For women at risk of PPP, the risks of medications need to be balanced with the risks of untreated illness. To reduce the risk of PPP relapse, guidelines recommend a robust antenatal care plan that should include37,38:
- close monitoring of a woman’s mental state for early warning signs of PPP, with active participation from the woman’s partner and family
- ongoing discussion of the risks and benefits of pharmacotherapy (and, for women who prefer to not take medication in the first trimester, a plan for when medications will be restarted)
- collaboration with other professionals involved in care during pregnancy and postpartum (eg, obstetricians, midwives, family practitioners, pediatricians)
- planning to minimize risk factors associated with relapse (eg, sleep deprivation, lack of social supports, domestic violence, and substance abuse).
Evidence clearly suggests that women with bipolar disorder are at increased risk for illness recurrence without continued maintenance medication.39 A subgroup of women with PPP go on to have psychosis limited to the postpartum period, and reinstating prophylactic medication in late pregnancy (preferably) or immediately after birth should be discussed.2 The choice of prophylactic medication should be determined by the woman’s previous response.
Regarding prophylaxis, the most evidence exists for lithium.6 Lithium use during the first trimester carries a risk of Ebstein’s anomaly. However, a recent systematic review and meta-analysis have concluded that the teratogenic risks of lithium have been overestimated.40,41
Lamotrigine is an alternative mood stabilizer with a favorable safety profile in pregnancy. In a small naturalistic study in which lamotrigine was continued in pregnancy in women with bipolar disorder, the medication was effective in preventing relapse in pregnancy and postpartum.42 A small population-based cohort study found lamotrigine was as effective as lithium in preventing severe postpartum relapse in women with bipolar disorder,43 although this study was limited by its observational design. Recently published studies have found no significant association between lamotrigine use in pregnancy and congenital malformations.44,45 While recent evidence suggests that lamotrigine is a reasonable option for treating bipolar disorder during pregnancy, further research is warranted to determine the best clinical practice.46 The Box30,47,48 provides more information regarding prophylactic medications in pregnancy.
It is essential to consider the patient’s individual symptoms and treatment history when making pharmacologic recommendations during pregnancy. Discussion with the patient about the risks and benefits of lithium is recommended. For women who continue to use lithium during pregnancy, ongoing pharmacokinetic changes warrant more frequent monitoring (some experts advise monthly monitoring throughout pregnancy, moving to more frequent monitoring at 36 weeks).47 During labor, the team might consider temporary cessation of lithium and particular attention to hydration status.30 In the postpartum period, there is a quick return to baseline glomerular filtration rate and a rapid decrease in vascular volume, so it is advisable to restart the patient at her pre-pregnancy lithium dosage. It is recommended to check lithium levels within 24 hours of delivery.47 While lithium is not an absolute contraindication to breastfeeding, there is particular concern in situations of prematurity or neonatal dehydration. Collaboration with and close monitoring by the pediatrician is essential to determine an infant monitoring plan.48
If lamotrigine is used during pregnancy, be aware that pregnancy-related pharmacokinetic changes result in increased lamotrigine clearance, which will vary in magnitude among individuals. Faster clearance may necessitate dose increases during pregnancy and a taper back to pre-pregnancy dose in the postpartum period. Dosing should always take clinical symptoms into account.
Pharmacotherapy can reduce relapse risk
To prevent relapse in the postpartum period, consider initiating treatment with mood stabilizers and/or SGAs, particularly for women with bipolar disorder who do not take medication during pregnancy. A recent meta-analysis found a high postpartum relapse rate (66%) in women with bipolar disorder who did not take prophylactic medication, compared with a relapse rate of 23% for women who did take such medication. In women with psychosis limited to the postpartum period, prophylaxis with lithium or antipsychotics in the immediate postpartum can prevent relapse.39 The SGAs olanzapine and quetiapine are often used to manage acute symptoms because they are considered acceptable during breastfeeding.33 The use of lithium when breastfeeding is complex to manage48 and may require advice to not breastfeed, which can be an important consideration for patients and their families.
Postpartum psychosis (PPP) typically presents with a rapid onset of hallucinations, delusions, confusion, and mood swings within days to weeks of giving birth. Mothers with PPP almost always require hospitalization for the safety of their infants and themselves. Mood stabilizers and second-generation antipsychotics are used for acute management.
- Clark CT, Wisner KL. Treatment of peripartum bipolar disorder. Obstet Gynecol Clin N Am. 2018;45:403-417.
- Massachusetts General Hospital Center for Women’s Mental Health. https://womensmentalhealth.org/. 2018.
- Postpartum Support International. Postpartum psychosis. http://www.postpartum.net/learn-more/postpartumpsychosis/. 2019.
Drug Brand Names
Bromocriptine • Cycloset, Parlodel
Cabergoline • Dostinex
Lamotrigine • Lamictal
Lithium • Eskalith, Lithobid
Olanzapine • Zyprexa
Quetiapine • Seroquel