Bipolar, BOLD Blog

00:00 good morning everyone thank you for
00:03 joining us as many of you know this is
00:05 maternal mental health awareness week
00:07 and I am thrilled to have dr. Katie
00:10 Hearst with us to share some information
00:11 about bipolar and babies
00:14 dr. Hurst is the mother of two adorably
00:17 precious young girls prior to becoming a
00:20 mother she attended Stanford University
00:22 for her dual undergraduate degree where
00:25 she earned her medical degree from UC UC
00:28 San Diego while there she received
00:30 honors for leadership academic
00:33 accomplishment and patient care after
00:36 graduation she completed a dual
00:38 residency in family medicine and
00:40 psychiatry
00:41 at UCSD and founded the UCSD maternal
00:45 mental health clinic she became a
00:47 regional expert in the field of
00:49 reproductive psychiatry caring for women
00:52 with anxiety mood disorders and
00:54 psychosis during pregnancy and the
00:57 postpartum period while on faculty at
01:00 UCSD School of Medicine dr. Hurst
01:03 developed the first maternal mental
01:05 health intensive outpatient program in
01:08 the southwest additionally she has
01:11 specialized training and experience in
01:13 the fields of perinatal mental health
01:15 and addiction medicine this morning
01:17 we'll hear about the unique needs of
01:19 women with bipolar disorder during
01:22 pregnancy and the postpartum period good
01:25 good morning dr. Hurst and thank you so
01:27 much for being with us good morning
01:30 thank you so much for having me this is
01:32 really an honor I'm always so happy to
01:35 be invited to give a talk like this so I
01:39 wanted to be on camera just for a moment
01:41 to say hi you can see my face so I'm not
01:43 just a voice coming through the speakers
01:46 but then Traci if you want to I don't
01:48 know how do I take my take me off
01:52 I'm alright now okay cool bye guys
01:56 [Music]
01:57 Thanks so I'm here to talk about as
02:01 Tracy said the unique needs of women who
02:03 have bipolar disorder during pregnancy
02:06 and postpartum I don't have anything to
02:10 disclose in terms of any kind of
02:12 financial conflicts of interest and
02:14 that's me and my hubby and my two sweet
02:17 girls just to say hello
02:19 so today's talk we're going to be going
02:23 over the use of medications and
02:25 pregnancy and breastfeeding and I'm not
02:27 going to be talking about specific
02:29 medications instead I'm going to be
02:31 going over a general outline of how to
02:33 look at the information that is out
02:36 there about different medications
02:37 because information is always changing
02:40 and there's always new data coming out
02:42 and so what's most important is not
02:44 what's out right now but how we look at
02:48 the information that's available so you
02:49 can really take this going take this
02:51 information and kind of use it going
02:53 forward and I'm going to give you some
02:54 important resources to find that
02:57 individual medication information so
03:00 that you can kind of use the strategies
03:01 we talked about to evaluate risks and
03:04 benefits so we're also going to go over
03:06 several or few strategies to minimize
03:08 the risk of a recurrent episode during
03:11 that early postpartum period early the
03:14 first few weeks after delivery tend to
03:17 be the ones that are most that are
03:19 highest risk for recurrent episode and
03:22 so there's a few ways that we can
03:23 especially protect mom during that time
03:26 and then if questions come up that you
03:29 want to ask I think there's a way to ask
03:31 them and you can Tracy's going to
03:33 collect them during the presentation and
03:35 I'll do my best to answer them as we get
03:38 to the end I'll leave some time at the
03:39 end so with respect to medication use
03:43 and as we all know there's lots of
03:45 different types of medications used to
03:47 treat bipolar disorder every medication
03:49 has a different risk profile and we're
03:51 going to talk about how to approach or
03:54 what risk looks like during pregnancy
03:56 and postpartum
03:57 there are however even though every
03:59 medication is different there are some
04:01 very clear common theme in the
04:03 risk-benefit kind of evaluation or
04:06 discussion that I have with my patients
04:08 and that you may want to have with your
04:11 physician or provider there's also six
04:15 key points to keep in mind that are
04:17 really universally true throughout kind
04:21 of the spectrum of illness when we're
04:24 looking when I'm working with women who
04:25 have bipolar disorder who are either
04:27 already pregnant or are looking at
04:29 becoming pregnant and having a baby so
04:33 the first key point is that you know so
04:36 often we think just of medication having
04:38 a risk to the mother or the baby but
04:41 actually having an active illness is
04:44 often carries even more severe risks to
04:47 the mother to the baby both unborn and
04:50 born and to the family around her so we
04:53 need to consider the risk of medication
04:55 but we also really need to consider is
04:58 there a risk to having a depressed
05:00 episode a manic episode or a mixed
05:03 episode and what do we know about those
05:05 risks so that we can balance those in
05:07 the risk benefit discussion the second
05:11 key point that comes along with that is
05:13 that what we want to do is minimize the
05:16 babies exposure to both mom's illness
05:19 and the medication so if the illness has
05:23 more risk in terms of baby's development
05:26 then the medication does and we need to
05:29 make that choice wisely so considering
05:33 that we want to have as little active
05:35 illness and as little medication
05:37 exposure as possible
05:39 now having bipolar disorder and being in
05:42 a stable mood does not confer risk to
05:44 your child what I'm talking about is
05:46 being in the midst of a mood episode so
05:49 as opposed to being stable having a
05:52 depressive episode a hypomanic or manic
05:54 episode of being in a mixed episode
05:56 having a stable treated illness that's
05:59 in remission does not confer risk but
06:02 the active almost does key point number
06:07 three is that with only one exception we
06:10 want to use what's worked in the past so
06:12 very often I've seen women who have
06:16 become either unexpectedly pregnant or
06:18 even it's been a plan
06:19 pregnancy and have just abandoned the
06:21 medications and they've even been told
06:23 to just stop all the medications and
06:25 convert to one magical pill that we know
06:28 more about but the reality is that
06:31 everybody is so individual and has such
06:34 different responses to medicine and as
06:36 I'm sure all those out there who are
06:38 listening though my polar disorder can
06:40 be very complicated and complex and so
06:43 what we really want to do is use with
06:45 treat or use what's worked for treatment
06:47 in the past we don't this is not the
06:49 time to be experimenting with new
06:51 medicines unless there's an active
06:54 illness going on that we need to make a
06:56 change to treat if somebody is stable we
06:59 use with already working because really
07:02 so often the risk of an active illness
07:05 is actually greater than the risk of a
07:08 medication now the one exception to that
07:11 is valproate or depakote so depakote in
