Bipolar disorder and pregnancy

• principles of management as for bipolar disorder in a non-pregnant woman but with various provisos (see below)
• risk of relapse of treated and untreated bipolar disorder is the same during pregnancy as at other times, women who are pregnant are more likely to stop treatment and this is often unplanned and abrupt
• postnatal risk of relapse is much greater for women who are not receiving treatment than at other times, and may be higher than 50%
• NICE guidance is summarised below:
  • pregnant women with bipolar disorder who are stable on an antipsychotic
    • if a pregnant woman with bipolar disorder is stable on an antipsychotic and likely to relapse without medication
      • then maintain on antipsychotic medication, and monitor for weight gain and diabetes
  • women with bipolar disorder planning a pregnancy
    • if a woman who needs antimanic medication plans to become pregnant
      • then treatment of choice is a low-dose typical or atypical antipsychotic
    • if a woman with bipolar disorder planning a pregnancy becomes depressed after stopping prophylactic medication, psychological therapy (cognitive behaviour therapy (CBT)) should be offered in preference to an antidepressant because of the risk of switching to mania associated with antidepressants
      • if an antidepressant is used, it should usually be an SSRI (but not paroxetine) and the woman should be monitored closely
  • women with bipolar disorder who have an unplanned pregnancy
    • if a woman with bipolar disorder has an unplanned pregnancy and is stopping lithium as prophylactic medication, an antipsychotic should be offered
  • pregnant women with acute mania or depressive symptoms
    • acute mania
      • if a pregnant woman who is not taking medication develops acute mania
        • then a typical or an atypical antipsychotic should be considered - dose should be kept as low as possible and the woman monitored carefully
      • if a pregnant woman develops acute mania while taking prophylactic medication, prescribers should:
        • check the dose of the prophylactic agent and adherence
        • increase the dose if the woman is taking an antipsychotic, or consider changing to an antipsychotic if she is not
        • if there is no response to changes in dose or drug and the patient has severe mania, consider the use of ECT, lithium and, rarely, valproate
      • if there is no alternative to valproate, then consider augmenting it with antimanic medication (but not carbamazepine)
    • depressive symptoms
      • if mild depressive symptoms in pregnant women with bipolar disorder the following should be considered, in the order:
        • self-help approaches such as guided self-help and C-CBT (computerised CBT)
        • brief psychological treatments (including counselling, CBT and interpersonal psychotherapy (IPT))
      • if moderate to severe depressive symptoms in pregnant women with bipolar disorder the following should be considered:
        • psychological treatment (CBT) for moderate depression
        • combined medication and structured psychological treatments for severe depression.
      • if prescribing medication for moderate to severe depressive symptoms in a pregnant woman with bipolar disorder, quetiapine alone, or SSRIs (but not paroxetine) in combination with prophylactic medication should be preferred
        • this is because SSRIs are less likely to be associated with switching to mania than the tricyclic antidepressants
        • monitor closely for signs of switching and stop the SSRI if the woman starts to develop manic or hypomanic symptoms
  • care in the perinatal period
    • after delivery, if a woman with bipolar disorder who is not on medication is at high risk of developing an acute episode, prescribers should consider establishing or reinstating medication as soon as the woman is medically stable (once the fluid balance is established)
    • if a woman maintained on lithium is at high risk of a manic relapse in the immediate postnatal period
      • consider augmenting treatment with an antipsychotic
    • women with bipolar disorder who wish to breastfeed
      • women with bipolar disorder who are taking psychotropic medication and wish to breastfeed should be offered a prophylactic agent that can be used when breastfeeding
        • first choice should be an antipsychotic

Reference:

1. NICE (2007). Antenatal and postnatal mental health