Bipolar Disorder (BD) in Pregnant Women

Pregnancy can present many challenges when trying to manage mental health illnesses, making prescribing for the population a challenging task. Whether the symptoms develop at the onset of pregnancy or are a continuation of a previous history, women face a difficult decision about how to manage their illness during pregnancy. It is common for women to discontinue or avoid pharmacologic treatment in order to decrease the risks of prenatal exposure to medications.  However, this is not always the safest option, as psychiatric illness in the mother can in some cases cause significant morbidity for the mother and child. 

During pregnancy, the body undergoes numerous physiological and hormonal changes and the stressors involved in pregnancy, anxiety and depression are the most common emotional disturbances during the perinatal period. However, Bipolar Disorder (BD) is a chronic mental illness characterized by extreme shifts in energy and mood. The mean age of onset of BD is in the early twenties, during a woman’s prime reproductive years. Pregnant women with BD are encouraged to continue drug therapy to prevent the recurrence of mood episodes that may result in poor infant outcomes (Montiel, Newmark, & Clark, 2021).

Pharmacological and Nonpharmacological Treatment Options

            Lithium is a first line drug used to treat bipolar disorders, approved by the FDA. Lithium is currently the most effective drug for relapse prevention.  Lithium has beneficial treatment effects during both depressive and manic episodes and is associated with decreased suicide risk.  Lithium is frequently prescribed to women of childbearing age, as the BD onset occurs during before age 25. Lithium continued during pregnancy has shown lower risk of relapse throughout the pregnancy course and postpartum. However, lithium does pose some risks during pregnancy. These risks include spontaneous abortion, congenital malformations, cardiac malformations (Ebstein’s anomaly), premature births, and low birth weight (Poels et al., 2021).

            When prescribing or continuing Lithium during pregnancy it will be important to monitor the nutritional status of the mother and baby, sodium levels, kidney functions, and cardiac function. It will be important to monitor the fetal weight and monitor fetal development.

            An off-label medication option for the treatment of BD with pregnant patients is Verapamil.  Verapamil, (Calan, Isoptin) is a calcium channel blocker drug that may be effective in the treatment of mania. This drug is considered the safest mood stabilizing medication for treating bipolar disorder during pregnancy (Cipriani et al., 2016).

            A non-pharmacological intervention for the treatment of bipolar disorder is electroconvulsive therapy (ECT).  ECT is an intervention that involves electric stimulation of the brain of a patient under anesthesia to control manic and depressive symptoms.  ECT is used when all other pharmacological interventions have failed or the severity of the episodes can only be controlled through this method (Yildizhan, Ozdemir, Aytac, & Tomruk, 2019).

            Clinical guidelines exist in the treatment of pregnant women suffering from BD with the most probable one being the severity of the symptoms as well as the risk of exposure to the fetus. Discontinuing the use of mood stabilizers prior to conception can be used to test the ability for a patient to cope with the medication. However, if signs of relapse arise, the patient can easily restarted.  Pregnant patients should always be well informed of the risks and benefits of the prescribed medications and discuss their options with their physicians concerning the medications they are placed on and alternative strategies (Volkmann, Bschor, & Köhler, 2020).  

References

Cipriani, A., Saunders, K., Attenburrow, M. J., Stefaniak, J., Panchal, P., Stockton, S., Lane, T.   A., Tunbridge, E. M., Geddes, J. R., & Harrison, P. J. (2016). A systematic review of calcium channel antagonists in bipolar disorder and some considerations for their future development. Molecular psychiatry21(10), 1324–1332.  https://doi.org/10.1038/mp.2016.86

Poels, E. M. P., Sterrenburg, K., Wierdsma, A. I., Wesseloo, R., Beerthuizen, A., van Dijke, L.,   Lau, C., Hoogendijk, W. J. G., Marroun, H. E. l., van Kamp, I. L., Bijma, H. H., & Bergink, V. (2021). Lithium exposure during pregnancy increases fetal growth. Journal of Psychopharmacology35(2), 178–183. https://doi.org/10.1177/0269881120940914

Montiel, C., Newmark, R. L., & Clark, C. T. (2021). Perinatal use of lurasidone for the treatment of bipolar disorder. Experimental and Clinical Psychopharmacology. https://doi.org/10.1037/pha0000509

Volkmann, C., Bschor, T., & Köhler, S. (2020). Lithium treatment over the lifespan in bipolar disorders. Frontiers in Psychiatry, 11. https://doi.org/10.3389/fpsyt.2020.00377

Yildizhan, E., Ozdemir, A., Aytac, H. M., & Tomruk, N. B. (2019). Prepartum relapses or treatment resistance: A case of unipolar mania.  Düşünen Adam: Journal of Psychiatry and Neurological Sciences32(2), 161–166.

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