07:14 pregnancy can cause pretty significant
07:17 blip defects early in pregnancy so often
07:20 before women even know that they're
07:21 pregnant and it can also cause problems
07:24 with the baby's neuro development or
07:27 brain development and so we do see
07:29 children who are supposed to depakote
07:31 even later in pregnancy having issues
07:34 with learning and with IQ so depakote is
07:38 the one medication that is really off
07:40 the table for women during pregnancy and
07:43 that even if that's worked in the past
07:45 we would absolutely switch if somebody
07:47 we know that somebody's going to get
07:49 pregnant I think that if they suddenly
07:51 find out that their present but key
07:56 point number four so if a woman is at a
07:58 medium to high risk for either
08:00 depression or a hypo or manic episode or
08:03 a mixed episode like I'm saying before
08:05 the risks from another episode might
08:07 outweigh the risks for medication so
08:10 going along with continuing if we have
08:12 somebody who's stable so often if
08:15 they're at a medium to high risk of
08:17 relapse into another episode or have a
08:20 recurrent episode so often the risks of
08:24 having an active episode are actually
08:26 higher than the risks of medication use
08:29 and coming back to the idea especially
08:32 about depakote because 50% of
08:36 pregnancies in the u.s. are unplanned
08:38 it's very important that when I'm
08:41 working with women who are in the
08:43 reproductive age group meaning that they
08:46 have not complete menopause whether or
08:49 not they have a partner we need to be
08:50 very clear about how to prevent
08:52 pregnancy that is doubly important for
08:55 somebody who could get pregnant meaning
08:57 that they are at the reproductive age
08:59 and are on death row just because
09:01 depakote can have negative effects very
09:04 early on in pregnancy so within one to
09:07 two weeks of a woman's missed period so
09:11 if you have bipolar disorder and you
09:13 don't want to get pregnant and this is
09:15 actually true whether or not you have
09:16 bipolar disorder right we want to use
09:18 reliable birth control and so that's a
09:20 discussion that we should be having from
09:22 a provider perspective with all of our
09:24 patients and I hope that as people are
09:29 listening if they have their own
09:32 possibility of getting pregnant really
09:34 we should be thinking about how to
09:36 prevent that unless we want to be
09:37 pregnant so this is a blank chart except
09:43 for one Square and this is how I look at
09:46 the risk and benefit of treating and not
09:49 treating so meaning when I say treatment
09:51 I mean medications and no treatment
09:54 would be no medications so if we look at
09:57 the bottom right square we can see the
09:59 only one that is filled in is the
10:02 benefit of not using medication and that
10:05 is that if we don't use medication then
10:08 there's no risk from meds and that makes
10:10 sense otherwise there's in there mate
10:13 somebody may come up with us and please
10:15 feel free to let me know but there's not
10:17 really a much other benefit from not
10:19 using medication if somebody has a
10:22 diagnosed mood or anxiety disorder that
10:26 we know requires medication for
10:29 stability so now let's look at these
10:31 other three squares that are empty to
10:33 see how can we kind of use this chart
10:36 and fill it in for individual patients
10:40 individual people who have bipolar
10:42 disorder so they
10:43 to evaluate their own risk and also for
10:45 the medications that we're looking at so
10:47 if we look at what's the benefit of
10:50 being on a medication so the question
10:52 really is what's the benefit of having a
10:54 stable mood for the mom for her baby or
10:59 babies if it's not a single timba twins
11:01 or triplets perhaps and for family so
11:04 meaning are there other children that
11:06 are in the family is there a partner or
11:08 spouse are there other extended family
11:11 members and so very often one of the
11:15 benefits of continuing on medications in
11:18 pregnancy is that the woman's mood is
11:21 going to remain stable that she will
11:24 likely have better function and that
11:26 means better more stable relationships
11:29 perhaps that are able to function at
11:31 work
11:32 that are able to take care of herself
11:34 and then this is where this becomes
11:37 personalized so what's the benefit for
11:39 you as an individual with bipolar
11:42 disorder to remain on medication either
11:45 at this time or going into a pregnancy
11:50 now coming to the risk of not treat not
11:54 treating so what is the risk of not
11:56 using medication this is the square
11:59 that's so often we don't fill in when
12:03 we're looking at the risk and benefit
12:04 very often we fix we focus only on
12:08 what's the risk of a medication versus
12:10 what's the benefit of a medication but
12:12 really we need to look at what's the
12:14 risk of not taking medication so if
12:16 somebody is at a medium to high risk of
12:19 having another mood episode what is the
12:22 risk of that episode occurring if
12:26 there's either a hypomanic or a manic a
12:28 mixed or depressive episode and is there
12:30 a risk if that occurs to the mom to her
12:34 baby and to family around her so there's
12:38 lots of different kinds of risks to mom
12:40 and her family right when somebody's in
12:43 a depressive episode manic or mixed
12:45 episode it's really hard to kind of
12:48 continue to have healthy stable
12:50 relationships until we can end up with
12:51 some dysfunction some challenges in our
12:54 relationships we do see that somebody is
12:57 it when somebody is in an active mood
12:59 episode there's a higher risk for
13:01 substance use among some parts of the
13:02 population there's even a higher risk of
13:05 getting into situations in which there
13:07 could be violence there's a higher risk
13:09 of self-harm whether that's self-harm or
13:13 actual suicidal behavior so hurting
13:19 oneself with the intent to commit
13:21 suicide or hurting oneself only to
13:24 commit the kind of a harm the other risk
13:27 that comes from mom and really
13:31 specifically to mom and this can also
13:32 move on to baby is the risk of increased
13:35 medication exposure so when we get into
13:38 an active episode so often we end up
13:40 having to add on or change medications
13:43 we may end up with higher doses of
13:46 medication to control symptoms
13:48 especially if they become severe and so
13:51 we do ends up with increased medication
13:53 exposure both for the mom and also
13:55 potentially for the child for the baby
13:58 and then there can also be physical
14:00 risks to the pregnancy that come from an
14:03 actor
14:03 episode so there's not really great data
14:06 it's specific to a manic episode or a
14:09 mixed episode but we do see risks when
14:13 there's an active depressive episode
14:15 during pregnancy we see a significantly
14:18 increased risk of preterm delivery so
14:20 the baseline risks might be around 5%
14:23 and it goes up to 20 to 25% there's an
14:27 increased risk like I said before
14:28 substance use in some parts of the
14:30 population if somebody has a depressive
14:33 episode during pregnancy it's much more
14:35 likely that it's going to either
14:37 continue or recur postpartum and even if
