Bipolar and other maternal health in peripartum

1. Postpartum Psychosis

most severe of the perinatal mood disorders
0.1 to 0.2%
escalates rapidly to florid psychosis within days
- presentation for treatment within 3 weeks
commonly associated with bipolar, unipolar dep, or FHx of affective disorder
hallucinations, disorientation/delirium, paranoid/grandiose delusions are common with high levels of impulsivity and impaired judgement
~20% shift to bipolar after 10 years (one study)
~30% never have another psychotic episode even without medication

medical emergency
risk of infanticide or suicide
imminent hospitalization and initiation of antipsychotic is indicated
70% increased risk of suicide in first 12 months postpartum
- peak rates: days to weeks post-discharge
infanticide
- 24% context of acute maternal psychosis
- 56% altruistic beliefs about alleviating suffering of the infant, often accompanied by maternal suicide

if treated aggressively and recognized early: good prognosis
maintenance of antipsychotics as per standard treatment
high-dose estradiol administered postdelivery was shown to reduce the risk of recurrent postpartum psychosis (open study, not replicated)

higher risk of non-psychotic, non-manic episode in perinatal period
50% of BD I women had perinatal mood episodes
- 25% non-psychotic mania
- 20% mania or psychotic depression
episodes are notable for short post-partum latency
- also more postpartum incidence vs pregnancy
BD II: more varying timeline
as many as 50% of cases of bipolar can present as unipolar PPD

Somatic treatments are the front-line
important: enlists supports to prevent sleep disruption and stabilize social rhythms in new mothers
CANMAT: 85% of women with BD who discontinue mood stabilizers relapse
CANMAT: 37% of women with BD who maintain treatment relapse
CANMAT: median time to relapse with abrupt d/c: 2 weeks
- 22 weeks for gradual taper
recurrence after discontinuation of treatment: 50% in pregnant and non-pregnant women, 3x higher in postpartum period vs non-postpartum
discontinuing mood stabilizer increases risk of relapse by 2x, still have recurrence rates of 20-25%.
- for recurrence: 50% of the time happens in first trimester
lithium prophylaxis in late pregnancy or with 24 hours postbirth has been associated with 10x decrease in rate of postpartum illness recurrence
- for unresponsive illness, benzo, antipsychotics, ECT have an important role
- low-dose mid-potency antipsychotic can be PRN for prodromal or breakthrough symptoms

Because the assessment of perinatal disorders can be confounded by somatic complaints common to the perinatal period, such as sleep and eating disturbances, decreased sexual interest, weight gain, and fatigue, widespread use of the Edinburgh Postnatal Scale for Depression, which de- emphasizes such symptoms, has become a common instrument utilized by obstetricians, family doctors, psychiatrists, and pediatricians.
EPDS is sensitive to symptoms of depression and anxiety and does not distinguish between them
A high index of suspicion is warranted in women with severe, early-onset postpartum disorder.

"hormonal triggers" are poorly understood
CRH, cortisol, estradiol, progesterone
withdrawal of estrogen and progesterone in 2-7 days portpartum can induce depressive relapse (but not in women without such hx)
CNS corticolimbic connectivity can be affected by hormonal changes
gestationally elevated CRH and reduced oxytocin, and prolonged blunting of the postpartum HPA axis have been associated with perinatal depression in, as yet, unreplicated studies
fMRI of new mothers activates brain regions associated with reward (striatum, midbrain, orbitofrontal cortex), empathy (superior temporal sulcus), emotional appraisal (insula and amygdala), and emotion–cognition integration centers (anteriorcingulate gyrus) with transitions to the maternal role. Depressed mothers activate this circuitry to a lower extent.

Sleep has a critical role. However, maternal sleep deprivation is a common, if not universal, consequence of the infant’s lack of a circadian rest–activity cycle, but in and of itself does not result in a major depressive disorder
identity transition, and a disruption of life’s routine including relationships, work, sleep, exercise, nutrition and finances. High social stress, marital discord, minority status, adolescence, and neuroticism

changes composition as infant ages
reduces food allergies, confers passive immunity, timely neuronal development
feed as needed, not by schedule
encourage breast-feeding
formulas are ok if breast-feeding can't be done
studies are inconsistent regarding whether lactation is protective or aversive for mental health
- skin-to-skin contact has important emotion-regulatory influences for both

most meds are category C, lithium, divalproex, paroxetine are D
- bupropion and clozapine are B
avoid divalproex
- loss of 9 IQ points, significant neurodev delay, 5% neural tube defects
higher dose of meds in late 2nd and 3rd trimester (more plasma volume, hapatic activity, renal clearance)

dearth of evidence
efficacy for benzo, antipsychotic, lithium for postpartum mania
quetiapine for bipolar PPD
no studies for acute treatment of bipolar PPD
encourage immediate initiation or optimization of what has worked before
in postpartum, follow normal guidelines considering breast-milk excretion risk: FDA PLLR
quetiapine and olanzapine were preferred for breastfeeding: lower infant dosage
schedule meds after breastfeeding
In women with postpartum psychosis or mania, breastfeeding may be more risky, and therefore may not be indicated, as the mother may be too disorganized to safely breastfeed
As childbirth can be a trigger for first onset of hypomania/mania in women with MDD, antidepressants should be used cautiously, especially in women with a family history of BD
Women with first onset of depression in the postpartum period or those who have recurrence of depression during the early postpartum period, may also be at a high risk of switching to BD following treatment with antidepressants