his has also been associated with adverse perinatal outcomes, for example, preterm birth (Mei-Dan, 2015). Di Florio and associates (2013) found that those women who experience pregnancy complications are more likely to exhibit periods of mania or depression. Women who tend to be manic present with exacerbations earlier in the postpartum period.
Typical therapy for bipolar disorder includes mood stabilizers such as lithium, valproic acid, and carbamazepine, as well as antipsychotic medications (see Table 61-3). Treatment of bipolar disorder in pregnancy is complex and is ideally managed concurrently with a psychiatrist. Decisions include risks versus benefits of using mood stabilizers, some of which are teratogenic. For example, lithium has been linked to Ebstein anomaly in exposed fetuses. More recent data, however, suggest a lower risk of cardiac malformations than previously indicated (Micromedex, 2016; Patomo, 2017) . Nevertheless, many recommend fetal echocardiography for lithium-exposed fetuses. Some limited evidence suggests that lithium in breast milk, when its elimination is impaired as in dehydration or immaturity, can adversely afect the infant (Davanzo, 2011). However, lithium use in mothers with a healthy, term fetus is considered moderately safe. A more detailed discussion of other mood stabilizers and antipsychotic medications side efects can be found in Chapter 12 (p. 244).
This severe mental disorder is usually a bipolar disorder, but it may be due to major depression (American Psychiatric Association, 2013). Its incidence is estimated to be 1 in every 1000 deliveries, and it is more common in nulliparas, especially those with obstetrical complications (Bergink, 2011; Blackmore, 2006). In most cases, illness manifests within 2 weeks of delivery. In one study of postpartum women with their first lifetime episode of psychosis, the median onset of psychiatric symptoms was 8 days after delivery, and the median duration of the episode was 40 days (Bergink, 2011). Because those with underlying psychiatric disease have a 10-to 15-fold risk for recurrence postpartum, close monitoring is imperative.
The most important risk for postpartum psychosis is a history of bipolar disease. These women typically exhibit symptoms within 1 to 2 days after delivery (Heron, 2007, 2008). Manic symptoms include feeling excited or elated, being active or energetic, feeling "chatty," and sufering insomnia. Afected women have signs of confusion and disorientation but may also have lucid episodes.
Postpartum psychosis has a 50-percent recurrence risk in the next pregnancy. As a result, Bergink and associates (2012) rec in women with a history of postpartum psychosis.
The clinical course of bipolar illness with postpartum psycho sis is comparable with that for nonpregnant women. Patients usually require hospitalization, pharmacological treatment, and long-term psychiatric care. Psychotic women may have delu sions leading to thoughts of self-harm or harm to their infants.
Unlike women with nonpsychotic depression, these women commit infanticide, albeit uncommonly (Kim, 2008). In most instances, women with postpartum psychosis ultimately develop relapsing, chronic psychotic manic-depression.