14:41 some woman's mood is stable during the
14:45 postpartum having that depressive
14:47 episode during pregnancy can also impact
14:50 bonding with the child postpartum we
14:53 also see independent of mom's mood
14:58 postpartum that having a depressive
15:01 episode warm very high anxiety during
15:04 pregnancy can actually is correlated
15:06 with higher rates of childhood anxiety
15:09 when we look at young children and also
15:13 into elementary school age behavioral
15:15 problems depression among children we
15:18 can see impact on IQ as well and delayed
15:22 language development when we have a
15:24 depressive episode during pregnancy and
15:26 all of that is increased as well when we
15:29 have a depressive episode postpartum so
15:31 all of this is to say that we need to
15:34 look and consider that it's not just the
15:37 medications that confirm risk it's also
15:40 that maternal illness confers risk when
15:43 there's an active mood episode going on
15:47 so finally we come to the last square
15:49 which is what's the risk of taking a
15:51 medication during pregnancy or while
15:53 breastfeeding so there's four types of
15:57 risk to baby during the pregnancy the
15:59 first one is toxicity and that would be
16:01 very early on leading to a miscarriage
16:03 or loss of the pregnancy the second one
16:06 is our big word teratogenicity which is
16:09 really birth defects so our baseline
16:11 rate of birth defects in the u.s. is
16:14 three to five percent so three to five
16:16 percent of babies are born with some
16:19 physical birth defect regardless of
16:22 exposure to medication or any illness
16:25 and so we're really looking at
16:27 medications to see does that rate of
16:29 birth defects increase above that then
16:33 kind of norm that we see in the US or
16:36 around the world
16:37 there's developmental risk so if a mom
16:40 is taking a medication especially if
16:42 it's closer to delivery is there some
16:45 effect on how the baby adjusts to life
16:49 kind of after delivery with some
16:51 medications we can see syndromes where
16:53 there's some jitteriness or some errant
16:55 abilities and difficulty feeding when
16:57 there's some medications taking close to
16:59 delivery and then there's potential
17:02 effects on long-term development so just
17:05 like I mentioned with depakote is there
17:07 an effect on babies IQ or child's IQ
17:11 when they're exposed to a medication
17:13 during pregnancy and these risks kind of
17:18 take place during very discrete periods
17:20 of time so we really see the risk of
17:23 miscarriage increase or we consider that
17:25 the risk for toxicity or miscarriage
17:27 that's with exposure at the time of
17:30 fertilization so if there's medication
17:32 that's in the mother's system at the
17:34 time that the embryo is being created
17:37 all the way through almost till the end
17:40 of the first trimester with birth
17:43 defects we see the risk present from
17:45 weeks four which is right at the time of
17:47 the missed period until week 12 by the
17:51 time we've gotten to week 12 the baby's
17:53 body and organ systems are fully formed
17:56 so we have a medication that has been
17:59 shown to increase
18:00 the risk of birth defects but does not
18:02 show any an impact on baby's development
18:06 or kind of long-term behavior then
18:09 perhaps we skip the first trimester you
18:12 know trying and minimize exposure during
18:15 the organ formation and then we would
18:18 reintroduce it during second and third
18:20 trimester if that makes sense
18:21 so kind of knowing when the different
18:23 risk times for risk to baby are present
18:27 is really important developmental and
18:30 affect on kind of how baby grows in the
18:32 womb and how the baby does after
18:34 delivery can take place anytime during
18:36 the second and third trimester and then
18:39 long-term neurobehavioral effects that's
18:41 also second and third trimester exposure
18:45 now I mentioned both pregnancy and
18:48 breastfeeding and so it's really
18:50 important also to keep in mind that
18:52 exposure and breast milk is this is my
18:56 way with a way last one exposure during
18:59 pregnancy so for example there are
19:01 medications that are considered safe
19:03 during breastfeeding but not during
19:05 pregnancy and actually depakote is one
19:07 of them
19:08 so we that can't that's not a safe
19:10 exposure during pregnancy but actually
19:12 the amount that is is present in breast
19:16 milk is incredibly low and so that very
19:20 small amount is actually considered safe
19:22 for the infants so I will have women who
19:25 are maintained on one medication during
19:27 pregnancy and then because we know
19:29 they've done very well perhaps on death
19:31 occurred in the past there may be an
19:32 informed decision to switch a delivery
19:35 and then she use depakote if they're
19:38 going to attempt to breastfeed the child
19:40 but keeping in mind that breastfeeding
19:43 and pregnancy are two different times in
19:46 terms of exposure and that the baby is
19:50 getting a lot more of the medication
19:52 during pregnancy than is getting in the
19:54 breast milk
19:56 so with that being said we've got this
19:59 chart we kind of know what questions to
20:01 ask and how to evaluate the risks were
20:05 three of the squares but for that last
20:07 square we need to get very individual
20:10 specific medication or specific
20:12 information for each medication and so
20:14 that's where these two resources are
20:16 really crucial the first one is mother
20:18 to baby org and this is an amazing
20:22 website that's I will say run out of UC
20:24 San Diego but it's available worldwide
20:29 they actually offer free phone
20:31 counseling you can do a web chat they
20:34 also have written summaries that you can
20:36 download that are really kind of easily
20:38 easy to understand and digest and you
20:41 could actually call them and say these
20:43 are the medications I'm taking kind of
20:45 what are the profiles for each of them
20:47 in terms of the risk during pregnancy
20:49 and they'll be able to really walk you
20:51 through and give you detailed
20:52 information on that or you can just look
20:54 at it on the little summaries the other
20:57 one if you're somebody who wants all of
20:59 the data which may or may not be helpful
21:02 keep in mind is a group called repro
21:05 toxin org and that one providers can
21:09 subscribe so for example i pay for an
21:13 annual subscription there but also
21:15 consumers so you're able to pay $17 and
21:19 you'll have access for a month to any of
21:21 the medications and so you can do a
21:23 search in their database and it will
21:25 pull up every study that's been
21:27 published about this medication use in
21:30 pregnancy and in breastfeeding now the
21:33 important thing to keep in mind is that
21:36 sometimes all of that data it can be
21:38 overwhelming as a clinician it can be
21:41 overwhelming and so it's something that
21:42 can also be really helpful to go through
21:45 with the mental health provider with
21:47 whom you're working to kind of look for
21:49 okay what is the trend what's the
21:51 overall message because so often we have
21:54 you know six or seven studies that you
21:56 know may have mostly similar but
21:58 slightly conflicting results and so
22:00 that's where even bringing that
