Bipolar Disorder in Pregnancy and Postpartum

Pregnancy does not have a protective effect on the occurrence of Bipolar Disorder as has been previously believed.  Many women with existing Bipolar Disorder report a relapse of their symptoms during pregnancy and approximately 60% of women with previous postpartum Bipolar Disorder will experience a recurrence in a subsequent pregnancy.

Bipolar Disorder I (BDI), historically known as manic-depressive disorder or manic depression, is a mental health condition in which people experience disruptive mood swings characterized by episodes of either mania or hypomania which often alternate with depressive episodes.  These episodes can be intense and interfere with daily life.  It is possible that both depressive and manic symptoms can occur in the same episode and this is called a ‘mixed state’.

If the onset of mood symptoms occurs during pregnancy or in the first 4 weeks following delivery, the episode is described as “peripartum onset”.  Peripartum–onset mood episodes, either manic or depressed, can present either with or without psychotic features.  Postpartum mood episodes with psychotic features occur in from 1 in 500 to 1 in 1,000 deliveries and may be more common in first time mothers. Those with a prior history of BDI have a very high risk of developing a postpartum psychosis. Once a woman has had a postpartum episode with psychotic features, the risk of recurrence with each subsequent delivery is between 30% and 50%.

Bipolar Disorder II (BDII) is characterized by repeated episodes of depression and at least one mild and short period of hypomania.  

What is Mania and Hypomania?

 A Manic Episode is an intense experience of elevated, expansive or irritable mood and persistently increased goal-directed activity or energy that lasts for at least a week and is present most of the day.  It is severe enough to make it difficult for the woman to function normally within her family or in a social or occupational setting.  Sometimes hospitalization is necessary to prevent harm to self or others.

A Hypomanic episode a is distinguished from a manic episode  by the absence of some of the more severe symptoms and by its shorter course (lasting 4 days) and lesser degree of impact on the woman’s ability to function.  Mild hypomania can be missed after the birth especially in first time mothers when some euphoria and sleep deprivation could be considered a normal response to giving birth.

In general, a first manic or depressive episode usually occurs in the teenage years or early adulthood.  Episodes of hypomania/mania and/or depression may last for days, weeks or months and the disorder itself may be lifelong.  If not treated, Bipolar Disorder tends to worsen with more frequent and severe episodes.  Appropriate treatment helps to reduce frequency and severity of episodes.

Risk factors

• Bipolar Disorder often runs in families.  The risk of developing a Bipolar Disorder is increased if your parent has a Bipolar Disorder.  
• The illness is often made worse by stressful life events such as poor partner or family relationships and lack of social support.  
• Childbirth may be a particular time of vulnerability for a mother at risk of developing Bipolar Disorder.   Her first psychiatric episode may be a postpartum psychosis, a postpartum manic episode or a postpartum depressive episode.
•  Women with a previous diagnosis of Bipolar Disorder are at increased risk of postpartum relapse.

Management of Bipolar Disorder in the perinatal period:

It is recommended that women with a diagnosed Bipolar 1 Disorder or Bipolar 2 Disorder have an Individualized Treatment Plan, agreed upon by the woman, her family and ALL members of their treatment team, including Family Physician, Obstetrician, Midwife, Psychiatrist and other health care providers.

The Individualized Treatment Plan should include:

• Educating family members about the risk of postpartum relapse.
• Medication management, including changes that need to made in number of medications and dosages of medications.
• Plan for longer postpartum stay in hospital to monitor the woman’s mood and facilitate sleep.
• Identifying what supports are needed for woman to care for her infant.

With planning wherever possible and treatment and management of symptoms, the risks and impacts of Bipolar Disorder for the woman and her baby can be minimized.