A recent webinar,  Bipolar, Pregnancy and Childbirth was part of the collaboration between Bipolar UK and the National Centre for Mental Health (NCMH) of which Prof. Jones is Director. Here we try to answer some of those extra questions sent in but not answered at that time. Because there were so many questions, we’ve grouped some together.

Questions relating to medication

 1. General guidance

We’re afraid we can’t give any advice to individual women about the right and wrong decisions about medications in pregnancy and when breastfeeding: your own personal history should be discussed with your clinician. 

We can, however, make some general points:

• For some women, carrying on medication they are taking for their bipolar through pregnancy may be the right decision. For others coming off medication or switching medication will also be an option to consider. The important point is that this must be a decision made with each woman individually - taking into account their experience of bipolar and their response to various treatments. There are often no right or wrong options - but it’s important to find the best decision for you.
• These decisions are best considered as early as possible and it’s important to have these discussions with your psychiatrist, mental health team or GP. Even if you are not thinking of trying for a baby for some time it’s never too early to raise the issue of future pregnancy. Ask if there is a specialist perinatal mental health team you could be referred to.
• If you find out you are pregnant unexpectedly its best not to stop your medication suddenly - but make an appointment as soon as you can to discuss your options with the doctor who prescribes the medication.
• One particular medication that is a problem in pregnancy is sodium valproate (also known as Depakote and Epilim and other names in other countries). If you are on this medication you should discuss this with your doctor as this is one medication which is banned in pregnancy.

2. Lithium

There were several questions about lithium which in the past was thought to be too risky to take in pregnancy.  However more recent research has shown the risks were exaggerated and many women who have very bad episodes when off medication decide the risks of becoming very ill (and the baby being further exposed to medication as a result) outweigh the risk of taking lithium and so continue.  This is a good example of why you need to have a detailed conversation with a psychiatrist – preferably a specialist perinatal psychiatrist – to help you understand the research and weigh up the options, whether you take lithium or other medication. You also need to consider after the birth as some women who stop medication in pregnancy, go back on it immediately the baby is born to reduce the chances of suffering a postpartum psychosis (see Clare’s example in the webinar). There are antipsychotic medications that you can take when breast-feeding but lithium is not considered to be one of them, and if you’re bottle-feeding you have a better chance of getting that all-important sleep. You need to talk through these options with your perinatal team and decide what’s best for you.

 

Questions relating to how to cope with pregnancy, particularly in relation to getting enough sleep, and what support there is for women with bipolar during pregnancy and after birth?

Best to refer you to the 10 Top Tips for keeping well:

• Plan ahead If you’re able to see a specialist Perinatal Mental Health team for preconception advice (you’re entitled to this so make sure your GP or psychiatrist refers you), then make full use of the appointments: one for preconception advice and then when your pregnancy is established to discuss the birth and afterwards. Do take your partner or someone else to support you and don’t worry about trying to write it all down as the psychiatrist will send you a detailed letter afterwards.
• I’d also recommend writing an Advanced Directive or Statement so you can cover some of the issues that might arise if you do become unwell – the link above takes you to a blog about this on the Bipolar UK website. There is also  a video interview Mothers on the edge  with friends of mine Henry and Jenny talking about how doing this really helped them when she had to go to an MBU after the birth of their second child.
• Try to avoid major life changes like moving house, often on the agenda because of needing more room, but it might be better to wait a year or so – the baby won't mind!
• Minimize stress – whether that means taking more time off work if you possibly can or practicing yoga or meditation to stay calm.
• Sleep is of paramount importance – we all know that but keep it constantly in mind: for example, ask for a private room at the hospital and, if you’re breastfeeding, investigate mixed feeding and expressing – get the necessary sterilising equipment ready.
• If you can, organise help for when you have the baby. Don’t try to be Super Mum – no one is – ask for help and if you can get someone to help with night feeds for a couple of weeks, don’t hesitate!
• Consider carefully the pros and cons of breastfeeding in your situation. I was keen to do it, but in retrospect, it would have been wiser to bottle-feed and start on lithium immediately my daughter was born.
• Try to get home to a more relaxing atmosphere as soon as you can, and don’t have too many visitors. Involve your partner so he/she can judge whether you're getting over-tired /over-stimulated.
• It goes without saying that you need to be as physically healthy as you can; don't smoke, drink etc., do moderate exercise; Try to eat well and keep your weight down but don't put pressure on yourself to be ‘the perfect mum’. As I said it's not the end of the world if you don't breastfeed, or if you need some extra help.
• I’m repeating ‘planning ahead’ as it’s such a good idea – and it can help keep you stay calm during the pregnancy and birth too because you feel more in control and reassured that you have back-up plans in place if your mood starts to be a problem – and you’re not completely thrown if they do. Remember that no-one can predict what’s going to happen in childbirth or afterwards with or without bipolar so every pregnant mum should keep an open mind – but being as prepared as possible for any contingency will make it easier to deal with whatever fate throws at you.