22:02 information into a visit with a provider
22:04 if you're planning for a pregnancy that
22:06 can be very helpful
22:09 now we used to have these classes from
22:12 the Food and Drug Administration so ABC
22:15 and I believe it would be and also X
22:18 those thankfully have been phased out so
22:20 now the FDA gives kind of a more general
22:22 discussion and anything that gives a
22:25 medication a very simplistic letter or
22:28 number ranking as safe or not safe kind
22:31 of in a tier ranking is really not as
22:35 helpful because we need to look at these
22:37 very individually based on what time of
22:39 pregnancy is the woman going to be
22:41 taking it and what has looked in the
22:43 past so it might be that for example if
22:47 I have bipolar disorder and I know that
22:51 lithium is the only medication that's
22:53 really kept me stable there might be
22:56 other medications that have slightly
22:59 less risk to the infant during some
23:02 periods of development during pregnancy
23:04 but I know that based on my history
23:07 lithium's the one that's going to keep
23:09 me most likely to be stable during
23:12 pregnancy it might be that the risk with
23:15 lithium use especially in the first
23:17 trimester which is actually very small
23:19 it might be that that risk is okay for
23:23 me individually because the risk of me
23:25 having another episode is so great and
23:28 we already know that other things have
23:30 not worked one other key point to come
23:36 back to regarding the specifics of
23:38 medication use during pregnancy is that
23:42 as women progressed in pregnancy the
23:45 volume of blood in their body increases
23:48 really dramatically and so because the
23:52 woman has more blood volume the
23:55 medication that they're taking is almost
23:56 diluted in a way and on top of that we
24:00 actually as women our livers and our
24:04 kidneys which serve to get rid of kind
24:07 of break down and get rid of a lot of
24:09 medications they go into overdrive
24:11 during pregnancy and so our livers
24:13 become like crazy machines breaking down
24:15 medicine faster and our kidneys start
24:18 working more quickly as well so I often
24:20 see that as we get towards the second
24:22 trimester
24:23 and and as we enter the third trimester
24:25 women may begin needed higher doses of
24:28 medication and so sometimes all if it's
24:32 a medication we can track blood levels
24:34 I'll make sure that I have kind of a
24:36 blood level early in pregnancy or even
24:38 pre pregnancy so that I know what the
24:41 level is that provides mood stability
24:43 for them and then perhaps we'll check
24:45 blood levels kind of as we get into
24:47 second trimester and third trimester
24:49 we might even proactively increase the
24:52 medication to maintain a certain blood
24:53 level or at the first hint of an episode
24:56 beginning will kind of increase it and
24:59 so that's really based on individual
25:01 medication needs and communication with
25:03 the provider but it does mean that we
25:06 can't you know I don't have somebody who
25:08 all seen once during first trimester and
25:11 then I don't see them again for three
25:13 months having a woman who is pregnant
25:15 and has a diagnosis or a history of
25:19 bipolar disorder means pretty close
25:21 follow-up during that pregnancy so at
25:23 least monthly and definitely
25:27 availability to make sure that if
25:29 something comes up and there's a concern
25:30 that you can get in to see that provider
25:33 sooner or at least talk on the phone and
25:35 in case an adjustment is needed I also
25:38 want to make clear sometimes as women we
25:41 get set in our minds and men do with -
25:44 of course as humans I suppose this idea
25:48 of well if I make it through to the end
25:51 of pregnancy and I don't need a most
25:53 dose adjustment and somehow that's like
25:55 a badge of honor or if I can make it
25:57 through pregnancy without medication or
25:59 I can make it through pregnancy and only
26:02 need this dose then somehow that's kind
26:05 of winning or maybe I'm just very
26:08 competitive but somehow that's
26:10 succeeding in some way and just making
26:13 sure that we recognize that success here
26:16 is keeping mother as stable and healthy
26:20 as possible and so expecting that there
26:23 will likely be dose increases or
26:26 adjustments because pregnancy is a long
26:28 period of time it's not all that common
26:32 I mean there's not that many women who
26:34 have bipolar disorder and go through an
26:35 eight month period of time
26:37 without needing some adjustments
26:39 especially given the emotional intensity
26:42 that a pregnancy brings and delivery in
26:46 the postpartum so just recognizing that
26:48 this is not a typical eight month period
26:51 or nine month period in your life this
26:53 is this can be very challenging and so
26:56 setting aside any expectations or
26:58 definitions of kind of success or
27:00 failure and recognizing that really self
27:03 care and doing the best you can for
27:06 yourself and your baby you're going to
27:07 be the most important things so I'm
27:13 going to transition now into postpartum
27:16 strategies actually I'm sorry go back I
27:20 just want to look at that chart one more
27:21 time because I have a couple minutes so
27:24 if we go back to this chart let's just
27:27 look at this and say okay so let's say
27:29 we have a woman who is evaluating the
27:33 risk for example of lithium loose during
27:35 pregnancy and of course this is I'm not
27:38 going to fight all of the data correctly
27:39 right now so please don't use this as a
27:41 medical advice but for example when I
27:44 have a woman in my office who has
27:47 bipolar disorder has been maintained on
27:49 lithium and disabled and ideally were
27:52 able to talk before pregnancy but you
27:55 know sometimes life happens as I said
27:57 50% of pregnancies are unplanned so
28:00 coming in I want to make sure that I
28:03 have this blank chart laid out either
28:05 mentally or even ideally printed out and
28:08 in front of her and then we're going to
28:10 go through and fill in all of the
28:11 squares together so the first two where
28:14 to start we'll start with is what is the
28:16 risk of treatment so what's the risk of
28:18 taking lithium during pregnancy or
28:20 breastfeeding and so first starting off
28:23 saying okay is there a risk of toxicity
28:25 so as lithium been associated with an
28:28 increased risk of miscarriage and
28:31 looking at the data they're looking at
28:34 okay is there data suggesting that
28:36 lithium has been associated with an
28:37 increased risk of birth defects looking
28:41 at then is there an increased risk of
28:43 some adjustment problem for the baby
28:46 after delivery and then do we know of
28:48 any long-term development risks
28:50 with lithium exposure during pregnancy
28:54 then I'm going to come back and look at
28:56 okay well what are the benefits of
28:58 staying on a medication lithium
29:00 specifically inter and and the woman
29:03 will hopefully be able to kind of fill
29:04 in well when she's stable and not an
29:07 inactive illness right she's able to
29:08 have a better relationship with a
29:10 partner she's able to take care of
29:12 herself better you know all the things
29:14 that were able to do when we're not in
