Original article The management of bipolar disorder in the perinatal period and risk factors for postpartum relapse K. Doyle a , J. Heron a,b, *, G. Berrisford c , J. Whitmore c , L. Jones a , G. Wainscott c , F. Oyebode a,b,c a Department of Psychiatry, Neuropharmacology and Neurobiology, University of Birmingham, Birmingham, UK b Perinatal Research Programme, Birmingham & Solihull Mental Health Foundation Trust, The Barberry, 25, Vincent Drive, Birmingham, B15 2QS, Birmingham, UK c Perinatal Mental Health Services, Birmingham & Solihull Mental Health Foundation Trust, Birmingham, UK 1. Introduction Bipolar affective disorder (BPAD) is a severe mental illness with a chronic relapsing nature and, in its severest form (BPI), is estimated to affect around 1% of individuals [17]. Onset is typically in early adulthood and therefore illness episodes can affect women during their childbearing years [33]. Traditionally the period during pregnancy has been considered a time of low risk for women with BPAD, as rates of admission and rates of suicide have been reported to be lower at this time [8]. A recent prospective study, however, indicates that mild to moderate depressive symptoms are common during pregnancy, particularly following medication discontinuation [28,27,32]. In contrast, it has long been recognised that the days after childbirth are a time of high risk for the onset of severe episodes of mental illness [21,29,26]. Women with a history of BPAD have a 25–50% risk of severe mood episodes at this time and this is not thought to be due to the cessation of maintenance medication alone [27,7,9]. The risk of relapse in the postpartum is higher for BPAD than other forms of mental illness [16]. Additionally childbirth is commonly related to the initial onset of BPAD [25]. Severe postpartum manic and psychotic episodes are a particular complication of childbirth for women with a history of BPAD [13,12,3]. Postpartum psychosis (PP) episodes should be regarded as a psychiatric emergency and require admission in all but a few cases, given their rapid onset, severity and timing when a woman is responsible for a newborn infant [14]. Studies indicate that risk is at its highest in the first two postpartum weeks, with symptoms often beginning on day 2–4 postpartum [10,11]. Fortunately PP is usually very responsive to treatment but delays in identification result in longer, more severe and difficult to treat episodes, as well as a risk of maternal suicide and of harm occurring to the infant [22]. 1.1. Specialist referral in pregnancy As an attempt to make childbirth a less dangerous event for women with BPAD, the National Institute for Clinical Excellence (NICE) published the recommendation for the proactive (i.e. before relapse) referral of pregnant women with BPAD to specialist mental health services with expertise in the management of perinatal illness [19]. Referral before childbirth allows for the formation of a written care-plan for pregnancy, delivery and the European Psychiatry 27 (2012) 563–569 A R T I C L E I N F O Article history: Received 11 February 2011 Received in revised form 12 April 2011 Accepted 28 June 2011 Available online 15 September 2011 Keywords: Bipolar disorder Postpartum relapse Risk factors Management Pregnancy Perinatal psychiatry A B S T R A C T Aims. – The perinatal period is a time of high risk of relapse for women with a history of bipolar affective disorder (BPAD). We describe the pregnancy management of women with BPAD and identify risk factors for postpartum relapse. Methods. – The case records of 78 women with BPAD referred to perinatal mental health services before conception, during pregnancy or the postpartum period, between 1998 and 2009 in Birmingham UK, were screened. In women who were managed during pregnancy, those who relapsed in the postpartum were compared with those who remained well. Results. – Forty-seven percent of women with BPAD referred in pregnancy suffered postpartum relapse. Women who were unwell at referral, younger, with unplanned pregnancy, previous perinatal episodes or a family history of BPAD were more likely to suffer postpartum illness. Conclusion. – Identifying risk factors for postpartum relapse enables us to individualise the estimation of a woman’s risk and modify care plans accordingly. Duration of wellness prior to pregnancy is not associated with a lower risk of postpartum illness and so it is imperative that all women with BPAD receive referral in pregnancy. ß 2011 Elsevier Masson SAS. All rights reserved. * Corresponding author. Tel.: +00 44 121 301 2333. E-mail address: Jessica.heron@bsmhft.nhs.uk (J. Heron). 0924-9338/$ – see front matter ß 2011 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.eurpsy.2011.06.011