Transcript bipolar affective disorder in pregnancy

Jo Naidoo
Dr Ramachandra
21/10/10






Introduction
General principles of Mx of women with BAP
Medication in BAD
Women in pregnancy
Perinatal period
Breastfeeding




Risk factor for relapse – as high as 50% (Jones
2005)
Viguera et al (2007) – small prospective
Observational cohort of preg. BAD. Risk of
recurrence in pregnancy was 71%.
27% of women with BAD, are admitted to
psychiatric care in the first post partum year
(Munk-Olsen 2009)
Risk of relapse after delivery – 8 fold in the
first month post partum




Majority of the episodes – depressive
Nearly half within the first trimester
Recurrence more likely if a woman :-has discontinued medication
-BAD II
-had previously been treated with a mood
stabiliser
These results emphasis the need to balance
the risks of treatment to the fetus with those
of a recurrence of an affective episode.
General Principles
Of Women with BAD
pregnancy
planned
unplanned
Perinatal
Period
Breast
feeding



The absolute and relative risks should be
discussed with women.
contact by specialist mental health services,
working closely with maternity services, should
be considered for pregnant women with bipolar
disorder, because of the increased risk of relapse
during pregnancy and the postnatal period.
written plan for managing a woman’s bipolar
disorder during the pregnancy, delivery and
postnatal period should be developed as soon as
possible.

If stable on an antipsychotic - she should be maintained on the
antipsychotic, and monitored for weight gain and diabetes.
What are some of the
concerns?


Risks of not treating incl.-harm to the mother thru poor self-care,
lack of obstetric care or self harm
-harm to the fetus or neonate ( ranging
from neglect to infanticide)
Mental health of the mother influences fetal
well-being, obstetric outcome and child
development




Cardiac malformation, Ebsteins anomaly (AR
1:1000, RR 10-20 times more than control
groups) (Cohen et al 2007)
Overall, recent evidence shows that the
teratogenic risks are lower than originally
believed
Max risk period is 2-6 weeks after conception
Preferred slow discontinuation before
conception.





Abrupt discontinuation – risk of relapse
Relapse rate postpartum – 70% in those who
discontinued lithium before conception.
If discontinuation is unsuccessful during
preg. – restart and continue
Li in preg – high resolution U/S, and
echocardiography at 6 and 18 weeks of
gestation
3rd trimester – due to the changing
pharmacokinetics, higher doses Li required
Lithium equilibrates across the placenta
 Effects on the neonate :i.
Neonatal Goitre
ii.
Hypotonia
iii. Lethargy
iv. Cardiac arrhythmia






Well known teratogen, most teratogenic
7-10% risk of Neural Tube defects – esp Spina
Bifida
Also assoc cardiac defects in the first
trimester; craniofacial abnornalities
Adab and colleagues (2001) described a
higher risk of additional educational needs
amongst school-aged children exposed to
valproate in utero compared to those
exposed to carbemazepine or those not
exposed to any ACD
Teratogenicity probably dose related




1 % risk of neural tube defects, esp spina
bifida in the first trimester
Also risk of craniofacial abnormalities and
microcephaly in newborns
If using Carbamazepine in the third trimester
– maternal and neonatal, Vit K may be
necessary
Ideally all patients should be on folic acid a
month before conception


North American Antiepileptic Drug Registry
suggested an increase risk of oral clefts
associated with first trimester lamotrigine
exposure (2006 /2007)
Increased risk of major malformations
compared to unexposed



Commonly used – mono or in combination
Relative safety – typical and atypical
Sparse data





If on antidepressants – risk of relapse high
Older TCA safe
SSRI – no increased risk of major congenital
defects
Paroxetine – cardiac defects (1.5-2 fold inc
VSD & ASD)
Some studies show use of antidepressants in
the last trimester – transient jitteriness,
tremulousness, tachypnoea, hypotonia and
pulmonary hypertension
(?withdrawal/intoxication)



Role of maternal depression on perinatal
wellbeing not evaluated
If mod – severe depression develops use
antidepressants if psychological management
failed / not available
Risk of neonate having discontinuation
symptoms – agitation, irritability, convulsions
(switch to bottle feeds) – SSRI & Venlafaxine