29:15 the midst of a mood episode then looking
29:19 at okay what's the risk of discontinuing
29:21 a medication or of not being on a
29:24 medication if this is somebody who has
29:28 not had very many mood episodes they've
29:31 not been very severe then that might be
29:33 a slightly different discussion than
29:35 somebody who's required hospitalization
29:36 or has had some really severe episodes
29:41 in the past looking at though that when
29:44 we do see specific episodes like a
29:46 depressive episode during pregnancy we
29:49 see actual effects on the pregnancy
29:52 duration and we see effects on the on
29:54 the baby the unborn child as well and
29:57 then finally I'm looking at okay is
29:59 there a benefit from not taking the
30:01 lithium and one of the benefit is no
30:03 list for meds sometimes women will say
30:05 the benefit being that they don't need
30:15 sorry sometimes they'll say that the
30:18 benefit is that maybe they'll have more
30:20 peace of mind because they won't be on
30:22 medication during that time tracy was
30:25 there a question that just came in also
30:29 there is let me read it for you it says
30:34 do you suggest changing medication
30:37 and/or dosing that would be safe for the
30:40 first trimester before a woman conceives
30:43 that's the first question okay so um do
30:47 I suggest changing medication or dosing
30:49 before the first trimester so you know
30:52 it really depends on what the person
30:54 what the woman is taking so if the woman
30:57 is if this is a patient for example who
31:00 has a history of severe mood episodes
31:02 and is there
31:04 a stable on the current regimen then
31:08 very often I would suggest staying on
31:13 the regimen that keeps that person
31:15 stable
31:15 if however sometimes I have actually
31:18 often I have women come in who are
31:20 stable and also recognize that they want
31:23 to get pregnant but we have some time so
31:25 they're planning out so if we wanted to
31:28 for example try and adjust some
31:29 medications and minimize how many
31:31 medicines are on maybe we have time to
31:34 do that it is best to like I said
31:36 earlier with that I think the second
31:38 point right to minimize medication
31:40 exposure as long as the women can be can
31:43 remain stable during that time so
31:46 sometimes I'll have people come in who
31:47 have had episodes and this happens very
31:49 often where medications get added on
31:52 during the mood episode and then the
31:54 person just gets kind of continued on
31:55 them and we end up on a cocktail of two
31:58 or three men and we're not really sure
32:01 if all of them are needed if we can plan
32:04 ahead of time and spend you know six
32:06 months to a year kind of slowly wean off
32:08 one or two of the medicines and really
32:11 evaluating okay how's the stability
32:13 how's your mood steps I mean that's like
32:16 the most beautiful situation because
32:18 then we can really see how little
32:21 medicine do we need but we can also do
32:24 it in a very mindful deliberate manner
32:26 what I don't recommend is hastily
32:30 getting off of medicine just for the
32:32 sake of being on only one because again
32:35 most of the medications that are out
32:37 there confer less risk than a severe
32:41 mood episode and as I said before with a
32:44 severe mood episode if you end up of
32:46 course hospitalized you know more often
32:48 than not even if you're not hospitalized
32:50 we end up treating with higher doses and
32:52 medicines to kind of restore restore
32:54 stability I hope that that makes sense
32:57 oh the other thing I will say is that
32:58 there is really interesting data showing
33:02 or a really interesting studies showing
33:03 that the duration of time for a taper
33:06 off of the medication before pregnancy
33:08 or even during pregnancy impact
33:11 stability so if we can spend four weeks
33:15 even 12 weeks or 16
33:18 doing a very slow taper off as a
33:20 medicine then we are much more likely to
33:23 have mood stability compared to if we do
33:26 a really quick taper off over just two
33:28 weeks I've rarely seen somebody do a
33:31 quick taper who's been able to stay
33:32 stable for very long so really the
33:35 longer duration of the taper I'm the
33:38 better enough true universally for
33:39 psychiatric medications I generally
33:41 spend like you know a year maybe taking
33:43 somebody off of any antidepressants and
33:46 that's you know not necessarily in the
33:48 context of planning for pregnancy but
33:50 the longer taper the better what was the
33:52 second question Traci I think you
33:55 answered it she said that she's done
33:57 research as she found that ideally women
34:00 only take one medication and that
34:02 potentially with a lower dose right and
34:06 yeah so right so again it's there's this
34:09 ideal out there of you know what's the
34:11 perfect plan and the perfect pregnancy
34:13 and it just doesn't exist right
34:15 everybody's different every woman is
34:17 going to have different needs and so
34:19 that's why I'm looking at doing this
34:20 very individualized risk benefit
34:22 discussion with your provider is so
34:25 important because for some women yeah
34:27 they can get down to a low dose of a
34:29 single mood stabilizer but for many
34:31 women that's not possible and that's
34:32 okay I've had plenty of patients who
34:35 have required two or three medications
34:37 during pregnancy and we've had lots of
34:40 discussions ongoing about that and
34:42 they've done beautifully during the
34:44 pregnancy and have these like gorgeous
34:46 healthy children afterwards so it's
34:49 really about assessing the whole picture
34:51 not just considering the medication to
34:54 be a problem Thanks those are great
34:56 questions
34:57 okay so I'm going to get back to then
34:59 now let's go into some postpartum
35:00 strategies so the first strategy if we
35:05 you know so we've gotten a woman's
35:07 gotten through pregnancy the first
35:10 strategy is actually in that third
35:13 trimester and ideally throughout the
35:15 pregnancy but having the partner or a
35:19 support person present and at least one
35:22 of the visits with a mental health
35:24 provider so you know I want to when I'm
35:26 seeing a woman who is pregnant or even
35:29 planning to get pregnant I really want
35:31 that part
35:31 or a support person involved in the
35:34 woman's care now that the woman can't
35:36 make choices for herself obviously but
35:39 because you know the more support we
35:41 have the better and so especially in the
35:43 third trimester I have at least one
35:45 visit that has a partner or a family
35:48 support person presence and I say that
35:51 very clearly because you know the
35:53 reality is I think in the u.s. it's more
35:55 than 50% of children are born and it's
35:57 not a marriage that they're you know a
35:59 partner situation or a woman having a
36:01 child by herself and so recognizing that
36:03 families take all different shapes and
36:06 forms these days and so but it is really
36:09 important to have at least one
36:10 identified support person come to a
36:14 visit before delivery to meet with you
36:16 the psychiatrist and possibly a
36:18 therapist as well to go over what are
36:20 the signs of a mood episode these are a
36:22 depressive episode or manic or mixed
36:24 based on the woman's history what are
