Bipolar and other maternal health in peripartum

Table of Contents

1. Postpartum Psychosis

  • most severe of the perinatal mood disorders
  • 0.1 to 0.2%
  • escalates rapidly to florid psychosis within days
    • presentation for treatment within 3 weeks
  • commonly associated with bipolar, unipolar dep, or FHx of affective disorder
  • hallucinations, disorientation/delirium, paranoid/grandiose delusions are common with high levels of impulsivity and impaired judgement
  • ~20% shift to bipolar after 10 years (one study)
  • ~30% never have another psychotic episode even without medication

1.1. Risks

  • medical emergency
  • risk of infanticide or suicide
  • imminent hospitalization and initiation of antipsychotic is indicated
  • 70% increased risk of suicide in first 12 months postpartum
    • peak rates: days to weeks post-discharge
  • infanticide
    • 24% context of acute maternal psychosis
    • 56% altruistic beliefs about alleviating suffering of the infant, often accompanied by maternal suicide

1.2. Prognosis

  • if treated aggressively and recognized early: good prognosis
  • maintenance of antipsychotics as per standard treatment
  • high-dose estradiol administered postdelivery was shown to reduce the risk of recurrent postpartum psychosis (open study, not replicated)

2. Bipolar

  • higher risk of non-psychotic, non-manic episode in perinatal period
  • 50% of BD I women had perinatal mood episodes
    • 25% non-psychotic mania
    • 20% mania or psychotic depression
  • episodes are notable for short post-partum latency
    • also more postpartum incidence vs pregnancy
  • BD II: more varying timeline
  • as many as 50% of cases of bipolar can present as unipolar PPD

2.1. Risks and treatment

  • Somatic treatments are the front-line
  • important: enlists supports to prevent sleep disruption and stabilize social rhythms in new mothers
  • CANMAT: 85% of women with BD who discontinue mood stabilizers relapse
  • CANMAT: 37% of women with BD who maintain treatment relapse
  • CANMAT: median time to relapse with abrupt d/c: 2 weeks
    • 22 weeks for gradual taper
  • recurrence after discontinuation of treatment: 50% in pregnant and non-pregnant women, 3x higher in postpartum period vs non-postpartum
  • discontinuing mood stabilizer increases risk of relapse by 2x, still have recurrence rates of 20-25%.
    • for recurrence: 50% of the time happens in first trimester
  • lithium prophylaxis in late pregnancy or with 24 hours postbirth has been associated with 10x decrease in rate of postpartum illness recurrence
    • for unresponsive illness, benzo, antipsychotics, ECT have an important role
    • low-dose mid-potency antipsychotic can be PRN for prodromal or breakthrough symptoms

2.2. Screening

  • Because the assessment of perinatal disorders can be confounded by somatic complaints common to the perinatal period, such as sleep and eating disturbances, decreased sexual interest, weight gain, and fatigue, widespread use of the Edinburgh Postnatal Scale for Depression, which de- emphasizes such symptoms, has become a common instrument utilized by obstetricians, family doctors, psychiatrists, and pediatricians.
  • EPDS is sensitive to symptoms of depression and anxiety and does not distinguish between them
  • A high index of suspicion is warranted in women with severe, early-onset postpartum disorder.

2.3. Mechanism/Etiology

  • "hormonal triggers" are poorly understood
  • CRH, cortisol, estradiol, progesterone
  • withdrawal of estrogen and progesterone in 2-7 days portpartum can induce depressive relapse (but not in women without such hx)
  • CNS corticolimbic connectivity can be affected by hormonal changes
  • gestationally elevated CRH and reduced oxytocin, and prolonged blunting of the postpartum HPA axis have been associated with perinatal depression in, as yet, unreplicated studies
  • fMRI of new mothers activates brain regions associated with reward (striatum, midbrain, orbitofrontal cortex), empathy (superior temporal sulcus), emotional appraisal (insula and amygdala), and emotion–cognition integration centers (anteriorcingulate gyrus) with transitions to the maternal role. Depressed mothers activate this circuitry to a lower extent.

2.4. Risk factors

  • Sleep has a critical role. However, maternal sleep deprivation is a common, if not universal, consequence of the infant’s lack of a circadian rest–activity cycle, but in and of itself does not result in a major depressive disorder
  • identity transition, and a disruption of life’s routine including relationships, work, sleep, exercise, nutrition and finances. High social stress, marital discord, minority status, adolescence, and neuroticism

3. Breast-feeding

  • changes composition as infant ages
  • reduces food allergies, confers passive immunity, timely neuronal development
  • feed as needed, not by schedule
  • encourage breast-feeding
  • formulas are ok if breast-feeding can't be done
  • studies are inconsistent regarding whether lactation is protective or aversive for mental health
    • skin-to-skin contact has important emotion-regulatory influences for both

4. Resourcecs

5. Treatment (CANMAT)

5.1. In pregnancy

  • most meds are category C, lithium, divalproex, paroxetine are D
    • bupropion and clozapine are B
  • avoid divalproex
    • loss of 9 IQ points, significant neurodev delay, 5% neural tube defects
  • higher dose of meds in late 2nd and 3rd trimester (more plasma volume, hapatic activity, renal clearance)

5.2. Post-partum

  • dearth of evidence
  • efficacy for benzo, antipsychotic, lithium for postpartum mania
  • quetiapine for bipolar PPD
  • no studies for acute treatment of bipolar PPD
  • encourage immediate initiation or optimization of what has worked before
  • in postpartum, follow normal guidelines considering breast-milk excretion risk: FDA PLLR
  • quetiapine and olanzapine were preferred for breastfeeding: lower infant dosage
  • schedule meds after breastfeeding
  • In women with postpartum psychosis or mania, breastfeeding may be more risky, and therefore may not be indicated, as the mother may be too disorganized to safely breastfeed
  • As childbirth can be a trigger for first onset of hypomania/mania in women with MDD, antidepressants should be used cautiously, especially in women with a family history of BD
  • Women with first onset of depression in the postpartum period or those who have recurrence of depression during the early postpartum period, may also be at a high risk of switching to BD following treatment with antidepressants

Author: Armin

Created: 2022-08-17 Wed 13:18