Bipolar affective disorder, postpartum psychosis, schizophrenia and related conditions

Mental health in pregnancy and after birth (SIGN)

Women/birthing parents with a complex mental illness require additional multidisciplinary support during the perinatal period and may benefit from psychological therapies to manage secondary anxiety, depression or other related difficulties such as trauma.

Women/birthing parents with bipolar affective disorder are at particular risk of relapse during the perinatal period, relating both to the risk of postpartum psychosis, antenatal relapse and postpartum depression. Severity of illness (bipolar I disorder compared to bipolar II disorder) is associated with a varying degree of relapse risk. Schizoaffective disorder carries a similarly high risk of relapse.

Postpartum psychosis requires specialist intervention and often inpatient care to a mother and baby unit. Women/birthing parents, families and services need to be aware of the predisposing risk factors for this condition, identify warning signs and have access to pre-conceptual care and support during pregnancy to reduce risks of relapse, including avoidance of prolonged sleep disruption. (see pre-conceptual and care planning sections in full guideline for more information).

Use of high-dose folic acid (5 mg/day), particularly in the first trimester, should be encouraged to reduce the risk of fetal malformation, particularly where an anticonvulsant medication is prescribed.

See the full guideline for more information.

Psychological therapies

Consider psychological interventions for women/birthing parents with bipolar affective disorder. This inludes:

cognitive behavioural therapy, interpersonal therapy and behavioural couples therapy for bipolar depression,
structured, individual and group family interventions for bipolar disorder to reduce the risk of relapse, particularly when medication is changed or stopped.

For women/birthing parents with a diagnosis of psychosis or schizophrenia, who become pregnant and are at risk of relapse, considering a psychological intervention such as cognitive behavioural therapy or family intervention.

Pharmacological therapies

Further general prescribing advice can be found in the use of pharmacological treatments section.

Choice of medication

Antipsychotic medications have a more favourable risk/benefit ratio than valproate and carbamazepine, and possibly a better reproductive safety profile than lamotrigine and lithium.
For women established on lithium therapy, stopping treatment during pregnancy is associated with an increased risk of relapse. It may be advisable to continue treatment during pregnancy and in the postnatal period. Close monitoring of litihium levels and dose during pregnancy are required.
Due to reproductive safety concerns use of anticonvulsant mood stabilisers during pregnancy should be limited to where alternative treatments have been ineffective or not tolerated.

Antipsychotic medication

Choice of antipsychotic should be based on the pregnant woman/birthing parent’s previous response to treatment, risk of relapse of switching treatment and their preference (including their wish to breastfeed or not).

Do not offer depot injection antipsychotics to a woman/birthing parent who is planning a pregnancy, pregnant or considering breastfeeding, unless they are responding well to a depot, there is a high risk of relapse and has had a previous history of non-adherence with oral medication.

Consider that infants exposed to medication in pregnancy may be at risk of adverse effects and may require additional monitoring after birth. Monitoring should be individualised and considered as part of multidisciplinary birth planning taking into consideration the medication dose, polypharmacy, infant feeding and infant vulnerability such as risk of preterm delivery, low birth weight and any obstetric complications.

Use antipsychotics to treat psychotic symptoms in pregnant women/birthing parents.

Use caution when prescribing metabolic-inducing antipsychotics to pregnant women/birthing parents, due to the increased risk of gestational diabetes.

If women/birthing parents commence or continue metabolic-inducing antipsychotic treatment during pregnancy, (such as olanzapine, clozapine, quetiapine) consider screening and monitoring for gestational diabetes (as per local protocols).

If considering use of clozapine in pregnant women/birthing parents, seek specialist psychiatric consultation.

Mood stabilisers

Prior to conception, there may be an opportunity to rationalise medication to reduce polypharmacy while continuing to ensure effective treatment and minimisation of risk of relapse.

Sodium valproate is contraindicated in women and potential birthing parents of childbearing age, due to associated high risks of congential abnormality and neurodevelopmental disability.

