Two Month Postpartum Update

I can't believe I was ever this small.

One of the readers of this blog has requested an update regarding how I’m doing post partum and specifically what happened with regards to readjusting my medications after my baby was born.
It’s been about two and a half months since my first child, conceived by IVF, was born. My child was born via vacuum extraction and was healthy other than slight jaundicing. As I have bipolar disorder and a hypothyroid disorder (suspected Hashimoto’s) I was kept in the hospital for several days post birth. Also, since the baby was born via vacuum and was slightly wheezy at first and slightly jaundiced (elevated levels of bilirubin) they would have kept me there longer than the typical one night or so that they keep women for in Victoria when they have an uncomplicated vaginal birth.

While in the hospital my blood was taken more than once to test medication levels. And the child had light therapy for a day in our room to lower the bilirubin levels.

I can't get over the little feet . . .

I was not a fan of being in the hospital for that long. The nurses tried to emphasize that it was great for me because I could rest or I didn’t have to cook or do laundry. While that may have been true, I found it detrimental in a lot of ways. Firstly, resting in the hospital is very difficult even in a private room (none were available when I arrived, but there was an empty double room and they never put anyone in with me because I have bipolar disorder and they told me I needed to be able to rest so as not to risk an episode, especially postpartum). Well, the hospital is loud, including beeping of machines, babies screaming down the hall, the busy nurses’ station which was outside my door, and people constantly barging into one’s room to do tests, clean, deliver food, take away trays, deliver medication, and check on the mother or baby. Secondly, cleaning of the room was always at an inconvenient time when I was trying to rest or have a shower, etc. so it would either hamper me showering or napping at a convenient time when the baby was sleeping or I’d send them away and they would get annoyed at me for sending them away and sometimes just barge in later even with a do not disturb sign on. Thirdly, the food in the hospital was abysmal. They feed the mother, but not the father, so while I would be trying to eat whatever horrible items were delivered (even with food orders being taken daily the order was often wrong), my husband would go off to find something in the hospital (not many choices there) or nearby at a store. After several days of bad food, almost no sleep, and constant interruptions (even when the do not disturb sign was on the door), I was really owly and I told my interim perinatal psychiatrist (my regular one was away, so a colleague supervised my medication change while in the hospital) that I wanted out of there as soon as possible. I’ve always thought that home was the best place to recover from anything anyways (and it’s not like giving birth is an illness).

. . . and little hands.

I was in the hospital five nights total. I was told that they sometimes suggest that patients with psychiatric conditions stay for up to ten days to re-establish and stabilize medications. I cannot imagine staying for that long. But, it’s certainly better to sort things out there and make sure you’re stable than to go off the rails at home and risk ending up in the psychiatric section of the hospital. I was told by a previous psychiatrist that in England where she did a practicum years ago they had a hospital ward where mothers receiving psychiatric care could stay with their babies. In Canada, I’m not sure if that’s done anywhere, but it certainly isn’t in Victoria. If you require hospitalization here, you will be separated from your baby. The baby could visit with your partner or someone, but not stay with you. Obviously, this is not ideal and I think it would make treatment even more distressing and probably dissuade many people from even seeking treatment (and this is really not what we want our medical system to do).

So, to the medication changes at the time of birth and post-birth.

When my labour started, I stopped taking lithium carbonate. Because I wasn’t sure how long prelabour would go on for, I took lithium the night before I went into full labour when I had prelabour pains. In the middle of that night the contractions were getting worse and I went to the hospital early in the morning. That night while I was labouring I did not have my usual dose of lithium carbonate. This is because when one gives birth the rapid loss of fluids can lead to lithium toxicity if one’s on the higher dose that one was on during one’s pregnancy (some people may not find their dose goes up in pregnancy, but most people do go up a higher dose as the increased levels of blood and fluid in the body and higher body weights often require a higher dose of lithium in order for it to still be in a therapeutic range).

My dose of lithium pre-pregnancy was 900 mg. It went up to 1050 mg about halfway through my pregnancy (my levels were tested at the lab every month). After I gave birth, I was given a very low dose of lithium, 300 mg in the evening. They started at this very low dose because sometimes people become hyper sensitive to lithium apparently. I was sure dose this would not be enough to be therapeutic for me. It was not. My blood was tested in the hospital and my levels were far below therapeutic. My dose was increased to 600 mg and this was also not therapeutic. A prescription was written for 900 mg of lithium carbonate, as pre-pregnancy, and I was released from the hospital with a requisition to repeat my lithium levels in a week. Then I would go see the interim perinatal psychiatrist again at the hospital to check in with how things were going. Other than fatigue, I felt relatively good. My husband and I were both at the meeting with the interim perinatal psychiatrist and she had no concerns. She said my lithium levels looked good and told me to continue at 900 mg. She booked me to see another perinatal psychiatrist in a few weeks to check in.