36:26 some reasons that the partner or support
36:30 person might want to or have permission
36:32 to call the psychiatrist and really
36:35 having that planned out ahead of time so
36:37 that the woman is aware of you know if
36:40 something is going on - for partner have
36:42 permission to make a call and say hey
36:45 need to come in sooner because earlier
36:48 intervention is always going to be
36:50 better when we're looking at these first
36:53 postpartum weeks it's also really
36:56 important because we have often made
36:59 medication adjustments as pregnancy has
37:01 gone on very important that there then
37:03 be a plan for what are we going to do
37:05 with medication during labor the long
37:08 labor and at the time of delivery so for
37:11 example lamictal lamotrigine is a mood
37:14 stabilizer and lithium often get up to
37:16 much higher doses during the second and
37:19 third trimester just because of how
37:21 quickly they get broken down so very
37:23 important then that the woman knows and
37:25 communicates with her obstetrics
37:27 provider and do the OB or a midwife what
37:31 is the plan for immediately after
37:33 delivery and oftentimes that dose is
37:35 going to come right down after delivery
37:37 because mom is going to stop processing
37:39 so quickly so she needs to have that
37:43 written plan from the psychiatry
37:45 Thurber's providing mental health care
37:47 to give to the OB treatment team ideally
37:49 in her chart and even to carry a written
37:52 plan with her to the hospital because we
37:53 all know how well medical record systems
37:56 functions they're not always the most
37:58 reliable another key point that goes
38:02 along with postpartum strategies is that
38:04 breastfeeding is great but for a woman
38:07 with bipolar disorder or even a history
38:09 of severe depression that's not bipolar
38:11 disorder sleep is really better and so
38:14 can breastfeeding an infant and getting
38:17 out of quick sleep coexist absolutely
38:19 but if I had to choose I would put sleep
38:22 ahead of breastfeeding I would consider
38:27 and I do consider sleep to be along the
38:29 lines of a medication for bipolar
38:31 disorder so when sleep is lacking it's
38:34 like having taken away I'm the
38:36 stabilizer sleep is healing for the
38:40 brain of somebody with bipolar disorder
38:42 especially the middle of the night hours
38:44 you know the midnight to 3:00 or 4:00
38:46 a.m. is crucial what are the exact hours
38:49 that an infant disrupt those
38:51 middle-of-the-night hours so when we
38:54 look at breastfeeding versus sleep it
38:57 doesn't have to be an either/or
38:58 situation but we do need to kind of
39:01 approach it with this idea of is breast
39:06 always best right recognizing formula is
39:09 food for the babies just like breast
39:10 milk kills from a provider standpoint I
39:13 always reinforce when I'm training
39:15 providers that we don't just say are you
39:18 breastfeeding right it's are you breast
39:20 or bottle feeding how are you feeding
39:21 your child that's the most important
39:23 part right there there's this pendulum
39:26 has swung so far from formula to breast
39:28 milk in this country and I think I know
39:31 a lot of parts of the world we really
39:32 need to bring it back to this place of
39:33 being rational and logical now there's a
39:36 lot of women for whom breastfeeding is
39:37 not the best solution is not the best
39:40 kind of plan and it's also not possible
39:42 so when we look at women though who want
39:46 to breastfeed their child and also want
39:48 to protect their sleep there's this myth
39:50 of nipple confusion so that if you
39:52 introduce a bottle to the infant too
39:54 early the baby won't be able to continue
39:56 breastfeeding
39:57 that's really
39:59 kind of along the lines of a myth it's
40:01 really uncommon for that to happen so
40:03 introducing the idea of a bottle early
40:05 on into baby's life is one of the things
40:08 that's going to allow a mom to get some
40:09 sleep also looking at milk supply
40:12 skipping one or two feedings in the kind
40:18 of during the night so that long can
40:19 sleep is for most women not going to
40:23 affect them multiplied to the point when
40:25 they won't be able to breastfeed it may
40:27 be that they need to pump during the day
40:29 to stimulate more but sleep is a
40:32 treatment sleep is a medication for
40:34 bipolar disorder it's not the only one
40:37 but it's a really important component so
40:41 we need to start the discussion with the
40:43 OB treatment team before delivery that
40:45 in those first few nights some women
40:47 spend one night in the hospital after
40:49 delivery some women spend you know 2 to
40:52 4 even 5 depending on how the delivery
40:54 went we have to minimize nighttime
40:56 disruptions in the hospital most women
40:59 that I see who have delivered have
41:01 gotten no sleep for goodness knows how
41:03 many days because of how many times
41:05 nurses and CNAs and providers are coming
41:08 in in the middle of the night I highly
41:11 recommend talking with the treatment
41:13 team ahead of time talking with the
41:15 nurses on the floor making sure that it
41:17 is clear that this is a woman for whom
41:20 sleep is really important and so having
41:22 a partner or a support person there we
41:24 can feed the baby during the night and
41:26 then actually putting a physical sign on
41:28 the door asking that providers don't
41:31 disturb and I will even go so far as
41:33 they do not disturb unless it's a
41:35 life-threatening situation between the
41:37 hours of 11:00 and 5:00 for example that
41:40 chunk of sleep is critical to promoting
41:44 postpartum mental health in in women as
41:49 we are in the hospital and then moving
41:51 home it's really important to look at
41:53 social support so who else can feed this
41:56 baby right and I say this baby wasn't
41:59 way and I hope it doesn't sound harsh
42:01 right but mom can't be the only person
42:04 who's responsible if we expect her to
42:07 remain stable we need other family
42:10 members partners to be able to help and
42:12 so
42:13 really protecting a chunk of sleep for
42:16 mom every day is going to mean that
42:17 other members of the family help with
42:20 feeding and early on that will likely
42:23 mean from formula supplementation for
42:26 those first several night feedings it
42:28 may be that mom is unable to pump enough
42:29 during the day to have breast milk in
42:32 the bottle at night it may be that baby
42:34 continues getting some formula at night
42:36 and mom's able to breastfeed the rest of
42:38 the time during the day everybody's
42:40 different but again the risk of a mood
42:43 episode when sleep is disrupted we know
42:47 at baseline even without a pregnancy in
42:49 the delivery right when somebody misses
42:52 sleep or has disrupted sleep for a few
42:54 nights in a row and they have bipolar
42:55 disorder a really risky period of time
42:58 and there's very higher likelihood that
43:01 that person is going to go into a mood
43:02 episode so it's really important that we
43:07 stabilize sleeves and protect it as much
43:09 as possible in these first few weeks
43:11 because what we see is that it's these
43:13 first few weeks that are the highest
43:15 risk time for a new episode the other
43:21 strategy is having very close follow-up
