Query: bipolar disorder treatments during pregnancy

title: Bipolar Disorder in Pregnancy: A Review of Pregnancy Outcomes
abstract: Women with bipolar disorder may benefit from continuation of their medications during pregnancy, but there may be risks to the fetus associated with some of these medications. This article examines the evidence relating to the effect of bipolar disorder and pharmacologic treatments for bipolar disorder on pregnancy outcomes.  MEDLINE, CINAHL, ProQuest Dissertation Theses, and the Cochrane Database of Systematic Reviews were searched for English language studies published between 2000 and 2017, excluding case reports and integrative reviews. Twenty articles that met inclusion criteria were included in this review.  Women with bipolar disorder have a higher risk for pregnancy complications and congenital abnormalities than do women without bipolar disorder. In addition, illness relapse can occur if psychotropic medications are discontinued. There are limited data to recommend discontinuing lithium, lamotrigine, or carbamazepine during pregnancy. Valproic acid is not recommended during pregnancy due to increased odds of neural tube defects associated with its use. Atypical antipsychotics are used more frequently during pregnancy, with mixed evidence regarding an association between these agents and congenital malformations or preterm birth.  The knowledge of benefits and risks of bipolar disorder and its treatment can help women and health care providers make individualized decisions. Prenatal care providers can discuss the evidence about safety of medications used to treat bipolar disorder with women in collaboration with their mental health care providers. In addition, women being treated for bipolar disorder require close monitoring for depressive and manic/hypomanic episodes that impact pregnancy outcomes.

title: The Management of Bipolar Disorder During and After Pregnancy
abstract: This chapter will discuss the issues of psychiatric management of bipolar disorder (BD) both during and after pregnancy. The risks and benefits of medication use during pregnancy will be discussed along with the risks of discontinuation of medications for pregnancy. Pharmacological treatments will be discussed in detail. The postpartum time period and its risks for depression, mania, and psychosis will be described, and recommendations for management during this critical time period will be detailed. Medication use during breastfeeding will also be discussed.

title: The safety of medications for the treatment of bipolar disorder during pregnancy and the puerperium.
abstract: Risks associated with pharmacological treatment of bipolar disorder are heightened during reproductive events. Treatments need to be planned with the mutual agreement of both the treating physician and the patient and tailored to the needs of the individual so as to minimise risk while providing adequate treatment. Conventional treatments have all been associated with teratogeny in first trimester exposure, lithium with cardiac malformation and valproate and carbamazepine with neural tube malformations. There have been an insufficient number of first trimester exposures to the newer anticonvulsant mood stabilisers, lamotrigine and oxcarbazepine, to determine whether there is a safety advantage in switching to these agents. Increasingly, atypical antipsychotics are being suggested as useful agents for the treatment of bipolar disorder. While not known to be teratogenic, there are other reproductive safety concerns associated with these agents. Bipolar disorder patients may be prescribed antidepressants, and many of these agents are associated with a low safety risk during reproductive events, however data regarding use of these agents are currently equivocal. Adverse outcomes from inadequate pharmacological prophylaxis have been documented for both the mother and the baby. Risks and benefits need to be carefully balanced based on an accurate review of the evidence.

title: Reproductive biology and psychotropic treatments in premenopausal women with bipolar disorder.
abstract: Treating women with bipolar disorder during the reproductive years requires special consideration because of the reproductive risks associated with specific psychotropic drugs and drug interactions with hormonal contraceptives. Some psychotropic drugs can disrupt the menstrual cycle, alter pregnancy potential, and increase the risk for chronic conditions associated with hormone changes, such as prolactin elevation and polycystic ovarian syndrome (PCOS) Valproate has been associated with an increased risk of PCOS features. Typical antipsychotics and risperidone can increase prolactin production, which may also disrupt the menstrual cycle. When the menstrual cycle is altered, fertility is reduced, and medical conditions such as osteoporosis and endometrial hyperplasia can result. This article advises establishing the regularity of menstrual cycles and discussing the potential reproductive impact of specific psychotropic medications before initiating treatment in women with bipolar disorder who are of reproductive age.

