Management of bipolar disorder in the perinatal period

Management of bipolar disorder in the perinatal period requires medications to stabilise symptoms and reduce the likelihood of relapse. Assessment and monitoring of the mother–infant interaction is a key part of care of both mother and infant.

Medications

Advice should be sought from a psychiatrist before medications are prescribed, changed or ceased, and the potential risks and benefits to the woman and foetus/baby should be considered. Medication should not be ceased suddenly.

The choice of medications will depend on the range of symptoms. Mood stabilisers are used to treat manic episodes and psychotic symptoms and help reduce relapse. Antipsychotics and antidepressants may also be of benefit.

Medications during pregnancy

If pregnant (or planning pregnancy), women taking mood stabilising drugs should be advised to supplement with high dose folate preconception and in the first trimester (to reduce the small increased risk of birth defects with these drugs) and consult with a psychiatrist.

Sodium valproate and clozapine should not be prescribed to women planning pregnancy or during pregnancy without consulting a psychiatrist.

Lithium is associated with a very small increased risk of birth defects and consultation with a psychiatrist is advised.

Medications during breastfeeding

Given the need for medication and maximising sleep in women with bipolar disorder, the advantages and disadvantages of breastfeeding for mother and baby need to be discussed with the woman and her partner.

Sodium valproate and clozapine should not be used without consultation with a psychiatrist.

Lithium should be used cautiously. Advice should be sought from a psychiatrist if breastfeeding and it is important to ensure close monitoring of the baby by a specialist (e.g. neonatologist/paediatrician).

A woman’s physical activity levels and diet need to be considered if she is taking antipsychotics in the postnatal period (due to their association with weight gain).

Electroconvulsive therapy (ECT)

ECT may be used to treat acute mania, psychosis and severe depression during pregnancy or following the birth. If ECT is used during pregnancy, close monitoring by a psychiatrist, obstetrician and specialist obstetric anaesthetist is required.

Psychological therapies

Psychological therapies such as CBT or IPT can assist women to develop effective coping strategies as they recover. Mother–infant therapy can be useful in promoting mother-infant bonding. Counselling/support is also recommended for the partner and key support people.