar disorder was 2.0%, in women with this pathology who did not receive therapy - 1.9% and in women taking normothymic drugs, this the indicator fluctuated within 0–3.5% (table).

Table Prevalence of fetal malformations in women with bipolar disorder treated with mood stabilizers in early pregnancy

Preparation Number of patients in the group, n Number of women with fetal malformations, n (%) p Description of malformations
Lamotrigine 116 4 (3. 5) 0.12 Equinovar clubfoot (n=2), congenital heart defects (n=2)
Antipsychotics 113 4 (3.5) 0.11 Equinovar clubfoot (n=1), cleft palate (n=1), malformations of the heart (n=1) and genitourinary system (n=1)
Lithium preparations 107 3 (2.8) 0.19 Malformations of the heart (n=2), hypospadias (n=1)
Valproic acid 32 1 (3.1) 0.34 Hypospadias (n=1)
Carbamazepine 7 0 – –

Summarizing the data obtained, R. Boden et al. emphasize that the choice of tactics for managing pregnant women with bipolar disorder is ambiguous. On one side of the scale is the potential risk of congenital fetal anomalies and perinatal complications due to the use of mood stabilizers, on the other is the risk of an affective episode in the absence of therapy.

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