Pregnancy and Elevated Mood
Caring for an elevated mood patient who wishes to become pregnant or becomes pregnant requires skill, tact, and an ability to work cooperatively with the woman and her partner. There are four distinct stages to this treatment, each of which has separate principles and guidelines.
Treating the potentially pregnant woman during the planning and prepregnancy period
Treating elevated mood during pregnancy
Peripartum period issues
Postpartum and lactation
Clinical principles
There is a paucity of information that specifically relates to hypomania in prepregnant and pregnant women. Therefore, we must extrapolate treatment principles on the basis of information derived from investigation of bipolar disorder. Hyperthymic and mildly hypomanic women may not present to a
mental health professional for evaluation or treatment at all. These patients, when they present to their maternal health care professional, may show minimal, if any, signs of psychiatric pathology. It would be easy for a health-care professional to mistake mildly elevated mood for the joy and pleasure of anticipating or being pregnant. Therefore, the principles discussed in the rest of this section are for the more easily identifiable hypomanic patients or those women who develop full-fledged mania.
mental health professional for evaluation or treatment at all. These patients, when they present to their maternal health care professional, may show minimal, if any, signs of psychiatric pathology. It would be easy for a health-care professional to mistake mildly elevated mood for the joy and pleasure of anticipating or being pregnant. Therefore, the principles discussed in the rest of this section are for the more easily identifiable hypomanic patients or those women who develop full-fledged mania.
“Traditional wisdom” has suggested that pregnancy may provide protection against bipolar relapse. However, more recent studies suggest otherwise (1,2,3). When a cohort of women with predominately bipolar I disorder who were studied as part of the National Institute of Mental Health (NIMH) Genetics Initiative became pregnant, half of them described severe emotional disturbances in relation to childbearing (4). Viguera et al. (2) found that the rate of recurrence of bipolar I and bipolar II disorders were approximately equal in pregnant and nonpregnant women. When these patients with bipolar disorder from the Massachusetts General Hospital Perinatal and Reproductive Psychiatry program were followed up over the course of their pregnancy, the overall recurrence risk for a mood episode in this sample was 66%, including 58% showing major depression, 16% showing mania, 13% showing hypomania, and 13% showing mixed states. Therefore, one fourth the number of these patients showed hypomania or a mixed affective state and approximately one sixth of them showed mania. These studies contradict previously held beliefs and indicate that the risk of elevated mood and depression is significant during pregnancy.
In the pregnant patient with minimal elevation of mood, consideration should be given to providing a limited treatment of close observation and follow-up. If treatment is necessary, in general, the psychotherapeutic strategies as outlined in Chapter 6 are first-line and preferable to medication. Those with mild symptomatology may respond to cognitive behavioral therapy (CBT), interpersonal psychotherapeutic strategies, psychoeducation, and lifestyle hygiene recommendations. Although it may be theoretically desirable for women with bipolar disorder to remain medication-free during pregnancy, this may not, however, be possible and maintenance treatment during pregnancy may be necessary. Even those patients who initially decide to discontinue medication during pregnancy may relapse with such significant symptomatology that the reintroduction of medication is indicated.
When medication is considered, it is the role of the clinician to do the following:
Provide up-to-date and balanced information to the patient about possible risks of medication and/or the possible complications of untreated mood illness.
Assist the woman to make the best decision for herself, always being cognizant that the final decision rests with the patient.
Once a decision is reached, verbally support the final choice of the patient and her partner.
If medication is being prescribed during the pregnancy, the following clinical guidelines should be adhered to.
The lowest possible dose that treats the symptoms satisfactorily should be used. Consider intermittent dosing if feasible, but do not hesitate to increase medication dosages to full therapeutic range if necessary for adequate symptom control.
Once a patient decides to use or restart medication, the clinician should be positive, encouraging, and supportive even if there are known risks to this course of action.
If elevated mood symptoms worsen to the point of full mania, especially with psychotic symptoms, the clinician should make a strong case for starting or continuing medication. In general, the risk to mother and fetus is small from medication treatment as compared to the effects of a major manic episode. Hospitalization or electroconvulsive therapy (ECT) may also be considered.
For the patient who has elevated mood escalating to confusion or disorganized thinking, or when manic delusions are present, the care giver should include input from the partner or caretakers to both assess the extent of symptomatology and behavioral risks during pregnancy. For patients who are declared legally incompetent, involve a guardian in any decision to start or restart medication.
If possible, use monotherapy and avoid polypharmacy.
