Prescribe Sleep Postpartum:
Monitor Bipolar Patients During, After Pregnancy

(April 15, 2004) -- TUCSON, ARIZ. -- Bipolar disorder can present an array of challenges during and after pregnancy, with the same influences that can make treatment most urgent also making it most complicated, Dr. Marlene Freeman said at a psychopharmacology conference sponsored by the University of Arizona.

If the pregnancy is unplanned--which may be more common in women with bipolar disorder because of increased impulsive behavior--some women may immediately discontinue medication upon learning of the pregnancy out of fear of harming the baby.

In doing so, those women can throw themselves into a state that could pose even more of a risk to the child, said Dr. Freeman, director of the women's mental health program at the university.

"Very often, a woman will find out she's pregnant and just suddenly discontinue all of her medications." Dr. Freeman said. "This has great significance because the risk of recurrence is much greater if there is a rapid discontinuation of medication."

Risks of problems are even greater in the highly volatile postpartum period, and research has shown that the risk for relapse for women who have bipolar disorder during this time is exceptionally high, she pointed out.

Dr. Freeman cited a retrospective study comparing two groups of women with bipolar disorder--one consisting of pregnant women and the other of nonpregnant women, all of whom had discontinued lithium maintenance therapy. Rates of recurrence were similar for pregnant and nonpregnant women (52% vs. 58%) during the first 40 weeks after lithium discontinuation.

Among those who remained stable during the first 40 weeks, the relapse rate during weeks 41-64 was significantly higher--70%--among the postpartum women, compared with the nonpregnant group, whose average relapse rate was just 24% (Am. J. Psychiatry 157[2]:179-84, 2000).

"The relapse rate of bipolar disorder in the postpartum women was three times greater than in nonpregnant women," Dr. Freeman said.

One way to avoid such problems may be to continue medications throughout pregnancy, but physicians are faced with various teratogenic concerns. Among the mood stabilizers most traditionally cautioned during pregnancy is lithium, which has been long associated with cardiovascular malformations with first-trimester use.

Recent research, however, shows that that association is not nearly as common as many were taught to believe, Dr. Freeman said. She noted that the absolute risk of 0.05%-0.1% may be relatively high--10 to 20 times more common than with no lithium exposure in the first trimester--but the baseline is not all that high in the first place.

When it comes to other mood stabilizers, some of the lowest rates of malformations from anticonvulsants have been reported with lamotrigine, which had about a 2% rate.

The highest rate was seen with valproate, at about 6.7%. But the overall risk of malformations in newborns after exposure to anticonvulsants in pregnancy is 3.1%, and that's in line with the baseline 3%-4% rates of malformation seen in the general population, Dr. Freeman said.

Whenever pregnant patients use mood stabilizers, physicians should always make sure patients receive level II ultrasounds, which offer extra focus and measurements. And if women are taking lithium, it's especially important to recommend fetal echocardiography.

"It's noninvasive and can be done at the same time as the ultrasound, and it can really take a good look at the heart," she commented.

Use of mood stabilizers after pregnancy continues to present the risk of exposure to the infant through breast milk. Almost all of the psychotropic medications can be seen as relatively safe, but it's important to use a careful risk-benefit analysis and use extra caution with lithium, Dr. Freeman said.

"Lithium is one of the toughest medications to consider. It's no longer contraindicated by the American Academy of Pediatrics, but toxicity has been reported and caution is still recommended," she said.

In addition to medications, another important way to help women with bipolar disorder through the postpartum period is through prescribing sleep.

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Sleep deprivation is one of the most difficult problems any postpartum woman must deal with, but it's particularly problematic for those with bipolar disorder, she noted.

"Sleep deprivation may in fact be a big reason why women with bipolar disorder are so super sensitive in the postpartum period, so it's especially important to help them get enough sleep," Dr. Freeman said.

Suggestions include talking to the patient about a sleep plan and encouraging the help of family or friends with some night feedings.

"Try to bring in significant others during the pregnancy, and talk to them about how they can help," Dr. Freeman said. "We really can't stress enough how important it is to have a support system for the patient at this time."

Source: OB/GYN News

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