Bipolar Disorder Poses Risks for Pregnant Women and Their Children
> 12/6/2007 3:02:07 PM

Bipolar disorder and pregnancy make for a very challenging pair - how can an expectant mother and the professionals directing her care effectively decide on the most appropriate course of treatment? Will the often extreme pharmaceutical regimens necessary to most chronic bipolar patients prove detrimental to the developing fetus? If a woman discontinues her medications, will she relapse, and will the hormonal imbalances in her brain and body affect the baby more than the medication itself? New research and analysis attempts to answer these heretofore unexplored questions.

The most recent study, arguably the first of its kind, involved a group of 89 women previously diagnosed with bipolar disorder who had been euthymic (or generally stable) for at least 4 months and were either planning to conceive or in the early stages of a pregnancy. Some were receiving mood stabilization therapies at the time while others had discontinued their medications less than 6 months before or 12 weeks after conception. Patients moving through the more extreme symptoms of bipolar disorder at the time of the study were thereby excluded, and the remaining subjects were followed during the course of their pregnancy and in the 12 months post-partum. Most of the women were married, educated and employed, and a majority had given birth before. They all sought specialty care, and most were also taking a combination of medications common to bipolar patients, usually a mood stabilizer such as lithium or depakote along with either a complimentary antidepressant or an antipsychotic, at the time of the study (further studies must obviously include more varied subject groups).

Very little research exists relating to mood stabilizers and antipsychotic or antidepressant medications taken during pregnancy, but concerns regarding the safety of the fetus and clinical liability for any subsequent developmental problems lead a surprising 70% of women and their doctors to discontinue all pharmaceutical treatments upon receiving notification of conception. Those concerns, though very imprecisely defined, are valid: depakote and particularly tegretol have been loosely linked to various birth defects, and lithium, though commonly named the safest mood stabilizer, has been tied to a higher instance of Ebstein's anomaly, a condition in which the heart develops an irregular shape and young patients suffer from severe palpitations and fatigue. Ebstein's is very rare even among bipolar mothers, occurring in .05% of all pregnancies, but that number is still 10 to 20 times higher for lithium-medicated patients than for the general population.

Some women remain euthymic for the course of the pregnancy even after discontinuation, but the majority do not. The study noted the risk of relapse for unmedicated women to be 85.5% as opposed to 37% for women who continued their prescriptions; not only did a majority of these patients suffer relapses, but the average was 1.3 relapses per individual, meaning that some in the subject group experienced more than one. Subjects with less severe conditions such as bipolar disorder type II, who typically experienced earlier onset and less extreme symptoms, were most likely to choose to stop taking all medications, but discontinuation predictably led to far more instability on the part of the mother during the pregnancy cycle. Their risk of recurrence was twice as high, the time period between relapses was 4 times smaller, and the amount of time spent affected by the illness was 5 times greater; the average unmedicated patient spent 40% of her pregnancy suffering from bipolar symptoms. Some variations on treatment are possible. Researchers noted that women who gradually tapered their medication fared considerably better than those who dropped their meds quickly or immediately. Within two weeks, a majority of the latter group had experienced some sort of relapse.

While worries over the safety of one's fetus while taking mood stabilizers is understandable, patients who discontinued their medications were not necessarily doing their unborn children any favors. Most relapses took the form of major depressive episodes which threaten to compromise the health of the patient and, therefore, her developing child, especially if their influence continues into the post-partum period; research has also implied a connection between prenatal depression and sleep problems in infants. The relationship between maternal depression/bipolar disorder and childhood disorders is, at best, uncertain. This collected data implies that each affected woman must seriously consider the relatively limited options available to her if she is expecting, but researchers warn against overprotective tendencies, noting that "decisions about continuing or discontinuing pharmacological treatment for mood disorders during pregnancy often are ill-informed, based primarily on fear of psychotropic use during pregnancy."In many cases, continuing to take one's medications may be the best response for the health of both the mother and the child. Until further research comes into play, bipolar patients expecting children must simply educate themselves and weight the available information very carefully.

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