Multiple studies have demonstrated that the postpartum period is a time of increased vulnerability in women with bipolar disorder.  However, because many of the commonly used mood stabilizers carry some teratogenic risk, many women elect to discontinue use of mood stabilizers during pregnancy. A recent study from Italy has examined risk for postpartum illness in a group of women with bipolar disorder who discontinued their medication during pregnancy.

The researchers reviewed the medical records of 276 women with bipolar disorder who were medication-free during pregnancy. Rates of postpartum illness were very high; 270 women (75.0 %) had one or more postpartum mood episodes.  Depressive episodes (79.7 %) were more common than (hypo)manic (16.4 %), or mixed (3.9 %) episodes.

Psychotic symptoms were present in 63 of the women (22.8%).  Psychotic symptoms were less commonly associated with depression (37 women or 22.4 %), than with mania (19 or 67.8 %) or  with mixed episodes in (7 or 87.5 %).  Women with postpartum manic and mixed episodes were more likely to have type I disorder and were more likely to exhibit psychotic features.

These findings are consistent with previous studies which have demonstrated high rates of postpartum illness in women with bipolar disorder.  Given the clear and consistent finding that rates of postpartum relapse are high in women with bipolar disorder and that lithium prophylaxis significantly decreases the risk of postpartum relapse, we recommend that all women with bipolar disorder receive prophylaxis with a mood stabilizer during the postpartum period.

While this is what we strongly recommend, some questions remain.  We do not yet have data supporting the prophylactic effects of mood stabilizers other than lithium, so what is recommended for a woman who is a lithium non-responder or who has never tried lithium?  Typically we select for prophylaxis a regimen that has worked well in the past for that particular patient.  This may be an anticonvulsant, such as valproic acid or lamotrigine, or more commonly we are seeing women maintained on atypical antipsychotic agents.

Ruta Nonacs, MD PhD

Maina G, Rosso G, Aguglia A, Bogetto F.  Recurrence rates of bipolar disorder during the postpartum period: a study on 276 medication-free Italian women.  Arch Womens Ment Health. 2014 Oct;17(5):367-72.