In general, it is best to return to a medication that was therapeutically effective and tolerated before pregnancy. Pregnancy is not the time to be experimenting with a new medication regimen unless earlier medications were ineffective. Exceptions to this principle would be during the first trimester with carbamazepine or valproic acid (see the subsequent text), which are pregnancy Class D medication. Other alternatives should be considered at least for the first trimester.
Preplanning with fertile women who have elevated mood
Patients seen for the treatment of elevated mood who are fertile and potentially pregnant require a discussion regarding the benefits of a planned pregnancy. If medication is to be started or has been ongoing, use of birth control should be discussed with all female patients of childbearing age and documented in the chart. For any woman of childbearing age where there are symptoms suggestive of pregnancy or the possibility of pregnancy cannot be ruled out with certainty, a pregnancy test should be obtained before the patient begins medication.
Some patients may present to a clinician in the midst of a major elevated mood episode, expressing their interest in becoming pregnant. The clinician should advise the patient to delay conception until her mental health episode is stabilized. Such a suggestion may displease a hypomanic woman. Providing an approximate time frame for a safe conception is useful in hopes that the patient will be more stable and able to make appropriate decisions about medication and pregnancy.
When an elevated mood patient becomes pregnant
Recommended steps for the clinician treating a patient with elevated mood who suspects or documents a pregnancy are as follows:
Document when the clinician was informed of the possibility of pregnancy, when it was confirmed by test and the estimated time of delivery.
Document any other medications taken at the time of conception over and above any psychotropics being prescribed by the clinician.
Document any history of ongoing alcohol or drug abuse.
If necessary, order a pregnancy test for confirmation.
If necessary, assist the patient in finding an obstetrical care provider and prenatal care.
Unless there is a previously agreed-upon plan, the treater should immediately schedule an appointment to discuss the medication treatment plan during the pregnancy.
Involve the patient’s partner in education and decisions about medication.
If the patient wishes to be medication-free, it is generally better to stop medications quickly rather than utilize a prolonged taper, even if this might be the preferred schedule during nonpregnant circumstances. Pregnant women who strongly wish to be off medication will generally appreciate this short interval to a medication-free state.
If medication is to be continued, it should be decreased to the lowest dose that provides reasonable symptom control.
Avoid polypharmacy. If the patient has been maintained on a combination of medication, monotherapy should be considered.
If the pregnancy is unplanned, the clinician can serve as an objective sounding board to assist the patient in evaluating whether to keep or terminate the pregnancy.
When possible, avoid medication in the first trimester when the teratogenic effect of medication is at its highest.
Maintain flexibility in the use of medication and/or other treatment, pending any change in clinical circumstances. Some patients may benefit from reinstituting medication in the second or third trimester when the risk of teratogenicity is less.
Monitor the patient directly in face-to-face evaluation more frequently. If the patient sees a psychotherapist in split treatment, maintain close contact with this therapist.
Consider nonpharmacologic interventions including CBT, individual or group therapy, or light therapy for depression.
Evaluate life stressors. When necessary, recommend psychotherapy to address job, family, and relationship issues.
If the patient is experiencing severe symptoms of elevated mood or depression, make a strong case for starting or continuing medication. In general, the risk of medication side effects to mother and fetus are small in comparison to the sequelae of a major mood episode. Maternal stress and distress, anxiety and depression have also been clinically associated with a wide variety of abnormalities in newborns including lower birth weight (3,4).
Once it is decided to use medication during the pregnancy, be positive, encouraging and supportive toward the patient’s decision even if there are some known risks.
In general, use medications that were successful and well tolerated earlier. Pregnancy is not a time to be experimenting with a new medication regimen.
Consider hospitalization and/or the use of ECT as an alternative for severe mood symptoms. For manic individuals with psychotic symptoms, involve the partner or caretakers in any decision about treatment and medication. For patients declared legally incompetent, involve the guardian.
Unless the patient is declared incompetent or incapacitated (this is unlikely in hypomania), the clinician cannot make unilateral decisions for the patient regarding use of medication during pregnancy.
Peripartum and postpartum
As the delivery date approaches, the clinician and patient should discuss plans for the last several weeks of the pregnancy and the immediate postpartum period. Mood stabilizers and antidepressants may be tapered and discontinued in the 7 to 10 days before delivery to prevent neonatal withdrawal, particularly with short half-life antidepressants such as paroxetine, venlafaxine, or benzodiazepines. Tapering of medication may become a moot point in the patient who has a spontaneous early labor.
