Bipolar and Pregnant: How to Manage and Succeed in Planning and Parenting While Living With Manic Depression

Chapter 1

Getting Started:
Looking at the Risks

 

Fred and I understood the importance of reviewing the facts before making a decision to start a family. Was parenthood worth the risks involved in managing my own moods without medication, let alone potential risks to our baby? The questions in our minds were spiraling endlessly. We needed answers.
In October 1990, Fred and I had an appointment for genetic counseling at Spectrum Health Genetics in Grand Rapids, Michigan. Judy Hiemenga, M.D., my obstetrician-gynecologist, referred us. Our primary concern was what might happen to our baby if I continued to take lithium while pregnant. We also wanted to learn about the potential risks of continuing any of the prescriptions or over-the-counter drugs I was taking. My mother joined us at this meeting to provide moral support and to help in the review of our family history.

Scheduling an appointment with a genetic counselor before conception is a wise first step in planning any pregnancy, especially if you're affected with bipolar disorder. Asking your ob-gyn to refer you to a genetic counselor works well because the doctor is familiar with your history and can easily send your records. I encourage you to bring a family member who is familiar with your health history—and if that's not possible, then bring as much pertinent information with you as you can.

Because I was taking lithium (lithium carbonate—Eskalith is the brand name) to treat my bipolar disorder, we focused on its potential risks to our developing baby. If you are on another medication, your concerns will be different. Be prepared to discuss all your medications in detail with your genetic counselor. If the genetic clinic in your area does not offer preconception planning, it can refer you to one that does.

Appendix A, written by Helga Valdmanis Toriello, Ph.D., contains important information about genetic counseling. Although the information is quite technical, Dr. Toriello does a thorough job of explaining the importance of this step. She has included a table that summarizes the medications used to treat bipolar disorder and the risks to the unborn baby of anomalies (i.e., abnormalities).

Letters summarizing our genetic counseling session were sent by Dr. Toriello to Dr. Hiemenga and me. An important objective for our genetic counselor was to research lithium risks to our baby and she did her job well. She described, in detail, several abnormalities (with accompanying statistics) that could occur while taking lithium during pregnancy. Since bipolar disorder is treatable, a lesser concern to us was finding out that our children could also have the condition.

After our genetic counseling session, and especially after reading the summary letter, I felt as if the wind had been knocked out of me. Fred and I wanted to have a baby—we desperately wanted to start a family. Our odds of having a safe pregnancy and a healthy baby seemed remote. After considering all the facts, Fred and I decided that if we moved forward with our goal to have a baby, I would discontinue lithium. My next step was to learn more about that decision.

I wanted to know how long it would take before my body was lithium free. I talked with a pharmacist I knew and respected. His conclusion, based on research he obtained from Micromedex Inc. (a drug evaluation monograph), is that once lithium was discontinued, I would have a good margin of safety at twelve days.
I also discussed going off lithium in detail with my psy­chiatrist, Ingrid Eerdmans. (Her instructions are summarized in Chapter 4.) It is imperative that you consult with your doctor about all medication changes.

The NAMI Advocate (Spring/Summer 2004) reported that a 2004 study by Yonkers et al. found that:

Because bipolar disorder emerges during young adulthood and persists throughout the lifespan, women of childbearing age are at risk for this illness. Pregnancy and delivery can influence 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.
Careful planning for pregnancy can help women with bipolar disorder to optimally manage their illness to minimize their symptoms and avoid risks to the fetus. Experts suggest it is important to avoid sudden changes in medication during pregnancy, because such changes may increase side effects and risks to the fetus and also increase the risk of relapse of the illness before or after the woman gives birth.

I've always been one to bite off more than I can chew, and this wasn't any different. Fred and I were determined to go against the odds, conquer our fears, and bask in the joys of having a family of our own. It became not only a distant dream but a reachable destiny.

The next section was written by Jay Carter, a licensed psychologist who is certified in psychoactive substance abuse disorders by the American Psychological Association. He focuses on two important points that will help in planning your pregnancy.

Doctor's Note
by Jay Carter, PsyD, DABPS

Bipolar is a spectrum disorder. That means it varies in intensity depending on what genes are awry and how many genes are awry. It also varies (within spectrum limits) depending on the amount of stress that comes from the environment.

If a woman has been hospitalized in the past for bipolar disorder, I would recommend that she obtain a legal document for mental health power of attorney, which appoints someone to be her legal guardian for a specified period of time—for example, from the time she goes off medication to six weeks after she gives birth. It must be irrevocable for that period. The assignee would be her spouse, her psychiatrist, a parent, or a trusted friend. This person should be able to legally admit the assignor to a mental health unit against her (current) will, for the purpose of protecting her and her unborn child from harm and to enable a smooth transition during pregnancy.

Someone who is manic or depressed loses part of his or her executive function. The executive function is in the prefrontal lobe of the brain; it enables us to see the big picture and the context of situations. The executive function can be totally lost or lost just to the degree that one is dysfunctional in significant ways. It includes the part of the imagination that enables us to understand the consequences of our actions. It lets us put ourselves in someone else's place and have empathy.
When the mind races six times faster than normal (as it often does with bipolars), the cognitive (concrete) part of the brain takes over all the brain's energy, leaving little for the executive function in the prefrontal lobe. This can be seen in brain scans of people who are manic. We lose our common sense, so to speak, but usually not to the degree that it causes catastrophic, irreversible acts to ruin our lives. One can say, 'He would never do that in his right mind' about someone who is manic.

 

Making the Decision

I will always remember the day that Fred and I decided we were going to try to have a baby. It was December 7, 1990; it was a day that continues to shape our lives. I was a medical center representative for a pharmaceutical company at the time. I was traveling for business, staying in a quaint hotel overlooking Lake Michigan. I extended my stay, Fred joined me, and we took this opportunity to focus on our future. The apprehension and uncertainty that we had been feeling was replaced with a surge of peace and joy.

Fred comments as follows:

When Kristin and I started talking about...