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Preconception Planning Postpartum Psychosis — MRCPsych Paper B MCQ

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ModeratePerinatal PsychiatryPreconception Planning Postpartum PsychosisMRCPsych Paper B

A woman with bipolar I disorder experienced postpartum psychosis after the birth of her first child. She is currently well on lithium and is planning another pregnancy. Which is the most appropriate preconception management?

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Correct answer: C — Arrange specialist perinatal preconception counselling to review relapse risk, lithium and alternatives, breastfeeding intentions, and a written perinatal care plan

The correct answer is C. Previous postpartum psychosis and bipolar I disorder confer a very high risk of severe postnatal relapse; recurrence of postpartum psychosis after a subsequent pregnancy is approximately 50%. NICE recommends specialist, preferably perinatal, preconception counselling for women with current or past severe mental illness. Counselling should address relapse risk, medication and breastfeeding options, fetal and neonatal risks, and develop a written plan covering pregnancy, childbirth and the postnatal period. Lithium requires an individualised risk–benefit review: it should neither be continued unchanged nor stopped without discussion and alternative relapse prevention. Valproate is unsuitable because of major fetal and neurodevelopmental risks. Waiting until pregnancy is confirmed would miss the opportunity to modify treatment safely before conception.

Reference: National Institute for Health and Care Excellence. Antenatal and postnatal mental health: clinical management and service guidance (CG192), recommendations 1.2.1, 1.4.2–1.4.3, 1.4.33–1.4.36 and 1.6.6. 2014, updated 2020. https://www.nice.org.uk/guidance/cg192/chapter/recommendations