43:24 with mental health so if I have a woman
43:26 who has a scheduled c-section that's
43:29 easy right easy peasy
43:31 in terms of scheduling her follow-up
43:33 when I have somebody who you know is not
43:36 in that small percentage of women then
43:38 what I generally schedule is you know
43:41 I'm seeing her probably every two to
43:43 four weeks and those last six weeks of
43:45 pregnancy to check in especially because
43:47 we may end up needing more medication
43:50 changes as her blood volume continues
43:53 increasing and medicine is kind of less
43:56 stable also the emotional strain of late
44:00 pregnancy and the strain it can take on
44:04 our sleep right when we are in our third
44:06 trimester of pregnancy it's
44:08 uncomfortable and most of us are not
44:10 sleeping so it's not just those
44:12 immediate first few weeks after delivery
44:14 which they can get disrupted it's in
44:16 that third trimester as well and so
44:18 recognizing you know I will often
44:21 actually use medication to stabilize
44:24 women's sleep during those last few
44:25 weeks of pregnancy
44:26 so that they're not already in a
44:29 disrupted sleep state going into
44:31 delivery following up closely around the
44:34 time of delivery so having an
44:36 appointment scheduled around the due
44:38 date you know with if we need to cancel
44:40 it and need to cancel it but you know if
44:42 you're not Labor yet please come on in
44:44 let's check having one about two weeks
44:47 after delivery every four weeks and then
44:50 six weeks postpartum when we've made it
44:52 to six weeks postpartum and the woman's
44:55 mood is stable I can do a little happy
44:56 dance because I feel like we're kind of
44:58 out of the womb it's those first 4 to 6
45:00 weeks where we're at the highest risk
45:02 for having another mood episode so
45:06 really close follow-up during that time
45:08 and plans in place communication with a
45:11 partner and sometimes communication with
45:13 a partner during those visits postpartum
45:15 as well because you know new babies are
45:18 stressful for moms and partners mom
45:22 having an illness that we're paying
45:23 close attention to just like if she had
45:25 lupus it's like if she had diabetes
45:27 right we probably had the partner coming
45:29 in to talk about it and so we want to
45:32 also make that an option with it with
45:35 bipolar disorder like I said before
45:39 treat insomnia so if the mom can't sleep
45:43 when baby sleeps at night right it's so
45:46 often it's impossible to sleep when the
45:48 baby sleeping during the day because
45:50 there's just other things to do but if
45:52 baby is sleeping at night and mom can't
45:55 sleep that's concerning
45:56 in those first few weeks as those that
46:00 need have had children know the baby
46:01 often doesn't sleep at night and so but
46:04 mom needs to be able to sleep during
46:05 those hours so if there's insomnia
46:08 somebody else has a baby has cared for
46:12 the baby and you still can't sleep then
46:15 you need to be in contact with your
46:17 mental health provider and that's where
46:19 if there's not a history of substance
46:21 use for example I'll use a short course
46:24 of something like ativan or klonopin
46:26 I'll do that as well sometimes in
46:28 pregnancy to stabilize sleep because
46:31 sleep is so important and then fine
46:36 let's just remind ourselves that there
46:38 is hope and there's a lot of success
46:40 when we approach pregnancy and plan for
46:44 it even when we're not planning for even
46:48 when there's a surprise pregnancy when
46:50 we can really respond rationally and
46:52 logically and make decisions taking into
46:54 account the entire picture I've seen so
46:58 many women get through pregnancy
46:59 successfully have babies and be able to
47:03 make it through the postpartum and when
47:06 a mood episode does arise we're usually
47:08 in a much better place to respond to it
47:10 earlier we have fewer we have newer kind
47:13 of ramifications of that or consequences
47:16 and we're able to do it in a much kind
47:17 of gentler more mindful way than if we
47:22 haven't been communicating throughout
47:24 the process so thousands adventure
47:27 millions of women who have had both
47:29 bipolar disorder over you know however
47:31 long centuries right millennia has made
47:35 it through pregnancy and postpartum both
47:37 safely but most importantly happily and
47:39 so this is very possible and I wanted to
47:43 make sure that we leave this with some
47:45 hope and looking forward because
47:46 pregnancy is a beautiful thing right how
47:48 wonderful that somebody wants to have a
47:51 child and I'm very honored always to be
47:54 included in that process to help make it
47:57 as good as possible so final resource is
48:03 I put in the to resources earlier for
48:07 medication information I also want to
48:08 put up postpartum net this is the
48:11 website for postpartum support
48:13 international and of course you know
48:16 it's not just for pardonnez pregnancy as
48:18 well and so there they have a research
48:20 list with providers who are trained in
48:22 pregnancy and postpartum mood and
48:24 anxiety disorders both therapists and
48:27 prescribers and that is all that's
48:30 international but that's certainly
48:32 within the u.s. in North America and so
48:35 if you are thinking of getting pregnant
48:37 or are pregnant you can go to that
48:39 website and ideally try and find
48:41 somebody who's close to you and just in
48:44 case your provider is not comfortable or
48:45 is not educated
48:46 this is unfortunately
48:49 not enough psychiatrists are they also
48:52 have a listing for support groups for
48:54 women who are pregnant postpartum and
48:56 the support groups even if you're doing
48:58 well can still be wonderful just to be
49:00 around other women who are kind of going
49:02 through similar similar things and then
49:05 finally there is my contact information
49:08 in case anything comes up down one and
49:13 Traci I think I'll hand it over to you
49:15 thank you so much dr. nerse for sharing
49:18 this information especially this week
49:20 where we're mindful and appreciating
49:23 focus on maternal mental health so we're
49:26 gonna have time for a few questions and
49:29 so if you have a question you can shoot
49:31 it over and we'll ask dr. Hurst the
49:33 first question comes about medication
49:36 and I know you referred to depakote as
49:40 not being compatible with pregnancy what
49:43 are your thoughts on risperdal while
49:45 pregnant oh that's a great question so
49:49 it's so interesting because the
49:51 risperdal and that class of medications
49:55 came out gosh just I mean while I was in
49:59 training so in the early 2000s and so
50:01 thankfully we've gathered a lot of
50:04 information in the last 15 years on
50:07 risperdal use during pregnancy I would
50:11 refer you to mother to baby org for
50:14 up-to-date information the last time
50:17 that I checked and again this is not
50:18 meant as individual medical advice but I
50:21 have had women go through pregnancy on
50:23 risperdal because again we're looking at
50:25 is their risk of birth defects and is
50:28 there any information on kind of child
50:30 development after exposure and what I've
50:33 seen is actually that things have looked
50:34 very favorable for risperdal in terms of