 

Questions about Fertility

Certain medications can impact fertility so it’s important to find that out and get advice early on (there are blood tests that may help identify whether this is an issue or not). As to the possible effects of fertility treatment on mood, or whether barriers exist to women with bipolar accessing such treatment, there hasn’t been research done.  Ian commented that many couples who have sought his advice have also accessed fertility treatment.

 

Postpartum treatment: how long do you have to stay on medication?

Prof Jones: This is an excellent question - and not one with a simple answer. It will depend on the individual woman and other factors such as if the treatment was for a postpartum episode of illness - or to keep a woman well who is at high risk but who did not suffer an episode of illness. There are a couple of important points to make, however.

• First, we know that stopping medication too early can result in a severe recurrence. For most women therefore, staying on medication for at least a year - maybe even two years would be sensible. If a woman has had previous episodes of illness staying on even longer would be a good plan.
• Second, for women taking medication in the postpartum because they are high risk, the risk remains for some months following delivery so even if there’s no immediate episode of illness, staying on for between 6 months and a year may be a good option.

The important point is to discuss this with the clinical team to understand the thinking and make a plan.

 

Psychosis risk

We don’t have any evidence that the method of birth impacts the level of risk; we also need more research to understand better how medication can impact on risk for women with bipolar disorder. For many women, if stable on a medication regime, it is likely that continuing medication though the postpartum period will reduce the risk of a serious recurrence. Discussing the various options with your clinicians is important to come up with a plan together.

For around 50% of women with postpartum psychosis they will have had previous episodes of illness, often bipolar. Therefore in around 50% of women with postpartum psychosis it comes “out of the blue” with no previous mental health conditions. Around 50% of these women will go on to have further episodes of illness - most commonly bipolar episodes - but some women may only have the PP episodes. It would be great to understand better how to predict these outcomes - so more research definitely needed.

What is the risk of postpartum psychosis for anyone whose mother has Bipolar 1 and had postpartum psychosis?  Should this risk be approached in the same manner as for someone who has bipolar themselves?

Prof Jones: This is a really important question - as for many health conditions vulnerability to Bipolar and postpartum psychosis run in families. If your mother has had an episode of postpartum psychosis then your risk is higher of experiencing postpartum psychosis but the risk of postpartum psychosis is only around 1 in 1,000 in the general population and although higher if there’s a family history, may still only be around 20 or 30 per 1,000 (so 2 or 3%). That means that it’s much more likely (97% or 98%) that you won’t experience it.

However, if a woman has experience of bipolar herself the risk is much higher. For women with bipolar whose mother had PP the risk may be 50% or more so discussing these risks with a clinician can be very helpful. We can see women in Cardiff (over videoconference) to discuss these risks if getting an appointment locally is difficult - contact Cheryl Buchanan, Clinic Coordinator at [email protected]

 

Can you ever totally mitigate the risk? Will there always be a risk no matter what you do?

Prof Jones: This is an excellent point - as in life in general - we can’t take all risk away. What is very important to remember is that however well prepared you are there will always be a risk of becoming unwell - and it’s so important that if this happens you don’t blame yourself or others.

 

One woman asked if it was irresponsible to choose to become a single parent while having bipolar, without the support of a partner?

Clare: This is something you can only judge for yourself after weighing up the risks, your contingency plans and the level of support you have from family and friends as you’ll need to call on them more than a couple would. Think about things like how often you have episodes, how severe they are, how well you’re able to stick to your medication and sleep regimes, whether you suffer from any other health problems.  Imagine yourself as your child and what it might be like for them - if you don’t tot up too many negatives there may be some positives too: your energy and enthusiasm; how very loved they would be.

 

Hyperemesis: we were asked what can you do if you suffer with this extreme nausea and sickness in pregnancy but can’t keep down your medications for bipolar?

This is very hard for someone to deal with. Perhaps a preconception appointment with an obstetrician/ obstetric medicine physician might be helpful to discuss ways to manage the hyperemesis and maybe a plan to see a psychologist during pregnancy to use some psychological strategies to manage mood changes? Obviously to be under the care of a perinatal team in pregnancy. And a plan to ensure effective doses of medication immediately postnatally even if you can't manage to take medication well in pregnancy.

 

Do you have any words of encouragement to us... we're a married couple, looking to starting a family soon. I would love to hear some positive/good news stories of bipolar women who have been through and handled postpartum well, and come through the other side :)

Yes! I know scores and scores of women with bipolar who’ve had children and not one of them ever said they regretted it: quite the opposite. Couples who think very deeply about whether they want a child and how much they want a child are likely to do everything they can to be great parents and that mostly involves that child knowing how loved they are. By them and by their extended family. So arm yourself with knowledge and a contingency plan and good luck! :)  

 

Learning more

If you are pregnant, it would be wonderful if you could help with research into how bipolar and pregnancy affect each other. Visit Bipolar disorder, pregnancy and childbirth

You can also go to the Pregnancy & Parenting thread on the Bipolar UK eCommunity for more information and peer support.

Or check out the information on pregnancy and parenting on Pendulum: our blog. 

If you missed the webinar, it is available to view at  Pregnancy: 10 tips for staying well