How do I bring up pregnancy planning with my psychiatrist?

Hi guys, I'm new here and just looking for some advice. Hopefully I get it right!

And heads up/content warning for pregnancy loss too.

I've got bipolar type 1 which was diagnosed in my late teens. I have become psychotic during both depressed and manic episodes, although never when I'm well. I have had two pregnancies. The first as a teenager which ended in miscarriage at 8 weeks, and had no effect on my mood. The second was about two years ago, and it was deeply traumatic. I fell pregnant with a mirena IUD in place and while I was on 2000mg of valproate, which was stopped after I found out about the pregnancy - we found out at twenty weeks that the baby had anencephaly and we had a termination about a week later. In the next couple of days I became increasingly depressed and then delusional, which was missed by my health care providers because they assumed it was normal grief. I got really unwell really rapidly after I left hospital, and after a week my partner called a crisis team and I spent four months in hospital and ended up having ect. I've been on valproate (2000mg) for the last eighteen months, during which I have had one episode of hypomania lasting two or three weeks about a year ago, and 10mg of olanzapine was added. I've been back in fulltime work for a year, and I'm doing pretty well.

So, I guess my question is - how do I bring up planning for pregnancy with my psychiatrist? I absolutely do not want to go through a pregnancy on valproate again, so I know I will have to get off of it, but I don't know if the olanzapine by itself will be enough? I don't want to be unwell again, and even if I stay fine during the pregnancy, what about postnatally??. Plus I get the feeling that my psychiatrist will judge me for wanting to risk my mental health by getting pregnant.

8 Replies

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  • Hello, and welcome to the forum.

    I was sad to read about your second pregnancy and then your illness afterwards. It sounds like a hugely traumatic time, it is not surprising you became unwell. It is good to hear that you seem to have recovered quite well.

    I really understand your apprehension in approaching your psychiatrist about having a child, but I think it's really natural to want to have children I think. And with the right planning and professional and personal support you can minimise your chances of getting ill. There are many women with bipolar diagnosis who have children, and remain well.

    It's great you have found us, and hopefully we can direct you to the right information and support. First of all, are you in the UK? If so I would find out if you have a perinatal mental health team in your area. If you do ask to be referred them for pre-conception counselling. Ideally, they would work with you and your psychiatrist in transferring to meds that are safe to take during pregnancy before you are pregnant and then they can obviously support you through your pregnancy and afterwards.

    However, sadly, we know that many areas of the country don't have a perinatal mental health team. If you don't have access to a perinatal psychiatrist then I would ask your psychiatrist to refer you to the APP second opinion psychiatry service. The link is here: app-network.org/what-is-pp/...

    You will see it says: "Dr Ian Jones is happy to see women via this service who have experienced postpartum psychosis or bipolar disorder and require advice regarding treatment or planning further pregnancies." There is a recent post on the forum from someone saying how helpful her consultation with Dr Jones was. He is a leading perinatal mental health psychiatrist. You will also see there is no charge to your NHS funding authority, or to you. He will look at your medical notes and be able to advise your psychiatrist on treatment / medication and what things to think about to stay well such as sleep, medication, breastfeeding or not etc.

    I also wanted to give you this link to this guide, free to download, which is about planning a pregnancy if you are at risk of postpartum psychosis. The link is here: app-network.org/what-is-pp/...

    This advises you about what things you might want to consider, and what kind of support you should be requesting etc. It was written by women who have had PP and leading perinatal mental health clinicians and researchers.

    I do hope all this is helpful, and good luck with your thoughts and planning.

    Take care,

    Ellie

  • I'm living in Australia, and it's not typical to see a perinatal specialist until you are actually pregnant - and even then it's often just a perinatal mental health nurse who liaises between your general psychiatrist and the obstetric team. I had a pretty poor experience with the routine perinatal mental health team during my last pregnancy.

  • Hi Cicerenella and welcome to the forum,

    Thankyou for sharing with us the sad story of your previous pregnancy losses and how you also became unwell afterwards, 2 years ago. As Ellie has said, thinking of having a baby is quite a natural thing and I hope that you will not encounter judgement from the mental health professionals - they should be absolutely supportive with your choices.

    To share my experience, I had an episode of PP in 2009 after my first child was born. I became very unwell over the first week or two and really struggled to get adequate support (although I was quite oblivious at the time due to being very manic and psychotic) so it was a difficult time for my family. I ended up being sectioned and spent 3 months as an in-patient in a couple of different places, including a Mother & Baby Unit, and had ECT.

    When I had my 2nd child in 2013, we asked for support through the pregnancy and postnatal period, but as I don't have a bipolar or other diagnosis and have been well since recovery, it was hard to get input as a lot of professionals don't have knowledge of PP. So I can imagine how you are feeling that you might not get the best response initially, as I didn't either (although for perhaps slightly different reasons).

    I would really encourage you to try and get any input you can, and it's sad to hear that you had a poor experience in your last pregnancy. Perhaps the APP Guide which Ellie has posted can be shared at your next appointment? I think it's really positive that you are thinking ahead and this should be supported by others. My experience was that they didn't necessarily know how to support me, due to a lack of services where I live, but I kept badgering them to be referred and eventually saw a psychiatrist late in pregnancy.