50:38 lower lift for taking that certainly
50:40 compared to depakote or some of the
50:43 other medications but I would definitely
50:46 look that at mother to baby we'll have
50:47 updated information as well Reaper talks
50:50 and as we are using more of the that
50:54 class of medication from the
50:56 stabilization so we're not just using
50:58 the traditional kind of depakote within
51:02 medication I think we do have a pretty
51:04 good amount of data on that for youth
51:08 and pregnancy so I definitely use that
51:10 with women when that's the medication
51:12 that we know has worked great thank you
51:15 so much as a great resource the next
51:17 question has to do with holistic
51:19 holistic and natural things to do so the
51:24 question is do you have any thoughts on
51:25 key holistic or natural things to do to
51:29 help with pregnancy and bipolar disorder
51:32 so I yes my I mean I am a huge supporter
51:38 of women using any resource that is
51:43 helpful to them so there's not I don't
51:46 know of specific studies looking at
51:48 bipolar disorder and methods like yoga
51:52 mindfulness meditation acupuncture but I
51:55 know that we do have data with
51:57 specifically unipolar depression showing
52:00 that acupuncture can be very helpful
52:03 during a depressive episode that's
52:06 showing that exercise I think even a
52:11 study on yoga and what things
52:13 incorrectly bright light exposure and
52:17 also my son mindfulness practices can be
52:20 helpful the concern is that you know
52:23 you're it's not a unipolar disease it's
52:26 a bipolar disease and so what I really
52:29 encourage women to do is this is where
52:31 if we're planning ahead for pregnancy
52:33 then we can maximize all of the
52:35 resources that a woman is taking
52:37 advantage of so if a woman is on a medic
52:40 you know a few medications that are
52:42 helpful we could perhaps try planning
52:45 ahead of time peeling back very slowly
52:48 tapering off one or two of those while
52:50 instituting these supportive treatment
52:53 so using acupuncture especially I'm a
52:56 big fan of mindfulness meditation in my
52:59 own I have a daily practice and I teach
53:00 it as a way to support mental health so
53:04 that the women can find all of those
53:06 other complementary treatments to use
53:08 along with a mood stabilizer
53:10 I have not however seen any data that
53:14 would show that
53:16 anything in the kind of complementary
53:18 alternative holistic treatment world can
53:20 replace the use of our traditional
53:24 psychiatric medications for a
53:25 fundamental mood stabilizing
53:28 unfortunately I if I wish that that were
53:30 there but I think that there is
53:32 something I'm not a huge fan of my own
53:36 field in a lot of ways in terms of the
53:39 amount of medication that we prescribe
53:40 I'm probably not supposed to say that
53:42 but that's okay I think we over
53:44 prescribe a lot
53:45 however with bipolar disorder I think
53:48 that we do end up having to rely on at
53:51 least a traditional mood stabilizer or
53:53 some sort of mood stabilizer but if we
53:55 can minimize or lower that dose with
53:57 using any alternative treatments
53:59 absolutely as wonderful I wish I had
54:01 more specific answers for you I'm sorry
54:03 now that was great thank you so much the
54:06 next question is about caregiving so as
54:10 a caregiver
54:11 what can I look for in the postpartum
54:13 period that might indicate at that
54:16 coming episode oh that is such a
54:19 fabulous question so this is where if
54:22 you're able to go with the partner
54:26 family member that you're with to talk
54:30 with the psychiatrist that is the most
54:32 helpful in terms of planning during
54:34 third Pricer trimester because then you
54:37 can really find out what are the signs
54:39 that are unique to to the person that
54:43 you're with because everybody is
54:45 somewhat different clearly I mean there
54:47 are clear signs of for example a hypo or
54:51 manic episode
54:52 insomnia is really universal to both
54:55 depression and mania and so if somebody
54:58 is having trouble sleeping that's a
55:00 really clear sign you know if we look at
55:04 increased activity so when somebody is
55:06 up having more activity during times
55:09 that they might otherwise be sleeping
55:10 talking more quickly physically moving
55:14 around more or the opposite right not as
55:19 motivated not as interactive with the
55:22 baby postpartum not not able to take as
55:26 much initiative those are some kind of
55:29 clear signs
55:30 this is where having a person's consent
55:33 to speak with their mental health
55:34 provider it can be so helpful great
55:38 thank you
55:38 the next question is about conception
55:41 and the question is I'm currently in the
55:45 middle of a hypomanic episode and
55:47 working closely with my doctor should I
55:50 wait a certain amount of time to try to
55:53 start conceiving oh great question so
55:57 first of all kudos to you for thinking
56:00 ahead like that that's awesome
56:03 I so many women you know don't do that
56:07 so I don't think that there's a specific
56:10 amount of time because of the hypomanic
56:14 episodes per se but what I would I
56:18 recommend to my patients and I guess
56:20 what I'm saying is I don't have a study
56:21 to back me up on this what I recommend
56:23 to my patients is six months of
56:25 stability before we talk about kind of
56:29 trying to conceive now that I'm involved
56:31 directly in that process obviously but
56:33 if I have somebody and we're looking at
56:35 this woman wanting to become pregnant
56:38 I do recommend six months of being out
56:41 of the hypomanic episode being stable
56:43 and especially being on stable doses of
56:46 medications for about that length of
56:48 time before starting trying to conceive
56:52 great thank you I'm time for one more
56:55 question and it is if I have a manic
56:59 episode during my last postpartum period
57:02 is it more unlikely that I will have one
57:05 in my next pregnancy um not necessarily
57:10 during the next pregnancy but I would
57:13 say that that puts you at a higher risk
57:15 during the next postpartum period with
57:19 that being said it would be very
57:21 interesting to look at sleep protection
57:24 because I think very often we are not
57:29 protecting women's sleep postpartum and
57:31 that is often a clear trigger of a
57:34 Munich episode just like that would
57:36 trigger anybody who wasn't postpartum so
57:38 just because somebody has had a manic
57:41 episode in a postpartum period does not
57:44 mean a hundred percent that they're
57:46 going to have another one that's
57:47 important to references recognize
57:50 doesn't mean that you shouldn't have
57:52 another child if you got a something
57:54 that you want and are planning for but
57:56 it doesn't mean that we need to pay
57:57 closer attention and really clearly plan
58:01 put into place some of those protective
58:03 strategies in order to kind of minimize
58:06 that risk well thank you
58:10 and so much dr. Hurst for your time this
58:12 morning and this really valuable in for
58:15 me I'm on pregnancy postpartum and
58:19 bipolar appreciate your time and
58:21 everyone have a great rest of your
58:23 maternal mental health awareness week
58:25 wonderful thank you so much it was my
58:27 pleasure