First trimester exposure associated with risk
of oral clefts in newborns
Third trimester – neonatal difficulties
including floppy baby syndrome
Best avoided in pregnancy



stop taking AC, mood stab. and alternative
prophylactic drugs (such as an
antipsychotic) should be considered.
Antipsychotics - advised that the raised
prolactin levels associated with some
antipsychotics reduce the chances of
conception. If prolactin levels are raised, an
alternative drug should be considered.
If a woman who needs antimanic
medication plans to become pregnant, a
low-dose typical or atypical antipsychotic
should be considered, because they are of
least known risk
If a woman taking lithium plans to become pregnant,
the following options should be considered:
• if the patient is well and not at high risk of relapse –
gradually stopping lithium
• if the patient is not well or is at high risk of relapse:
− switching gradually to an antipsychotic, or
− stopping lithium and restarting it in the second
trimester if the woman is not planning to breastfeed
and her symptoms have responded better to lithium
than to other drugs in the past, or
− continuing with lithium, after full discussion of the
risks, while trying to conceive and throughout the
pregnancy, if manic episodes have complicated the
woman’s previous presentation




If Mx lithium during pregnancy - serum lithium
levels should be monitored every 4 weeks, then
weekly from the 36th week, and less than 24
hours after childbirth. The dose should be
adjusted to keep serum levels within the
therapeutic range. The woman should maintain
adequate fluid intake.
depression after stopping prophylactic
medication, psychological therapy (CBT) should
be offered in preference to an antidepressant.
If an antidepressant is used, it should usually be
an SSRI (but not paroxetine because of the risk of
cardiovascular malformations in the fetus) and
the woman should be monitored closely.




Confirm pregnancy
stop taking valproate, carbamazepine and
lamotrigine
first trimester- stable, lithium should be
stopped gradually over 4 weeks, and the
woman informed that this may not remove the
risk of cardiac defects in the fetus
if the woman remains on lithium during
pregnancy serum lithium levels should be
checked every 4 weeks, then weekly from the
36th week, and less than 24 hours after
childbirth; the dose should be adjusted to keep
serum levels within the therapeutic range, and
the woman should maintain adequate fluid
intake


an antipsychotic should be offered as
prophylactic medication
offer appropriate screening and counselling
about the continuation of the pregnancy, the
need for additional monitoring and the risks
to the fetus if the woman stays on
medication.



not taking medication - an atypical or a typical antipsychotic
should be considered.
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 atypical 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 the woman should be
informed of the increased risk to the fetus and the child's
intellectual development. The lowest possible effective dose
should be used and augmenting it with additional antimanic
medication (but not carbamazepine) considered. The maximum
dosage should be 1 gram per day, in divided doses and in the
slow-release form, with 5 mg/day folic acid


mild depressive symptoms :• self-help approaches such as guided self-help
and computerised CBT
• brief psychological interventions
• antidepressant medication.
For moderate to severe depressive symptoms:• psychological treatment (CBT) for moderate
depression
• combined medication and structured
psychological interventions for severe
depression.


For moderate to severe depressive symptoms
:- quetiapine alone, or SSRIs (but not
paroxetine) .
Monitor closely for signs of switching and
stop the SSRI if patients start to develop
manic or hypomanic symptoms.
prescribed an antidepressants - potential, but
predominantly short-lived, adverse effects of
antidepressants on the neonate.


Women taking lithium should deliver in
hospital, and be monitored during labour by
the obstetric medical team, in addition to
usual midwife care. Monitoring should
include fluid balance, because of the risk of
dehydration and lithium toxicity.
After delivery, Patient is not on medication is
at high risk of developing an acute episode,
prescribers should consider establishing or
reinstating medication as soon as medically
stable (once the fluid balance is established).


If maintained on lithium and is at high risk of
a manic relapse in the immediate postnatal
period, augmenting treatment with an
antipsychotic should be considered.
If patient develops severe manic or psychotic
symptoms and behavioural disturbance in the
intrapartum period rapid tranquillisation with
an antipsychotic should be considered in
preference to a benzodiazepine because of
the risk of floppy baby syndrome. Treatment
should be in collaboration with an
anaesthetist and obstetrician



have advice on the risks and benefits of
breastfeeding
be advised not to breastfeed if taking
lithium, benzodiazepines or lamotrigine, and
offered a prophylactic agent that can be used
when breastfeeding – an antipsychotic should
be the first choice
be prescribed an SSRI if an antidepressant
is used (but not fluoxetine or citalopram).


Symptoms including irritability, constant
crying, shivering, tremor, restlessness,
increased tone, feeding and sleeping
difficulties and rarely seizures have been
reported in neonates of mothers taking SSRIs.
Many of these symptoms are mild and selflimiting. In many cases these symptoms
appear causally related to antidepressant
exposure although there is debate about to
what extent they represent serotonergic
toxicity or a withdrawal reaction.