    We put plans in place, including with professional input when we got it, and medication was something I chose to take after the birth to try and minimise symptoms. We also made various choices around the birth, feeding, what I would have wanted to happen treatment wise if I had become ill etc. This felt like an uphill struggle at times, but for us it was really worth it to try and feel like we were minimising the risks wherever possible.

    I stayed well with no further PP episode after my 2nd child. I had some mild anxiety, which the psychiatrist I saw said was completely natural given my history. I appreciate that as you are not in the UK, the APP 2nd Opinion Service isn't available but are there other services you can look into where you are perhaps?

    Planning is really key and although it can feel like this takes away the "magic" of pregnancy, it is an important part of trying to stay well. Although I had stopped taking meds by the time I was pregnant again, I took a low dose of Olanzapine on delivery as I knew it had worked for me last time and felt like something that might help. It will likely be important that any medication change for you will also need to be monitored and supported by your care team both before and during any pregnancy.

    I think bringing up the question of planning for pregnancy can be something that you perhaps mention at your next scheduled appointment, or ask for one putting in if you don't have it already. I hope that the APP Guide may also be helpful, as I found it to be for general health professionals (including mental health ones) who didn't have much knowledge around PP. And what I found to be most helpful was to keep asking for support and input, and don't take no for an answer! You absolutely deserve good support and empathy from everyone involved, and I wish you all the very best. Please do come back to the forum and let us know how you get on, or if you have any more questions. Take care, xx

  • I am very happy with my general psychiatrist, I have been seeing him for almost four years and with the exception of the episode following my pregnancy I have been largely stable for those four years. When I unexpectedly fell pregnant he was supportive of me stopping all medication and seeing how I went, and was prepared to be involved in postnatal planning at a meeting that was scheduled for 32 weeks. And when I became unwell postnatally he was probably more involved in my care because I was on a closed ward in a general hospital that he's employed by - instead of a MBU, where I would have had a new psychiatrist completely for however long I was there. The MBU in my state normally has one bed free for PP patients (there are ~7 per year in the region). Strangely, the crisis team that initially detained me and took me to hospital actually made a referral for that bed at the MBU because they thought I would be "distressed at being around general patients" which everyone doctor/nurse/social worker thereafter thought was ridiculous- personally I think being around mothers and babies would have been more distressing (I'm pretty bitter about that referral). I actually have my next appointment booked for tomorrow (and the following one in three months time). I wasn't planning on speaking about pregnancy planning at this appointment, but maybe I'll test the waters a little and see if I can get off of valproate as a first step. It's just incredibly nerve racking, but we'll see how we go. :)

  • Hello Cicerenella

    It's been interesting to read your posts and replies although I'm sorry for your loss. I wondered if you did test the waters and ask your Psychiatrist about pregnancy planning at your recent appointment? I'm glad you have had the same Psychiatrist for a few years and are happy with him ..... I would think that makes him more approachable, so I hope all went well.

    My PP episodes were a long time ago and it's better that other mums here have been able to share their more recent experiences and treatment.

    Take care.

  • Lilybeth,

    I did mention it, and it felt very awkward for me, but he was open to coming off of valproate straight away and seeing how I go. I'm halving my doses for the next two weeks, and then I'll be done! I'll stay on the 10mg of olanzapine though. We wrote out a bit of a pregnancy plan as well, which was more or less the following:

    - wait until one cycle after stopping valproate before trying to get pregnant

    - take 5mg of folic acid because of the history of neural tube defects

    - get antenatal care as soon as possible

    - early team meeting (around 24 weeks) between obstetrics and my psychiatrist to make a plan about late pregnancy and early postpartum (probably will return to the medication I am taking now)

    My partner and I are thinking of seeing a private obstetrician so we get more control over what happens surrounding the care and support we'll get - a private doctor and hospital here means that I will have the same person the whole way through and that it's more likely plans will be followed and changes in mood will be picked up, plus I can stay in hospital for longer than I would be able to in a public hospital (24 hour discharge for an uncomplicated vaginal birth!).

  • Hello Cicerenella

    Thanks for taking the time to reply. That sounds like a good plan you made. It's a good idea to have continuity of care with a private doctor and a longer stay in hospital to be monitored, though I imagine it can be expensive.

    All the best for the future ..... we are always here if you would like to talk.

  • Unfortunately it is expensive, but I am working to minimise cost as much as possible - I never worked as a midwife in the NHS, so not sure how much it difers, but here in Aus maternity care is excellent in the public system if you have an pregnancy that is uncomplicated by psych issues! I work in a public hospital, and we are inundated every day by women with psychosocial issues, and there are many women who I feel could benefit from having more support but we just don't have the time or the resources. And most of my midwifery colleagues are unfortunately unprepared for working with somebody with PP. As somebody with a diagnosis of bipolar disorder and of a psychotic episode in the postpartum I am *meant* to get a lot of support, but I am painfully aware that even with the best planning I may not actually get my needs met in the public system. My partner also has a genetic illness, and although we've been given the all clear that a baby won't be affected it's important to us that we work with somebody who has a good understanding of his illness and the implications it has. I am going to ask a colleague to see me as a private patient in a public hospital - so I won't need to pay for a hospital stay during labour, there won't be any costs associated with needing a caesarean or neonatal care etc, and my only real cost will be the gap between the doctor's fees and the medicare rebate for antenatal/postnatal care, which will probably be between $20-50 a visit. I think in total I'll pay about $800 out of pocket for antenatal and postnatal care, but over ten or eleven months that should be manageable!!

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