Pregnancy is a profound life event that evokes many emotions. It is important for women with bipolar disorder who plan to become pregnant—or have just found out that they are pregnant—to think through the best strategies that will give them the best likelihood of healthy outcomes for both mother and baby. It is important to confer actively with doctors about their individual history, medication choices, support strategies and stress-management ideas to help them through this important time in their lives.
Bipolar disorder is a severe mental illness that affects millions of Americans and their families. Bipolar disorder often consists of multiple well-defined manic and depressive episodes that reoccur throughout oneís lifetime. Depressive episodes—lasting often weeks to months—can include depressed mood, guilt, hopelessness, worthlessness and even suicidality, as well as associated changes in sleep, appetite, energy and focus. Manic episodes—periods lasting days to weeks—are usually characterized by decreased sleep, increased energy and impulsive behaviors, racing and disorganized thoughts and other disturbing symptoms. Bipolar disorder is often diagnosed in younger people in their teens and 20s. Therefore, at some time during or after their diagnosis, many women with this illness will either become pregnant or consider becoming pregnant.
While initially debated by researchers, it has become clear over the past decade that women with bipolar disorder are at increased risk of experiencing a manic or depressive episode during or after pregnancy. This is likely due to a number of factors such as hormonal changes associated with pregnancy and disturbed sleep during this time, as well as the emotional, familial and financial stressors associated with pregnancy and delivery. For many young women, pregnancy and the postpartum period may also be the first time they experience the symptoms of their illness. Some studies suggest that women may be five to 10 times as likely to experience an episode during these time periods. For women with an established diagnosis of bipolar disorder, other studies suggest that up to 20 to 30 percent of women experience recurrent episodes during pregnancy, and between 30 to 40 percent of women experience episodes during the postpartum period.
Every womanís strengths and risks in approaching the interplay between bipolar disorder and pregnancy are unique. For all women this is an important time to develop a working knowledge of the strategies that have worked for other people, and review personal strategies that have been successful in the past.
Significant risk factors for experiencing worsening symptoms of bipolar disorder may include abruptly stopping medication treatment, unexpected pregnancies and unstable interpersonal relationships. The key is to make decisions with the most complete information available about treatment options, strategies and the risks and benefits of medications.
Even with treatment, many women with bipolar disorder will experience more symptoms of their illness during pregnancy. Depressive and manic episodes can place both mother and the developing fetus at risk, due in part to the fact that women with severe symptoms are less likely to follow up with their doctors and continue treatment as a result of their illness.
Women who are depressed are more likely to experience difficult pregnancies (e.g., pain, worsened sleep or appetite). Those with depression may also be more likely to have premature deliveries, problems with fetal growth and other related complications. However, of greatest concern is the rare but still increased risk of maternal suicide, both before and after delivery.
Women with manic episodes are also at increased risk of both maternal and fetal complications during pregnancy and birth. This is generally thought to be due to the impulsive behaviors associated with manic episodes (e.g., increased drug abuse, poor compliance with medical treatment).
Many women with bipolar disorder manage their illness well and deliver healthy babies as well. This is a common outcome. It is clear that organizing resources, planning and carefully weighing the risks and benefits of decisions is the best way to improve the chances of a good outcome.
In the absence of a fetus, medications are typically thought of as a cornerstone of treatment to reduce the frequency and intensity of bipolar disorder symptoms. Yet many of the medications used for bipolar disorder add risks to the pregnancy. How does one weigh these risks against the risk of lower or no medications on a womanís mental health, which is also crucial for the baby? This discussion will center in part on a womanís other supports and stresses, her history, prior pregnancies and her ability to recognize the recurrence of symptoms. An open dialogue with oneís doctors is a key piece of the process and accessing specialized consultation is advised. Academic medical centers may have specialists in this exact and important area.
There is evidence that medications reduce risk of maternal mood problems in the pregnancy. This important area needs to be balanced against the risks of the medications. Importantly, the risks of medications may change with the age of the fetus so again getting good information to inform decisions is critical.
