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Table 4 Mood episodes in pregnancy and early postpartum period for women with bipolar disorder

From: Bipolar disorder in pregnancy and childbirth: a systematic review of outcomes

First author, year of publication Key findings: reported by authors Potential mechanisms suggested by authors Key recommendations made by authors
Mood episodes
 Akdeniz 2003 [68] In 13.9 % (n = 10), the BD illness started in the peripartum period.
Twenty-three (32 %) women with BD reported at least one mood episode during pregnancy or within the first month after childbirth. Eleven mood episodes occurred in pregnancy (11 out of 252 pregnancies (4.4 %)) and which started between 2nd and 8th pregnancy months. Mean duration of episode was 5.5 weeks (SD 3.8, range 1–12).
Twenty-six mood episodes occurred in the first month postnatal (26 out of 160 births (16.3 %)). Mean duration of episode was 4.5 weeks (SD 4.9, range 1–23.5).
Women who had a mood episode during their 1st pregnancy, were more likely to have another episode postpartum (OR 9.6 (95 % CI, 1.002–91.964)).
Women were more likely to have a postpartum mood episode after the birth of the first child. Women who had a mood episode in the 1st post-partum period were more likely to have a mood episode in the 2nd post-partum period (OR 3.6 (95 % CI, 0.257–50.330)).
Biological factors such as onset of BD at an early age, antenatal mood episode and obstetric complications appeared to influence the risk, but psychosocial factors did not. Need rigorous prospective studies. Avoid discontinuing lithium treatment too abruptly.
 Di Florio 2013 [73] Perinatal episodes across the mood disorder spectrum Women with BD-I: 49.8 % had a mood episode in pregnancy or the post-partum period (pregnancy 8.6 %, postpartum period within 12 months of childbirth 91.4 %). More than 20 % were affected by mania or psychotic depression in the pregnancy or the post-partum period. 25 % had an episode of non-psychotic depression.
Women with BD-II: 42.2 % had a mood episode in pregnancy or the post-partum period (pregnancy 18.4 %, postpartum period within 12 months of childbirth 81.6 %). Women with BD-II had a higher incidence of any perinatal mood episode compared with women with BD-I (chi-square = 10.38, d.f. = 1, p < 0.002 (calculated by review authors).
The mood episodes were significantly more common during the first month post-partum than during pregnancy (BD-I OR 44.5 95 % CI 26.9–76.0 and BD II OR 4.7 95 % CI 2.4–9.8).
Only most severe episodes were rated, so other less severe disturbances may not have been recorded; rates of BD recurrence in pregnancy may thus be artificially low. Prospective longitudinal studies are needed.
Women with BD should be informed of the risk of peri-natal BD episode.
 Di Florio 2014 [74] Mood disorders and parity Women with BD-I: 35 % reported an episode (mania/ psychotic depression) in the first pregnancy, 20.5 % in second pregnancy and 14.6 % in subsequent pregnancies. Rates of depression were similar across all pregnancies and postpartum periods.
Women with BD-II: Rates of depression: first pregnancy 46 % and second pregnancy 33 %.
A significant association between parity and mood episodes within 6 weeks postpartum was found. There was no significant association between parity and mood episodes in pregnancy or later postpartum.
Women having their first baby are more anxious and stressed, due to lack of experience. Multiparous women with BD may be more aware of the possibility of postnatal episodes, and may start treatment prophylactically. Clinical studies on the effect of parity on mood disorders should also investigate possible effect of medication reducing the risk of perinatal relapse.
 Grof 2000 [75] Five out of 28 women had a relapse during pregnancy (18 %), all in the last five weeks of pregnancy. Seven (25 %) had a postpartum relapse: 1 to 5 times, lasting 3.5 months in average, 42 % of these were manic. Postpartum episodes were significantly more than the other two periods (before and during pregnancy). Pregnancy seemed to confer a protective effect. In pregnancy, the mean rate of recurrence was 0.14, whereas mean rate in the 9 months prior to pregnancy was 0.43 (p < 0.05). Duration was also less (mean of 0.9 weeks during pregnancy, compared with mean of 6.1 weeks before pregnancy, p < 0.01). Duration postpartum was mean 12.2 weeks compared to mean 0.9 in pregnancy, p < 0.001. May be due to placental hormones increasing throughout pregnancy, and abrupt cessation after birth. Stop psychotropic medication in pregnancy, but continue to monitor women. Maybe recommence medication in the last 6 weeks of pregnancy.
 Mei-Dan 2015 [71] 3.6 % (n = 66) of BD were hospitalised for psychiatric reasons during the index pregnancy. (this is more than for the major depressive disorder group: 1.9 % (n = 69)   Women with BD need more social support
 Munk-Olsen 2009 [72] Women with previous diagnoses of BD, had the highest risk of readmission 10 to 19 days postpartum (RR, 37.22; 95 % CI, 13.58–102.04) compared with mothers with BD who gave birth 6 to 11 months earlier. Cumulative incidence of admission 0–3 months postpartum was 22 %. During the first postpartum year, 26.9 % of all women with BD predating childbirth were admitted. May be due to decrease of hormones post birth. Pregnancy, a time of emotional well-being, provides protection from BD. Women with BD who are pregnant or considering pregnancy need careful monitoring and relevant psychoeducation.
  1. BD Bipolar Disorder, CI Confidence Interval, OR Odds Ratio