The most recent issue of the New England Journal of Medicine includes the presentation of a case from the Center for Women’s Mental Health of a woman with bipolar disorder who developed postpartum psychosis after the birth of her child. The case highlights some of the clinical challenges in treating patients with bipolar disorder during pregnancy and the postpartum period and reviews the current literature on postpartum psychosis.
This case follows the clinical course of a 35- year-old woman with bipolar disorder across pregnancy and the postpartum period. Prior to conception, she had been stable on a regimen of lithium carbonate and citalopram (Celexa). Against the recommendations of a consulting psychiatrist, the woman discontinued her medications and, within two months, was pregnant. During the course of her pregnancy, she elected to remain off medication despite symptoms of anxiety, insomnia, and dysphoria.
The patient delivered via emergency Caesarean section due to prolonged fetal heart-rate decelerations during labor. For the first 3 days postpartum, the patient seemed stable and was breastfeeding. On the third night, she developed insomnia and later presented with severe disorientation, paranoid delusions and auditory hallucinations. The patient was given haloperidol, lorazepam, and benztropine with the husband’s consent.
The next day, the patient was alert and calm and was transferred to an inpatient psychiatric unit. She was discharged 10 days postpartum on a regimen of valproic acid, lorazepam, and haloperidol. A week after discharge, sertraline (Zoloft) was added due to persistent depression.
Ten days later, the patient was brought to the ER because of intrusive thoughts about harming the baby. She was readmitted and received 8 sessions of ECT. The patient decided to stop breastfeeding, discontinue valproic acid, and began lithium treatment.
She was again readmitted to a psychiatric hospital shortly afterwards due to recurrent auditory hallucinations and intrusive thoughts, where she was treated with olanzapine and citalopram. A week later, the patient’s mood was normal and she was able to care for her baby while working part-time. Her treatment consisted of olanzapine (25mg), citalopram (20mg), and lithium (900mg).
Postpartum psychosis in a woman with bipolar disorder.
Discussion of Management:
Bipolar Disorder during Pregnancy
The likelihood of relapse is greatest soon after an episode of affective illness. At the time of initial consultation, the patient had had two significant episodes within the previous 12-month period; we suggested that the patient delay pregnancy until she was euthymic for at least 6 months. Recent studies have suggested that the risk of relapse during pregnancy is high in women who discontinue treatment with a mood stabilizer. Thus, we also recommend that the patient continue both lithium and citalopram during pregnancy to minimize the risk of relapse.
Despite these recommendations, the patient decided to discontinue all medications and became pregnant within 2 months. The patient also declined treatment when first reporting symptoms of anxiety, depression, and insomnia during pregnancy and remained medication-free throughout her pregnancy.
Postpartum Bipolar Disorder and Psychosis
For women with bipolar disorder, the risk of a postpartum mood disorder (mania or depression) ranges from 50-70%. Postpartum psychosis, the most severe postpartum mood disorder, occurs after 25-50% of deliveries for bipolar women. We typically recommended that women with bipolar disorder resume treatment with a mood stabilizer several weeks before delivery to reduce the risk of postpartum relapse. However, the patient elected to defer treatment.
Given that suicide is the leading cause of maternal mortality, and the majority of women who die by suicide have postpartum psychosis, we instituted a 24-hour monitoring of the patient while she was in the hospital. The family was trained to take over this monitoring after discharge.
Rachel Vanderkruik, BA
Viguera AC, Emmerich AD, Cohen LS. Case 24-2008: A 35-year-old woman with postpartum confusion, agitation, and delusions. N Engl J Med 2008; 359(5): 509-15.
(Click above to see entire publication, including a brief Q&A with other psychiatrists in the field)