I recently saw a 19 y/o G1P0 pt at 38 weeks, Kay, with a history of Hyperthyroidism and DM in the L&D unit. This was not readily apparent to me at the time, while thumbing through tones of info in her charts. She came in through triage for “frequent and painful, unrelenting contractions.” After further assessment with a pelvic, nitrazine paper and NST, she was admitted. Upon insertion of an IV, she near flew off the bed, screaming, and cursing up a storm. The nurse thought this was strange and looked closely at her charts. Kay had a history of Bipolar disorder, hence the overly exaggerated response to the IV insertion, I learnt.
Women with chronic mental health disorders such as Bipolar , can and will get pregnant, some planned, many may not be. It is important to screen and ask women about mental health history, the use of prescribed medication for the illness and ask “are you still taking your medications, if not, why?” Teaching and counseling comes into play her because some women may choose to stop taking these meds once they find they are pregnant.
According to the National Alliance on Mental Illness (NAMI), Lithium and first generation antipsychotics like Haldol are still safe to use in pregnancy (Category D) if deemed necessary. Concerns about relapse, maternal safety, hydration status (if meds are taken) and fetal well-being present an opportunity to educate, reeducate, and/or refer. Preconception counseling and the impact of these disorders during and after pregnancy (beacuse of breast feeding) is vital.
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I thought about this problem as well. This patient population caught between rock and a hard place. Careful planning is key.
ReplyDeleteManaging Pregnancy and Bipolar Disorder
Ref: www.nami.org
Many women with chronic mental illnesses, including bipolar disorder, become pregnant or plan to have children at some point in their lives. Managing bipolar disorder throughout a pregnancy is a delicate balance of the risks and benefits of the illness versus treatment, and should be done in close collaboration with knowledgeable professionals, both psychiatric and obstetric. Many women are concerned about the impact of a pregnancy on their illness and about the potential effects of medications they take on their child. Because bipolar disorder typically emerges during young adulthood and persists throughout the lifespan, the illness usually overlaps with a woman’s prime childbearing years.
Pregnancy and delivery often increase the symptoms of bipolar disorder: pregnant women or new mothers with bipolar disorder have a sevenfold higher risk of hospital admission and a twofold higher risk for a recurrent episode, compared with those who have not recently delivered a child or are not pregnant.
since many pregnancies are unplanned, all women of childbearing age should talk to their psychiatrists about managing bipolar disorder throughout a pregnancy regardless of their future reproductive plans.Lithium and first-generation antipsychotics (e.g., Haldol, Thorazine) are preferred mood stabilizers because they consistently show minimal risks to the fetus.2 Some anticonvulsants (e.g., Depakote and Tegretol) have been proven harmful to fetuses, possibly contributing to birth defects. Studies show that exposure to only one mood stabilizing medication is less harmful to the developing fetus than exposure to multiple medications.
Lithium: While taking lithium, it is important that women stay hydrated to prevent lithium toxicity in themselves and the fetus. Careful monitoring of lithium levels, especially during delivery and immediately after birth, can help prevent a relapse in the mother and will also show if there are high lithium levels in the infant. Data from lithium birth registries suggest an increase in cardiac and other anomalies, especially Ebstein's anomaly ( www.Rxlist.com).Women who choose to breast-feed should know that lithium is secreted in breast milk. Breast-fed newborns whose mothers take lithium should have their blood monitored for lithium.
Depakote: VALPROATE CAN PRODUCE TERATOGENIC EFFECTS SUCH AS NEURAL TUBE DEFECTS (E.G., SPINA BIFIDA). ACCORDINGLY, THE USE OF DEPAKOTE TABLETS IN WOMEN OF CHILDBEARING POTENTIAL REQUIRES THAT THE BENEFITS OF ITS USE BE WEIGHED AGAINST THE RISK OF INJURY TO THE FETUS (Rxlist.com). If a woman decides to continue taking Depakote, a single daily dose can be more harmful than separate doses. Experts recommend that doses of less than 1000 mg/day be taken in divided doses. It is recommended that women continuing Depakote also take vitamin K to help prevent conditions that affect the infant's head and face. The American Academy of Neurology and the America Academy of Pediatrics agree that Depakote is compatible with breast-feeding.
Tegretol: Most experts feel that Tegretol should only be used during pregnancy if there are no other options. For women who choose to continue therapy with Tegretol, vitamin K should be taken to promote mid-facial growth and the formation of proper blood clotting factors in fetuses.The American Academy of Neurology and the American Academy of Pediatrics agree that Tegretol is compatible with breast-feeding.