Lamotrigine (Lamictal) has been effectively used for the maintenance treatment of bipolar disorder. Many women suffering from bipolar disorder are of childbearing age; therefore an adequate contraception is a major concern that needs to be addressed in this population.
Post-Traumatic Stress Disorder (PTSD) after childbirth is an understudied condition. Traditionally, much of the data have been based on case reports, indicating that PTSD can occur following a range of childbirth and child loss situations, including long or complicated labor, severe pain with labor or delivery, cesarean section, and unanticipated pregnancy outcome, such as child loss, miscarriage or infant birth defects. PTSD related to childbirth is frequently overlooked by physicians; the relative newness of the diagnosis and lack of literature on this topic are factors which may hinder recognition of this disorder.
At our clinic we have the opportunity to see patients at various stages of pregnancy. When we evaluate a patient while she is still in the planning stages, we may recommend changing medications to those that have a better studied safety profile during pregnancy and see how she does on those medications prior to conception. If that same patient came into our clinic for an evaluation, but was already pregnant, we may make different recommendations than if she was in the planning stages.
Most women experience some degree of sleep disturbance during pregnancy, and for a significant number of women sleep disruption may be quite severe. There are many different causes for sleep disturbance during pregnancy, and choosing the appropriate intervention relies on an accurate diagnosis of the problem.
Polycystic ovarian syndrome (PCOS) occurs in 4-7% of women and is characterized by irregular menstrual cycles and hyperandrogenism (facial hair, acne, male-pattern hair loss, acne, or elevated male hormone levels). The majority of women with PCOS also suffer from obesity and insulin resistance. PCOS has been associated with a spectrum of health problems including infertility, diabetes, and possibly heart disease and endometrial cancer. Recently there has been concern that women with bipolar disorder who are treated with the mood stabilizer valproate (VPA; brand name Depakote or Depakene), may be at higher risk for PCOS, although the data have been somewhat conflicting.
While there have been concerns regarding the reproductive safety of psychotropic medications, it must be recognized that withholding or withdrawing pharmacologic treatment for depression or anxiety during pregnancy may not always be the safest option. Untreated psychiatric illness in the mother cannot be considered a benign event, and a number of studies have indicated that depression during pregnancy may negatively affect pregnancy outcomes (reviewed in Bonari 2004).
Depression affects women almost twice as often as men, with about one in four women suffering from it in her lifetime. While depression may strike at any time, studies show that women are particularly vulnerable during their childbearing years.
Early reports suggested that women with bipolar disorder may be at lower risk for onset or relapse of this disorder during pregnancy and that some women may be able to remain well during pregnancy despite medication discontinuation. However, more recent studies have suggested that recurrence of affective illness during pregnancy is relatively common among women with bipolar disorder. Dr. Adele Viguera and her colleagues at the Center for Women's Mental Health reported that among pregnant bipolar women, relapse rates were very high (58%) in those women who discontinued maintenance treatment with lithium during pregnancy (Viguera et al 2000).
Because rates of postpartum illness are very high in women with bipolar disorder, it is generally recommended that mothers continue treatment with a mood stabilizer throughout the postpartum period to reduce their risk of relapse; however, the use of medications during the postpartum period is complicated by the issue of breastfeeding. All medications are secreted into the breast milk, although their concentrations appear to vary (Chaudron and Jefferson, 2000).
Unfortunately the mood stabilizers most commonly used to treat bipolar disorder (including lithium and valproic acid) can increase the risk of certain types of congenital malformations in children exposed to these medications during the first trimester of pregnancy. For women who need a mood stabilizer during pregnancy, lithium is the safest option; however, when used during the first trimester, it carries a 0.1% risk of a cardiac malformation called Ebstein's anomaly. Although this is a potentially serious complication, it is important to keep in mind that the risk of malformation is relatively small.