There is increased risk of major congenital malformation associated with use of carbamezapine. There is emerging evidence of risk with use of pregabalin. The evidence of risk associated with gabapentin and lamotrigine is unclear.

Use great caution in prescribing anticonvulsants as mood stabilisers for pregnant women/birthing parents and seek specialist psychiatric consultation when doing so. Consider alternatives to mood stabilisers such as antipsychotic therapy.

Given their teratogenicity, only consider prescribing anticonvulsants (especially valproate) to women/people of childbearing age if other options are ineffective or not tolerated and effective contraception is in place.

Provide high-dose folic acid (5 mg/day) to all women on anticonvulsant mood stabilisers who are planning pregnancy including before any possibility of pregnancy.

If a women/birthing parent is taking a mood stabiliser or anticonvulsant during pregnancy provide high-dose folic acid (5 mg/day), particularly in the first trimester.

When exposure to psychoactive medications has occurred in the first trimester (especially with anticonvulsant exposures) pay particular attention to the 11–14 or 18–20 week ultrasound due to the increased risk of major malformation.

Where a mood stabiliser is provided, ensure women/birthing parents and their families are provided with up-to-date information regarding the safety of their use during pregnancy and in breastfeeding. Provide relevant written information, including the risks relating to fetal anticonvulsant syndrome.

Sodium Valproate

Do not prescribe sodium valproate to pregnant women/birthing parents.

If a woman/birthing parent is on valproate and becomes pregnant wean them off this over 2–4 weeks, while adding in high-dose folic acid (5 mg/day) which should continue for the first trimester.

Valproate must not be initiated in any individual under the age of 55 years unless independent review by two specialists to consider and document that there is no effective or tolerated alternative.

For exceptions where women are already on sodium valproate, women of childbearing potential must be enrolled in the pregnancy prevention programme with long-acting contraception in place to avoid pregnancy and be aware of the risks and reasons to avoid pregnancy: Valproate use by women and girls - GOV.UK (www.gov.uk).

Lithium

Lithium use during pregnancy is associated with spontaneous preterm labour, large-for-gestational age infant and neonatal hypoglycaemia. Changing physiology during pregnancy and postpartum affects drug metabolism and excretion requires close monitoring and dose adjustment where required as well as hypervigilance for signs of lithium toxicity. Pregnancy complications such as pre-eclampsia affecting renal function may significantly alter lithium metabolism and increase risk of toxicity.

Tapering of lithium or dose reduction may be considered, but needs to be weighed against the risk of relapse. Lithium blood levels vary during pregnancy, require closer monitoring and dose adjustment as appropriate.

If lithium is prescribed to a pregnant women/birthing parents, ensure that maternal blood levels are closely monitored and that there is specialist psychiatric consultation.

If lithium is prescribed to a pregnant woman/birthing parent, monitor lithium levels carefully and adjust individual dose prior to and after delivery.

Where possible, avoid the use of lithium in women/birthing parents who are breastfeeding.

Lamotrigine

If lamotrigine therapy is continued during pregnancy, dose adjustment (increase) may be required, due to changing metabolism as pregnancy progresses, with significant variation in serum-level-to-dose ratios in pregnancy compared to postpartum. Caution regarding breastfeeding is required, with significant variations in levels reaching breastmilk, with relatively high infant exposure described (average 18%, varying 3-33%). Adverse infant outcomes are not common but infants should be monitored for apnoea, rash, drowsiness, poor sucking and serum levels if toxicity is a concern. In some cases, monitoring of platelet count, liver function and serum levels in the neonate may be appropriate. If a rash occurs, it is suggested breastfeeding should be discontinued until the cause of the rash is established. Use of lamotrigine is not contraindicated during breastfeeding.

If prescribing lamotrigine to a woman/birthing parent who is breastfeeding, arrange close monitoring of the infant and specialist neonatologist consultation where needed.