Many scientific studies have shown that people with bipolar disorder who stop treatment with their medications are at increased risk of experiencing a manic or depressive episode. This is particularly the case for people who abruptly stop their medications, as can often happen when a woman unexpectedly discovers that she is pregnant. As previously discussed, many women are at increased risk of experiencing worsening symptoms of bipolar disorder both during and after their pregnancy, even when continuing treatment for their illness. Scientific studies have shown that rapidly stopping oneís medications greatly increases this risk, especially during pregnancy and in the postpartum period.
Therefore, it is advised that all women discuss the issue of pregnancy with their psychiatrists. It is useful to discuss the risks of continuing treatment with medication, as well as the risks of recurrence with and without ongoing medication treatment. Psychiatrists can also be helpful in discussing pregnancy planning. Planned pregnancies—as opposed to unplanned pregnancies—may be less likely to increase the risk of symptoms, as they allow the individual to slowly taper off of their medication if that is their choice, to maximize no medication supports and reduce stress and to watch with their psychiatrists and loved ones for any changes in symptoms.
Whether or not they are considering becoming pregnant, all women with bipolar disorder should regularly discuss this issue with their doctors. Many women with bipolar disorder will want to stop treatment with all medications before they become pregnant. A discussion regarding the safety and risks of stopping oneís medications is very important and may end with a plan to slowly taper off oneís medications. Other women will wish to continue being treated with their medications throughout pregnancy in order to avoid the risks of increased symptoms, which can also be harmful to the baby. For these women, many will continue on the same medication—perhaps with decreased doses or with increased monitoring. Still others will change from one medication to another in order to avoid possible risks to the developing fetus.
In general, psychiatrists can be most helpful in explaining the risks and benefits of treatment, but it is the patientís decision to stop, continue or change medications based on a number of factors. For patients who wish to continue or initiate treatment, many psychiatrists will recommend using the same medications that have been previously successful for the woman, as there is not one specific medication that is necessarily safer in all situations. In fact, none of the medications certified for use by the US-FDA in the treatment of bipolar disorder are without risks to the developing fetus (e.g., they are potentially teratogenic). Therefore, women being treated with these medications may have increased screening tests (e.g., ultrasounds and blood tests) throughout their pregnancies, depending on which medications they are using.
The specific risks and benefits of psychiatric medications in the context of pregnancy are beyond the scope of this review and should be discussed with oneís psychiatrist, obstetrician and other care providers. What is key is to get good and timely information when making decisions will impact mother and child.
As with any mental illness, the role of psychotherapy can be critical in alleviating symptoms and decreasing distress. Behavioral interventions (e.g., eating a healthy diet, exercising regularly and keeping as regular a sleep schedule as possible) are also very important in preventing and treating bipolar disorder, both in pregnancy and the postpartum period.
Everyone with bipolar disorder deserves to have an evaluation by a psychiatrist. Many psychiatrists have experience in treating pregnant women; others have less experience and can provide referrals to colleagues with specialized training in this field. Similarly, some obstetricians may refer their patients for consultations to high-risk obstetricians who have additional training in maternal-fetal medicine. In either situation, a woman, her psychiatrist and her obstetrician should be in regular contact to ensure that care is complete and coordinated.
As the risk of developing a manic or depressive episode may be greatest immediately in the postpartum period, many women at high-risk (e.g., women with a history of multiple episodes or prior episodes in the postpartum period) will often be advised by their psychiatrists to either start or continue treatment with a mood-stabilizer immediately after delivering their child. Scientific studies have shown that this may be the best way to prevent new episodes from occurring in the postpartum period.
Following delivery, new mothers will choose to breast-feed or bottle-feed their babies based on a number of factors. Medications again are important variables in this equation and should be carefully reviewed.
Families, friends and others can be most helpful in providing empathic and non-judgmental support of their loved ones and encouraging them to have regular contact with their psychiatrist. With this support and proper medical care, women with bipolar disorder can increase their chances of having a healthy pregnancy and delivery.
A well-regarded resource is the Massachusetts General Hospitalís Women Center for Mental Health. Updates on treatments and side effects for women, including during pregnancy, can be found at their website.
Reviewed by Ken Duckworth, M.D., and Jacob L. Freedman, M.D., July 2013
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