title: Managing Bipolar Disorder during Pregnancy: Weighing the Risks and Benefits
abstract: Challenges for the clinical management of bipolar disorder (BD) during pregnancy are multiple and complex and include competing risks to mother and offspring.  We reviewed recent research findings on the course of BD during pregnancy and postpartum, as well as reproductive safety data on the major mood stabilizers.  Pregnancy, and especially the postpartum period, are associated with a high risk for recurrence of BD. This risk appears to be limited by mood stabilizing treatments and markedly increased by the abrupt discontinuation of such treatments. However, drugs used to treat or protect against recurrences of BD vary markedly in teratogenic potential: there are low risks with typical neuroleptics, moderate risks with lithium, higher risks with older anticonvulsants such as valproic acid and carbamazepine, and virtually unknown risks with other newer generation anticonvulsants and atypical antipsychotics (ATPs)  Clinical management of BD through pregnancy and postpartum calls for balanced assessments of maternal and fetal risks and benefits.  Les problemes lies au traitement clinique du trouble bipolaire (TB) durant la grossesse sont profonds et peuvent entrainer des risques concurrents pour la mere et l'enfant.  Nous avons examine les resultats recents de la recherche sur le cours du TB durant la grossesse et le post partum, de meme que les donnees d'innocuite reproductrice des principaux regulateurs de l'humeur.  La grossesse et surtout la periode du post partum comportent des risques eleves de recurrence du TB. Les risques semblent etre limites par les traitements aux regulateurs de l'humeur et notablement accrus par la cessation abrupte de ces traitements. Toutefois, les medicaments utilises pour traiter ou prevenir les recurrences du TB varient beaucoup en ce qui concerne les risques teratogenes: les risques sont faibles pour les neuroleptiques typiques, moderes pour le lithium, eleves pour les anciens anticonvulsivants comme l'acide valproique et la carbamazepine, et presque inconnus pour les autres anticonvulsivants de la nouvelle generation et les antipsychotiques atypiques (APA)  Le traitement clinique des femmes souffrant du TB durant la grossesse et le post partum demande des evaluations equilibrees des risques et des avantages pour la mere et le foetus.

title: The use of lithium and management of women with bipolar disorder during pregnancy and lactation.
abstract: The introduction of lithium salts almost a century ago and the subsequent approval of lithium carbonate for the treatment of patients with bipolar disorder represent one of the cornerstones of modern psychopharmacology. The onset of bipolar disorder in women often occurs during the childbearing years, which complicates the treatment decisions secondary to the possibility of conception while taking medication. The establishment of the lithium registry for fetal teratogenesis in the late 1960s ushered in a heightened level of concern for the use of lithium during the reproductive years; although, in the years to come, it has become apparent that alternative pharmacologic treatments for bipolar disorder may exceed the teratogenic risk of lithium monotherapy. In this paper, the available data on the use of antimanic medications during pregnancy and lactation are reviewed with an emphasis on providing a realistic risk/benefit assessment for medication selection and management of these patients. Treatment strategies are discussed for (1) women who are contemplating pregnancy (2) women who inadvertently conceive while taking medications (3) women who choose to become pregnant while taking medication, and (4) women who intend to breastfeed while taking medications.

title: Use of antipsychotic drugs and mood stabilizers in women of childbearing age with schizophrenia and bipolar disorder: epidemiological survey
abstract: To determine the prevalence of women of childbearing age with schizophrenia and bipolar disorder exposed to antipsychotic (AP) drugs and mood stabilizers (MS) in Lombardy, a European region of 10 million inhabitants and 1 752 285 women of childbearing age.  The data concerning psychiatric care, drug treatments and pregnancy outcomes were retrieved from local administrative databases during a 12 month census period.  During a 12 month census period, 2893 women of childbearing age with schizophrenia (74.8% of all women of childbearing age with schizophrenia) and 918 with bipolar disorder (80.1% of all women of childbearing age with bipolar disorder) were exposed to AP drugs or MS, yielding a prevalence of exposure for women with schizophrenia of 1.65 (95% confidence interval (CI) 1.59 1.71) per 1000 female inhabitants, and for women with bipolar disorder of 0.52 (95% CI 0.49 0.55) per 1000 female inhabitants. Persistent exposure to potentially teratogenic medications accounted for one in every 1000 women of childbearing age. Of the 57 pregnancies in women with schizophrenia, normal delivery was recorded in 23 (40% cases; of the 26 pregnancies in women with bipolar disorder, normal delivery was recorded in 10 (38% cases.  In women of childbearing age with severe mental disorders, exposure to psychotropic drugs is substantial, which suggests that the issue of reproductive health is epidemiologically relevant and a major public health concern.

