Risks Associated with Bipolar Disorder in Women
Perhaps more significant a gender difference lies in the fact that women can give birth. Relatively little study has been done regarding the risks of bipolar disorder in the period during pregnancy. Sometimes it is difficult to distinguish bipolar symptoms from regular pregnancy symptoms. Pregnant women often do suffer from depression, depending on their environment and stresses. Nonetheless, it is unclear as to whether or not pregnancy increases or decreases bipolar symptoms. Some studies suggest that pregnancy may lessen symptoms: “In one study, 800f patients with affective illness (predominantly bipolar) experienced an improvement or a diminution of symptoms of their mood disorder during pregnancy” (Altshuler et al. 1998). At the same time, these studies are contradicted by other studies. For instance, in a study involving women with bipolar type I disorder, “…women reported manic mood changes, in each case occurring during pregnancy” (Blehar et al., 1998). Manic episodes and cycling seemed to occur exclusively during pregnancy.
Although the reason for this point is unclear, it is apparent pregnancy also poses a question of relapse, which has an important effect on women and the fetus that they are carrying. The fetus can be at risk due to lack of attention to prenatal care, if the woman is not treated for the psychiatric illness. Precipitated episodes in the absence of treatment may be very detrimental to both parties involved. Secondly, the woman would be at risk because with each successive episode, the length of time to following episodes gets smaller. That is, the woman could have manic and depressive episodes more often. This would neither be beneficial to the woman or her child. The effect on the fetus due to many mood episodes is unclear (Viguera et al., 1998). “During pregnancy, a woman’s glomerular filtration rate increases” (Llewellyn et al., 1998). This means that any medication that she takes, such as lithium (discussed below), will be excreted more rapidly. This is very dangerous because if she does not have enough medication in her system, she can fall into relapse. A dilemma arises in that if she increases her medication amount, she may be exposing her fetus to grave side effects and even danger (discussed below). Moreover, during labor, it is important that women remain fully hydrated. Since the period of time for delivery varies with each individual, a pregnant woman can become very dehydrated. When a woman gets dehydrated, the serum medication concentrations will increase (Llewellyn et al., 1998). This is the opposite effect of the increase in glomerulus filtration. Nonetheless, both situations are dangerous and can be very toxic to the woman and indirectly to the fetus.
As varying as the symptoms of bipolar disorder, per individual, so are the treatments. It is very important that bipolar pregnant women get the appropriate care and treatment that they need, in order to properly care for themselves as well as for the child that they are carrying. In treating pregnant women who have bipolar disorder, there exist several clinical problems. There are several drugs or chemicals that are used to treat bipolar disorder. However, such drugs have been shown to cause clinical problems. Drugs that are antimanic agents, such as lithium, valproic acid, and carbamazepine, all have teratogenic effects. Prenatal exposure to lithium increases risk for cardiovascular malformations (Viguera et al., 1998; Llewellyn et al., 1998). With lithium use, cardiovascular abnormalities such as Ebstein’s anomaly may result. This risk in the infant is “400 more common if the mother was being treated with lithium during pregnancy” (WWW1). Ebstein’s anomaly is a cardiovascular malformation where the right ventricle has hypoplasia and there is downward placement of the tricuspid valve into the right ventricle (Viguera et al., 1998). In addition, lithium use during the first trimester of pregnancy increases the risk for Ebstein’s anomaly dramatically. Since lithium can cross the placenta, it is particularly risky because fetal serum concentration is similar to that of the mother (Llewellyn et al., 1998). Moreover, lithium can also cause cardiac arrhythmia, where the heart beats are asynchronous, irregular, or especially slow. Often physicians will counsel their patients to terminate the pregnancy.
Early reports urged the change from lithium use to that of carbamazepine and valproic acid. However, these carbamazepine and valproic acid have been shown to cause defects in the fetus. They have teratogenic effects. Rates of neural tube defects due to carbamazepine and valproic acid exposure has been estimated to be about 1 percent and 3-5%, respectively (Viguera et al., 1998). Studies now suggest that carbamazepine and valproic acid treatment for pregnant bipolar patients may cause even more severe fetal defects than lithium. In addition to the neural defects, carbamazepine and valproic acid exposure to the fetus is associated with craniofacial abnormalities and cognitive dysfunction, if given late in pregnancy. At least with the damage caused by lithium, early detection and surgery can repair the effects. Another study believes that giving pregnant women folate reduces the neural tube defects (Viguera et al., 1998). Nonetheless, studies now show that lithium may be the lesser harmful of the three.
Other treatments are now being discovered to treat bipolar disorder. Yet, newer anticonvulsant agents such as gabapentin and lamotrigine seem to have contradicting effects. Newer antidepressants, such as bupropion, supposedly have good response rates and low risk for manic episodes or rapid cycling. However, as with all new medications, bupropion studies have been met with mixed results (Leibenluft, 1998). Apparently, patients had to discontinue use of bupropion because upon its use, patients occasionally switched to hypomania. Another possible treatment for bipolar disorder is electroconvulsive therapy. This should be considered for as an alternative medication for bipolar depression. In comparison of medication effectiveness, specifically that of monoamine oxidase inhibitors and tricyclics, electroconvulsive therapy seems to be more effective. Five out of seven studies show that electroconvulsive therapy is more useful (Leibenluft, 1998). As with all treatments so far discussed, there exists a drawback in using electroconvulsive therapy. It seems that electroconvulsive therapy is capable of alleviating depression symptoms of bipolar disorder, but there is a possibility that patients will switch into mania or hypomania.
Psych Central. (2007). Women and Bipolar Disorder. Psych Central. Retrieved on October 22, 2014, from http://psychcentral.com/lib/women-and-bipolar-disorder/0001250
Last reviewed: By John M. Grohol, Psy.D. on 30 Jan 2013
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