Fiona Judd，Grant Blashki，Leon Piterman

·World General Practice/Family Medicine·

Case Studies of M ental Health in General Practice(13)
——Pregnancy and Bipolar Mood Disorder

Fiona Judd，Grant Blashki，Leon Piterman

Bipolarmood disorder;Mania;Depression;Pregnancy;General practice;Mental health services

【Introduction of the Colum n】The Journal presents the Column of Case Studies of Mental Health in General Practice; with academic support from Australian experts in general practice，psychology and psychiatry from Monash University and the U-niversity of Melbourne.The Column's purpose is to respond to the increasing needs of mental health services in China.Through study and analysis ofmental health cases，we hope to improve understanding ofmental illnesses in Chinese primary health settings，and to build capacity of community health professional inmanaging ofmental illnesses in general practice.Patient-centred and whole-person approach in general practice is the best way tomaintain and improve the physical and mental health of residents.Our hope is that these case studieswill lead new wave of general practice and mental health development both in practice and academic research.A number of Australian experts from the disciplinesof general practice，mental health and psychiatry will contribute to the Column.You will find A/Professor Blashki，Professor Judd and Professor Piterman are authors of General Practice Psychiatry.The Journal casesare helping to prepare for the translation and publication of a Chinese version of the book in China.We believe Chinesemental health in primary health care will step up to a new level under this international cooperation.

1 History

Anna Brown is a 24-year-old married woman with no children，who works part time as a chef in a restaurant.She has a diagnosis of Bipolar A ffective Disorder following her first episode ofmania 1 year ago.She has just discovered she is20 weeks pregnantand has ceased the lithium she was taking for her mood disorder.Her husband has brought her to see you as he is very worried she will have a relapse of her bipolar disorder.

2 Other history

Anna had a second episode of mania 5 months ago after stopping her lithium as she did not believe that she had an illness.The relapse was characterised by sexual disinhibition(she wasmaking inappropriate sexual comments to themale restaurant customers)，grandiose delusions(she believed that she would soon be world famous for her cooking)and risk taking behaviour(including erratic driving on the freeway).Thiswas very similar behaviour to her first episode 1 year ago.There is a positive family history of bipolar disorder(father and paternal uncle).There is no history of substanceabuse.She has not been troubled by side-effects of her medication，and when taking the lithium hermood has been stable.

3 Exam ination

Anna is well groomed and pleasant during the interview.Her husband is visibly anxious.Hermood appears normal，affect is not elevated or depressed，and there is no pressure of speech.There is no odd or unusual thought content and she denies any perceptual disturbance.Thus，mental state examination is normal，other than her insistence that she does not have a psychiatric illness and that she does not need to takemedication.She also states that she knows lithium will harm her baby-thus she will not take it whilst pregnant.

Physical examination was unremarkable.No leg swelling，Blood Pressure 110/80 mm Hg，urine dipstick was normal and the xiphisternum-pubicmeasurementwas 20 cm.Of note there was no suggestion of goitre or signs of hypothyroidism.

4 Questions

4.1 What is likely to happen if she does not restart her medication?

4.2 What are the risks to her baby if she recommences lithium now?

4.3 What risks has the baby already been exposed to during the first 20 weeks whilst she was taking lithium，and what investigations do you need to do?

4.4 What are the treatment options during pregnancy and in the post-natal period?

5 Answers

5.1 Anna's history shows she has had 2 manic episodes in one year.The frequency of these episodes indicates she is likely to have more episodes，and that she should takemedication to prevent recurrence of her disorder.The usual recommendation is thatmaintenancemedication is required if there are 2 ormore episodes(either depression ormania)or if the firstepisode is particularly severe.In addition，she has precipitously stopped her lithium.Risk of relapse，particularly ofmanic relapse，ismarkedly increased if cessation of lithium is sudden compared to a lower risk if the drug dose is slow ly reduced over severalmonths［1］.

5.2 If Anna restarts the lithium now，when 20 weeks pregnant，assuming the serum lithium levels are kept within the therapeutic range(0.6-1.0 mmol/L)，there are few risks to the baby.There have been case reports of babies born with goitre，of prematurity and of babies born large for gestational age［2］.

5.3 Themain risk to the baby due to Anna taking lithium in the first 20 weeks is the risk of congenital malformations.Studies show that there is an increased risk of Ebstein's anomaly，a rare cardiovascularmalformation that occurs in 0.005%of the general population.The risk following first trimester exposure to lithium is 0.01% -0.05%［2］.In order to check whether the baby has been affected by the lithium Anna has been taking the baby should have a high resolution ultrasound and fetal echocardiogram.As is the routine preventative approach for allmothers，Anna should be encouraged to take a folate supplement to reduce the risks of a fetalmalformation.

5.4 Themost importantpriority for Anna is to restartmedication to avoid a relapse(particularly amanic episode)of her bipolar disorder during pregnancy.Asshe isnow 20 weeks pregnant，the lithium could be restarted(now beyond the time of teratogenic risk)or she could be prescribed an alternativemood stabiliser.The anti-epilepticmood stabilisers such as Carbamazepine and Sodium Valproate should be avoided during pregnancy if possible due to their teratogenic risk，which may persist beyond the first trimester.The third commonly used mood stabiliser group is the atypical antipsychotic drugs，and themostoften used drug isOlanzapine.A comparison of the possible risks versus benefits of prescribing Olanzapine during pregnancy shows that the benefits(preventing maternal illness relapse)far outweigh the risks to Anna and to the baby［3］.Themain risk for Anna is excessive weight gain and so an increased risk of gestational diabetes.Themain risk for the baby is also weight gain.

The early postnatal period is a time of very high risk forwomen with bipolar disorder.Whilst both depression and mania may occur in the postnatal period，the greatest risk isof amanic relapse in the first few days postpartum.Episodes at this time are often very severe and respond poorly to treatment.Thus it is essential that amood stabiliser is continued during this period.The choice of Olanzapine asa mood stabiliser has an important advantage over lithium-it is safe for Anna to breast feed her baby whilst continuing on the medication.By contrast，it is generally recommended that women do not breastfeed if taking lithium as the drug is concentrated in breast milk and may lead to lithium toxicity in the newborn baby.Thus，if Anna was given lithium during pregnancy and she plans to breast feed she will need to change her medication when the baby is born.If this is the case，she will need to be carefully monitored as the change ofmedication at this time will further increase her risk of relapse.

If possible，Anna should remain in the obstetric ward for several days after the birth of her baby.Thiswill enable carefulmonitoring of hermood for any signsof amanic relapse，allow her to sleep and rest，and if she wishes to breastfeed，be provided with assistance to establish breastfeeding.Once discharged from hospital Anna'smood should continue to be monitored as part of the ongoing management of her bipolar disorder.

Notes:

Mood stabiliser:the term mood stabiliser is generally used to describe a drug that is effective for the acute treatment of mania and/or bipolar depression or prevents episodes ofmania or bipolar depression.

Maintenancemedication:the pharmacological component of a broadly based treatment program designed to prevent recurrent episodes ofmania or depression in an individual with bipolar affective disorder.

(本文編輯:閆行敏)

2012-12-12)

Affiliation:Melbourne University，Victoria 3010，Australia(Fiona Judd，Grant Blashki);Monash University(Leon Piterman)

1 Megan Galbally，Matthew Roberts，Anne Buist.Perinatal psychotropic［Z］.

2 Review Group.Mood stabilisers in pregnancy:A systematic review［J］.Australian and New Zealand Journal of Psychiatry，2010，44:967-977.

3 Therapeutic Guidelines.Psychotropic［Z］.2008.