The meeting with the other perinatal psychiatrist was disappointing. I was exhausted on that day after a sleep of only a few hours in total (broken into several pieces) the night before. I was asked to come in two hours earlier than my original appointment because she had a cancellation. Even though this was hard to do, I did it (getting out of the house is a lot harder when it’s not just yourself anymore). Then the psychiatrist was 30 minutes late. I was really annoyed by this disrespectful behaviour. She didn’t apologize for her lateness either. Then she stared at me for two seconds after meeting me for the first time and said, “I think you’re depressed.” Wow. If there’s any wonder left as to why people with psychiatric conditions or even concerns don’t seek treatment, this illustrates part of the problem (and what a 180 turn from the other two perinatal psychiatrists who I had dealt with who were very professional and kind). Having myself judged and/or diagnosed (and incorrectly) when I now have a child and have even more to lose if I end up being prescribed even more drugs or worse yet I have to go to the psychiatric hospital for a stay (I’ve done this a couple of times and cannot imagine having to do this now and be separated from my baby for possibly weeks).

Back to the judgmental psychiatrist though, she said she had no idea why she was meeting with me and that I should have not been seen again till later (even though my medication level was being reviewed post delivery and I had gone to the lab for another level test prior to this appointment). She also said that once I’m out of the post-partum period, about a year after birth, that I should be discharged to my GP instead of to another psychiatrist. She says the system is too overburdened for “regular” people to have psychiatrists. Then after a very short meeting she asked to see my child. I showed her the child, sleeping in the carriage, and when I smiled at the child, she pronounced in a most condescending way “oh, a smile, good, I can see you’re bonding with your child.” Right, well I’m glad this isn’t my regular perinatal psychiatrist, because I never want to see her again. And if I had actually been receiving good psychiatric care prior to going through IVF, I’d be upset about being discharged to my GP, but in light of the spotty care I was receiving pre-pregnancy, I’d rather let me GP manage my bipolar disorder in the future after I’m discharged from my regular perinatal psychiatrist. I’m booked in to see my regular perinatal psychiatrist towards the end of September (about three months post birth) for another review of my medication level and how I’m doing postpartum.

One more item, obviously it’s important to do regular blood tests for not just lithium level, but also occasional tests of kidney function as lithium carbonate can impact this significantly. I asked for a lab requisition so that I could test my lithium level before I see my regular perinatal psychiatrist in September (since obviously it would be useful for her to know if I’m on the right dose by checking what my blood serum level is). The psychiatrist who I saw was reluctant to give me one. She didn’t seem to think it was useful at all. While I am on the same dose of lithium carbonate as I was pre-pregnancy, things can change post-pregnancy and it’s important to check the blood serum level every once it a while to not just check that the lithium level is in the therapeutic range, but also to make sure that it’s not at a toxic level. Lithium carbonate for all its benefits for people with bipolar disorder, is also a powerful drug that can poison when not given at the right dose (and if it’s not at a therapeutic level, the patient can relapse with an episode that may cause them considerable distress, require PRN medications, land them in the hospital, or at the worse lead to suicide).

I think the takeaway here is that as with other areas of our medical system, one has to be one’s own advocate. If something doesn’t feel right, even if you feel like you’re being pushy, get the care you need. If you don’t demand it, you might not get it.

My pictures at the doctor before were usually solo selfies . . .

. . . now I have someone else to take a selfie with.

There have been a couple of times post birth where the lack of sleep combined with stress has pushed me and I’ve started to feel very anxious, have panic attacks, trouble sleeping, and feel like I’m starting to go a bit hypomanic. The PRN medication that I have used in the past and was prescribed to me in pregnancy as well if I felt unwell, is Loxapine. I have used this a couple of times postpartum and it has reset my mood and sleep enough to make me feel better without having to see a psychiatrist or anything more drastic like go to the hospital. It is more important than ever before for me to be self-aware and to catch things early if they start to slip so that I can avoid bad episodes or having to go on heavy doses of Loxapine or be hospitalized (I haven’t been hospitalized, both times were voluntary, for just over four years and I would like to never, ever return to that place).

Going on walks to stay healthy.

