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By Nancy Walsh, Staff Writer, MedPage Today
Published: March 08, 2012
Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco.

For pregnant women with a history of postpartum psychosis or bipolar disease, the decisions about prophylaxis to prevent relapse of psychosis should be guided by her past pattern of episodes.
Note that women whose episodes of psychosis occurred only during the postpartum period can avoid prophylaxis during pregnancy whereas patients with bipolar disorder require continuous prophylaxis throughout pregnancy and the postpartum period.
For pregnant women with a history of postpartum psychosis or bipolar disease, the decisions about prophylaxis to prevent relapse of psychosis should be guided by her past pattern of episodes, a Dutch study found.
Women whose episodes of psychosis occurred only during the postpartum period can avoid prophylaxis during pregnancy, as was shown by the finding that no gestational relapses occurred among 29 women with this history, according to Veerle Bergink, MD, and colleagues from the Erasmus Medical Center in Rotterdam.
In contrast, among 41 women with bipolar disorder, 24.4% relapsed during pregnancy (P<0.01), suggesting a strong need for maintenance treatment, the researchers reported online in the American Journal of Psychiatry.
Prevention of postpartum psychosis, which can be a life-threatening event, must balance the mother's need for psychiatric stability with the potentially teratogenic effects of lithium or other drugs.
However, it has not yet been determined whether prophylaxis can begin after delivery or if medication is needed throughout the pregnancy.
To provide clinical data addressing this, Bergink and colleagues conducted a prevention program from 2003 to 2010 among high-risk women referred to their clinic.
The researchers advised women who were stable and off medication at the time of enrollment to remain drug-free throughout pregnancy and to initiate prophylaxis immediately after delivery.
But they recommended that those who were on lithium maintenance remain on the drug.
"It is important to note that the final decision regarding prophylaxis during pregnancy was always made by the patient, following a collaborative discussion to consider the risks and benefits of each pharmacologic treatment option including the potential for teratogenicity and the risk of relapse," the authors wrote.
Women who chose to remain on lithium during pregnancy were on a three-times-daily dosing schedule, to help avoid high blood levels of the drug, and a once-daily schedule after delivery.
Those not on lithium were instructed to start taking the drug once daily beginning the first night after the birth.
Because sleep deprivation is an important risk factor for postpartum psychosis, the women were advised to remain in the hospital for a week after delivery, with nurses providing overnight neonatal care.
The researchers termed it "remarkable" that none of the women with a history of postpartum psychosis experienced a relapse during pregnancy.
However, four did have a postpartum episode and three were hospitalized.
Among the 10 women with bipolar disorder who relapsed during pregnancy, seven who had manic or mixed episodes needed hospitalization.
Postpartum relapses were seen in 22% of the bipolar women, including three who also had relapsed while pregnant.
Eight of the bipolar women had previously had both pregnancy-related and non-pregnancy-related episodes; half of this group had peripartum relapses during the study.
A total of 20 of the 29 women whose history included only postpartum episodes of psychosis initiated treatment within a day of delivery. None of these women relapsed.
The other nine women who declined medication -- generally because they wanted to breastfeed -- had a relapse rate of 44.4%, which was a significant difference compared with those on medication (P<0.01).
Among the bipolar women, 19.4% of those using prophylaxis relapsed during pregnancy, compared with 40% of those not on prophylaxis.
The prophylactic medication most commonly was lithium in this group, but a few also used an antipsychotic or antidepressant.
And even with medication, 60% of bipolar women who had pregnancy relapses also had postpartum relapses (OR 14, 95% CI 2.5 to 80, P<0.01), the researchers found.
"In bipolar women, prophylaxis during pregnancy appears critically important for maintaining mood stability during pregnancy and for minimizing the high risk of postpartum relapse," observed Bergink and colleagues.
In comparison, women who are not bipolar but who have had a past episode of postpartum psychosis may be able to remain medication-free during pregnancy and begin prophylaxis immediately after giving birth, according to the researchers.
A limitation of the study was its naturalistic design, although that could also be considered a strength because it reflects the real-world experience of affected women, they noted.
Future studies should more fully explore the efficacy of other pharmacologic options for prophylaxis.
The study was supported by the European Commission for FP7-Health-2007, the NeuroBasic-PharmaPhenomics consortium, and the Netherlands Organization for Scientific Research.
Primary source: American Journal of Psychiatry
Source reference:
Bergink V, et al "Prevention of postpartum psychosis and mania in women at high risk" Am J Psychiatry 2012; DOI: 10.1176/apppi.ajp.2012.11071047.


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