We searched PubMed, Embase, PsycINFO, and the Cochrane Library without language restrictions. Original searches were done for systematic reviews (past 20 years) and epidemiological or experimental studies (past 3 years) with the following search terms: “pregnancy” or “prenatal” or “antenatal” or “postnatal” or “postpartum” or “perinatal” or “puerperal” or “breastfeeding” or “birth” or “weaning” or “childbirth” or “trimester” or “peripartum” or “lactation” or “ante-natal” or “post-natal” or
SeriesBipolar disorder, affective psychosis, and schizophrenia in pregnancy and the post-partum period
Introduction
Pregnancy is a major event in any woman's life. The transition to motherhood involves major challenges in the psychological, social, and biological domains. For a woman with, or who is susceptible to, severe mental illness this transition might prove particularly complex and difficult. Although many forms of psychiatric illness can be severe, in this Series paper severe mental illness refers to schizophrenia, affective psychosis, and bipolar disorder, including psychotic and non-psychotic forms of bipolar disorder. This definition includes both women with pre-existing illness who become pregnant, and those who develop severe post-partum episodes as the first manifestation of psychiatric illness. The acute onset of severe psychiatric episodes following childbirth—post-partum (or puerperal) psychoses—are among the most severe forms of illness seen in psychiatry. Psychiatric disorders in the perinatal period result in significant distress, can disrupt the developing bond between mother and child, and have long-term implications for the wellbeing of the woman, the baby, her family, and wider society. In rare but tragic cases, the illness can lead to suicide, a leading cause of maternal death,1, 2 and infrequently, infanticide.3
Section snippets
Fertility
Women with severe mental illness have consistently been reported to have lower fertility rates than do women in the general population, with women with schizophrenia usually having much lower fertility than do women with bipolar disorder.4, 5, 6, 7 Although women with psychiatric disorders have high rates of abortion compared with the general population, this does not appear to explain the decrease in fertility.5 Prolactin-raising antipsychotics, which reduce fertility, seem to partly explain
Severe mental illness in the post-partum period
Severe mental illness can occur in the post-partum period as the continuation of a chronic psychotic condition that began in or before pregnancy, or as an episode of severe mental illness with a rapid onset shortly after childbirth. These later episodes, traditionally labelled as post-partum or puerperal psychosis most commonly take the form of mania, severe psychotic depression, or mixed episodes with features of both high and low mood.26 Despite the current Diagnostic and Statistical Manual
Post-partum psychosis: risk factors and pathophysiology
As discussed, the strongest and best-established risk factor for susceptibility to post-partum psychosis is a history of bipolar disorder or previous severe post-partum episodes, although several other potential risk factors have been investigated.
Treatment of severe mental illness in pregnancy and the post-partum period
Several different scenarios ought to be considered regarding the management of the perinatal period. Issues for women with a diagnosis of schizophrenia need to be distinguished from those with bipolar disorder, as do issues that arise before conception from those that arise in pregnancy and later in the post-partum period. Finally, it is important to differentiate women with longstanding psychotic illness from those women with the acute onset of a post-partum psychosis. Moreover, the breadth of
Preconception care
Guidelines from several countries63, 64, 65 and the Confidential Enquiries into Maternal Deaths1 emphasise that pregnancy should be a consideration in the management of all women of childbearing age with severe mental illness. Contraception and optimisation of physical and mental health in potential future pregnancies should therefore be discussed at all stages of care, not just when a women becomes pregnant or wants to start a family. Indeed, the evidence linking valproate exposure in utero in
Care of women with severe mental illness in pregnancy
Up to now, little research has been done into interventions for psychotic disorders in pregnancy and in particular, few studies have been done into use of antipsychotic medication.72 Extrapolation from studies outside the perinatal period is therefore needed when caring for women with schizophrenia in pregnancy.
The relapse of schizophrenia at other times in a woman's life suggests that rehospitalisation and relapse rates are significantly increased after discontinuation of antipsychotic
Care of women in the post-partum period
For women with severe mental illness who stopped medication in pregnancy, re-establishing their prepregnancy medication regimen should be considered. Effectiveness of prophylactic medication in the immediate post-partum period for those women at high risk of post-partum psychosis has been assessed. Although no randomised controlled trials have been done, retrospective and open studies support the use of lithium prophylaxis in women with bipolar disorder in this context,86, 87 but several
Psychiatric mother and baby units
The severity of many post-partum episodes requires admission, and guidelines from several countries recommend mothers should be admitted with the baby whenever possible.63, 64, 65 Until now, no studies have been done into the effectiveness or cost-effectiveness of MBUs, although a National Institute for Health Research (NIHR)-funded study is underway (Howard LM, unpublished). Mother and baby units avoid separation of mothers and babies, encourage breastfeeding, provide specific interventions
Child protection
The presence of severe mental illness might generate concerns among health and social care professionals about the mother's ability to safely parent. Concern about professionals' judgments of their parenting ability and worry about losing access to their children can be an important deterrent to mothers seeking psychiatric help.97 Children can be at risk in various ways, and in addition to situations of frank neglect or abuse, severe mental illness might subtly impair mother–infant interaction
Conclusions
Childbirth is a powerful trigger of psychiatric episodes, and episodes at this time cause substantial morbidity and mortality, with suicide a leading cause of maternal death. Despite the undoubted importance of severe perinatal mental illness, these disorders are under-researched and there is still a poor evidence base in many areas. Further research is vital to help us understand more about the triggering of episodes by pregnancy and childbirth, enable us to better predict women at risk, and
Search strategy and selection criteria
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