The immediate postpartum period has long been known for exacerbation of mood disorders. Postpartum depression is common. Postpartum psychosis, although infrequent, is potentially catastrophic. Patients with a history of bipolar disorder are at special risk for worsening of their mood disorder during the postpartum period (5,6). This occurs with enough frequency that postpartum worsening of a mood disorder is one signal supporting a diagnosis of bipolar disorder. Studies with American and international populations of women have shown that women who are at risk for postpartum depression can be identified as early as the third postpartum day (7,8,9,10). Instruments such as Maternity Blues Scale and the Edinburgh Postnatal Depression Scale are useful tools for this early detection.
The most recent research on postpartum psychosis (11) confirms the risk. Blackmoor et al. studied 129 white women with lifetime diagnoses of bipolar or schizoaffective disorder of the bipolar type who had suffered at least one manic or affective psychotic episode within 4 weeks after childbirth. Ninety-seven percent of these psychotic episodes had the onset within the first 2 weeks after delivery. Comparison of these findings with 75 unaffected deliveries showed that 82% of these high-risk women had psychotic episodes after their first deliveries. The only other risk factor that could be confirmed in this study was self-reported complications with labor and delivery that also increased postpartum psychosis. This study confirms the necessity of evaluating all pregnant women for history of previous psychiatric disorder. Women with a prior history of bipolar or psychotic disorder should be monitored very carefully during the first several weeks following delivery. Any evidence of severe mood disorder and/or psychotic symptomatology bears immediate action.
Because of this high risk, most, if not all, patients with bipolar disorder should receive a recommendation to rapidly reinstitute mood-stabilizing and possibly antidepressant medication shortly after delivery unless a definitive decision by the mother has been reached to not restart medications. On the basis of current data, the clinician should make a strong recommendation to medicate in this critically vulnerable period.
Breast-feeding
Prospective evidence-based data on the use of psychotropics during breast-feeding is virtually absent, so the evidence for the recommendations in this text comes solely from isolated case examples and on retrospective review of data. Women and their partners, therefore, must be advised that recommendations have little documented supporting evidence. This being said, from the information that we do have, it appears that psychotropic medications in general do not seem to have long-term effects on the infant. Adverse effects seen in infants are generally reversible side effects rather than long-term brain toxicity (12). Mothers should, however, be informed that virtually all psychotropic medications taken during breast-feeding do appear in breast milk in varying concentrations. In general, these concentrations are small but the long-term effect of this small amount of medication is uncertain. The following principles and strategies are useful for the patient with elevated mood who will be medicated while breast-feeding.
Many mothers have a strong predisposition to breast-feed despite any medication risk. Beyond the opportunity for mother-child bonding, there is clear evidence that breast-fed infants may have lower rates of various medical problems (13,14).
Although the exact incidence is not known, risk to infants from mood stabilizers and antidepressant exposure during breast-feeding appears low.
The risks of harm and neglect to the infant from a mother who is profoundly manic, psychotic and/or depressed can be significant and, at times, catastrophic. In any patient with serious mood symptoms, the treatment should favor the maintenance of the mother’s mental health, which is likely to include psychotropic medication.
Maintain the lowest possible medication dose that controls the patient’s symptoms. Premature infants have less well-developed hepatic and kidney function and, therefore, this information should be taken into account before a mother on medication decides to breast-feed.
It may be useful to suggest weaning an infant sooner than the mother might otherwise do, to reduce the infant’s exposure to psychotropic medication.
Ensure that the condition of the baby is carefully monitored by both the mother and the pediatrician.
As with pregnancy, the breast-feeding period is not a time for new, untried medication unless all previous medications have been unsuccessful or poorly tolerated.
Specific medications
Having described the clinical principles and overarching clinical guidelines for dealing with the pregnant patient who evidences elevated mood, we turn our attention to specific medications and medication groups that are commonly used to treat elevated mood in the pregnancy.
Lithium
Since lithium came into common use in the late 1960s and early 1970s, there has been concern about an association between first-trimester lithium exposure and congenital malformations. This was particularly of concern with Ebstein’s anomaly (a malformation with downward displacement of the tricuspid valve into the right ventricle, causing backward leakage and weakening of the ventricular outflow to the lungs). An early voluntary physician-reported database cited a 400-fold higher rate of Ebstein’s anomaly in infants exposed to lithium (15). Recent estimates (16,17,18) show an incidence of between 1 and 2 per 1,000 babies born to mothers on lithium. Because the overall incidence of this anomaly in the general population is approximately 1 in 20,000, this yields a rate 20 to 40 times higher than the general population. The absolute risk, however, remains small. Cardiac fetal ultrasound evaluation performed at 16 to 19 weeks of pregnancy can reveal the presence of Ebstein’s anomaly. This may be a useful diagnostic tool to patients who have had first-trimester lithium exposure to aid in decisions regarding pregnancy continuation.
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