title: Current issues: women and bipolar disorder
abstract: While the treatment of bipolar disorder (BD) is typically complex, the treatment of women with bipolar disorder is even more challenging because clinicians must also individualize treatment based on the potential for pregnancy, drug interactions with oral contraceptives, and an increased risk of endocrine diseases that can either impact the course of illness or become manifest with some treatments. Women with BD should be checked for hypothyroidism, and if prescribed antidepressants, carefully watched for rapid cycling or a mood switch to mania, hypomania, or a mixed state. Several medications interact with oral contraceptives or increase the risk of developing polycystic ovary syndrome. Consideration of possible pregnancy is essential, and should be planned in advance whenever possible. Rates of recurrence have been shown to be equal in pregnant and nonpregnant women with BD. Risks of medication to the fetus at various points of development must be balanced against the risks of not treating, which is also detrimental to both fetus and mother. The postpartum period is a time of especially high risk; as many as 40% to 67% of women with BD report experiencing a postpartum mania or depression. The decision to breastfeed must also take into account the adverse impact of sleep deprivation in triggering mood episodes. In order to best address these issues, clinicians must be familiar with the data and collaborate with the patient to assess risks and benefits for the individual women and her family.

title: Pregnancy and Electroconvulsive Therapy: A Multidisciplinary Approach
abstract: To scrutinize a series of pregnant women treated with electroconvulsive therapy (ECT) at a tertiary treatment center and combine these data with a literature review to refine the treatment guidelines for ECT during pregnancy.  A retrospective chart review of mentally ill pregnant patients treated with ECT since the establishment of a formal women's mental health program.  A total of 8 pregnant women treated with ECT were identified from January 2012 to August 2014. Information was extracted from the medical records of a total of 30 ECT treatments across this group. Subjects received an average of 3.75 ECT treatments (range, 1 7) All women were diagnosed as having a mood disorder (either unipolar or bipolar) and 5 of the 8 women had suicidal ideation. The treatment team for ECT was consistent across all treatments. Two women experienced significant complications after the initial treatment: 1) an acute episode of complete heart block; and 2) acute onset of mania after ECT. Obstetrical complications included 2 women with preterm delivery one secondary to premature rupture of membranes. No other complications or adverse outcomes were recorded. The 5 women with suicidal ideation had symptom resolution, and significant symptom improvement was noted in 6 of the 8 women.  Electroconvulsive therapy is a safe and effective treatment during pregnancy and of particular benefit in the acute treatment of suicidal ideation.

title: Special considerations in treating bipolar disorder in women.
abstract: There are obvious gaps in research surrounding issues specific to women who suffer from bipolar disorder, including gender differences and their implications for management, the impact of the reproductive cycle, and evidence based treatment guidelines for pregnancy and the postpartum period. Gender differences have not been reported for the prevalence of bipolar disorder; however, women are more likely to experience rapid cycling, mixed mania, and antidepressant induced manias. This may affect response to treatment, which has been found, in some cases, to differ in men and women. In addition, side effects in response to treatments may well differ in men and women, especially with regard to lithium and valproate prescription. The course of bipolar disorder in women may be influenced by the menstrual cycle, pregnancy, the postpartum period, and menopause, although many issues require further clarification. Treatment of bipolar disorder during pregnancy and the postmenopausal period requires careful consideration, as does treatment during the childbearing years, as some mood stabilizers influence the metabolism of oral contraceptives. This review article has attempted to evaluate existing literature regarding women with bipolar disorder in a comprehensive and critical way, and to consolidate into a single source the gender specific aspects of the disorder that may have treatment implications for women.