In the use of anti-manic treatment, some studies suggest periodic use and disuse of drugs for pregnant women. For example, some women discontinue taking these drugs for the first trimester of pregnancy. This may decrease the defects mentioned above. These women then use the drugs in later trimesters. How exactly does this work? Data shows that there is increased risk for relapse upon abrupt discontinuation of medications. Gradual, as opposed to rapid, discontinuation may have a more positive effect for pregnant women with respect to relapse. However, although gradual discontinuation is most ideal for pregnant women, the fetus may be exposed to these antimanic agents for a longer period of time–a time that is critical for organogenesis, or the development of the organs. Teratogenic risks are also quite high at this time. The risk of relapse is especially high in women with a greater number of prior mood episodes. Low lithium circulation also increases the risk of relapse; thereafter, there is an increased suicide risk (Viguera et al., 1998).
Viguera et al. (1998) also describes possible treatment guidelines for women with varying episodes. Bipolar patients with a history of one episode of mania and usually function well should be able to discontinue lithium before conception. Those who have moderate illness (2-3 episodes) could take either of two paths. First, the patient may choose to gradually discontinue lithium before conception. If they find that they are unable to handle this, lithium may be easily resumed. Or, they could wait until they find out that they are pregnant. This way, the patient minimizes exposure during placental implantation. Thus, these critical factors must be considered before beginning treatment of pregnant women suffering from bipolar disorder. Women with the most severe forms of bipolar disorder (i.e. more than four episodes) should continue to use lithium throughout the first and second trimesters. They should use lithium treatment before as well as during pregnancy. This is because they are most prone to have severe manic-depressive episodes in the absence of medication treatment. As emphasized before, this would be very detrimental to both the mother and fetus. In general, all women who use lithium during the first trimester of pregnancy should get a level II ultrasound at 18 to 20 weeks gestation (Llewellyn et al., 1998). This is to check for cardiac abnormalities.
An even more critical period in a pregnant woman’s life is during the postpartum period, after the woman has given birth. This is because the postpartum period of a woman’s life is one of especially high risk. Relatively more studies have been done on bipolar disorder during the postpartum period as opposed to during the actual pregnancy. The relapse from bipolar disorder during the postpartum period has been estimated between 33% (Altshuler et al., 1998). Since some women do suffer from depression after giving birth, it is especially crucial to be aware of the possibility of elevated depression. During the postpartum period, women often feel the need to commit suicide, because the depressive episodes seem to dominate (Blehar et al., 1997). Postpartum psychotic episodes vary and they can be very severe. This has to be noted in order to prevent the mother’s suicide or infanticide of the newborn. Moreover, postpartum relapse can be greatly decreased by five-fold when lithium is taken right before birth (within 48 hours of delivery) and continued throughout the postpartum period (Viguera et al., 1998).
Altshuler, L.L., Henrick V., Cohen, L.S. Course of mood and anxiety disorders during pregnancy and the postpartum period. Journal of Clinical Psychiatry 59 Suppl 2: 29-33 (1998).
Blehar, M.C., DePaulo J.R. Jr., Gershon, E.S., Reich, T., Simpson, S.G., Nurnberger, J.I. Jr. Women with bipolar disorder: findings from the NIMH Genetics Initiative sample. PsychopharmacologyBulletin 34(3): 239-243 (1998).
Leibenluft, E. Issues in the treatment of women with bipolar illness. Journal of Clinical Psychiatry 58 Suppl 15: 5-11 (1997).
Llewellyn, A., Stowe, Z. N., Strader, J.R. Jr. The use of lithium and management of women with bipolar disorder during pregnancy and lactation. Journal of Clinical Psychiatry59 Suppl 6: 57-64, discussion 65 (1998).
Viguera, A.C., Cohen, L.S. The course and management of bipolar disorder during pregnancy. Psychopharmacology Bulletin 34(3): 339-46 (1998).
Psych Central. (2007). Women and Bipolar Disorder. Psych Central. Retrieved on July 25, 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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