Regarding my thyroid medications that I take for suspected Hashimoto’s (hypothyroidism), these were stopped when I went into labour (also due to the rapid loss of fluids and the fact that I was on a much higher dose of levothyroxine than pre-pregnancy, so the doctor wanted me to not go into a state of hyperthyroidism). The day after the birth of my child, my endocrinologist sent a prescription to the hospital for a new lower dose of my levothyroxine. My liothyronine was kept at the same level as it had not changed during pregnancy. My serum levels were tested in the hospital and were retested a few weeks post birth (my endocrinologist reviewed my results online and sent me instructions so that I did not have to come into the office unnecessarily now that I have a child; he’s a real professional and so considerate). My endocrinologist was satisfied with the levels of T3, T4, and TSH. He booked me an appointment to see him about four months post birth and I will repeat blood tests before then so that he can check how my levels are at that point and make any adjustments as necessary.

Because I was on lithium while pregnant, my child was tested a couple of times for thyroid function to make sure that there was no problem from the lithium exposure in utero. There was no problem. The child is healthy and well on track.

Finally, a note on breastfeeding while on lithium carbonate. I was initially told that I should only breastfeed for a week or two to give the baby my colostrum, but no longer so as to minimize the baby’s exposure to lithium. Once the baby is born, it has to process the lithium itself instead of the placenta preforming this function and as the baby is so small the impact of the lithium on the baby is much greater without the help of the placenta. I read several studies on lithium and breastfeeding before, during, and after my pregnancy. Unfortunately, there are not a lot of studies and they are not very large or long term. It is not fully known what impact lithium has on infants who are breastfed in the long-term. Some women have breastfed for months, others for very short time periods. As I mentioned above, lithium for all its benefits for someone with bipolar disorder, is a toxic drug which can poison people at the wrong doses and tends to make people who don’t have bipolar disorder just feel really sick (I’ve heard it makes people throw up and while it can be hard on the stomach even for people with bipolar disorder, especially if taken on an empty stomach it, doesn’t have this same impact for most people with bipolar disorder, in fact it generally makes us feel better).

While I was in the hospital, I discussed breastfeeding with both my interim perinatal psychiatrist who thought that around a range of a few weeks was reasonable without endangering my child. Then they sent a perinatal pharmacist up to my room to discuss the pros and cons of breastfeeding on lithium. This was very useful as I had someone to further discuss some of the aspects of medical literature I had read. She went away to further clarify some points we discussed and then came back and we discussed breastfeeding again. She thought that I could breastfeed safely for up to four weeks before I was starting to enter into a grey and potentially hazardous area. Part of the problem is that while we test blood serum levels on adults, the infant who is breastfeeding and being exposed to lithium doesn’t get tested for their lithium serum levels so we have no way of knowing what their levels are like or if they’re dangerous or even when they are tested (this has been done before) what these numbers even mean for an infant as opposed to an adult with bipolar disorder.

The other issue is that while I was in the hospital, the child spent the first night in NICU due to the vacuum birth and some slight snuffly breathing (they wanted to observe the baby). They advised that the baby should be fed formula and breastmilk to help the baby gain weight (the baby was a healthy average weight) and heal from the vacuum birth (it’s tough on their tender little heads). It was also discussed that as I have bipolar disorder it would be helpful to get the child’s father involved with formula feeding in the night to increase the amount of rest I was able to get, especially at the beginning when I was exhausted from birth and potentially fragile with all the hormones coursing through me.

Especially in light of the fact that I was supplementing breastmilk with formula, the perinatal psychiatrist and pharmacist were both comfortable with me breastfeeding for four weeks. This is what I did instead of the original plan of breastfeeding for two weeks.

When I saw the other perinatal psychiatrist a month after giving birth, she was glad that I had stopped breastfeeding. The perinatal psychiatrist's reason for me stopping breastfeeding was multifaceted. High serum levels of lithium in my blood of about 0.8 (really this is just above where lithium become therapeutic) and the baby's inability to process lithium as adults can now that they are no longer in utero. She also mentioned the lack large long term studies in impact of lithium exposure in infants (and blood testing in infants isn’t really done here and we don’t know what the number really mean in infants anyways). She confirmed how formula fed infants can be fed by anyone and tend to sleep longer than breastfed infants so more sleep might be had by a mother who was using formula (and sleep is crucial to bipolar patients). The final reason she mentioned and one that I had not really considered was the complex feedback loop in brain that is created when breastfeeding. The hormonal implications of breastfeeding can make a bipolar mother more prone to episodes.

Bipolar disorder is made more complex in women because of the hormonal fluctuations that happen with not just a woman’s cycle, but also the hormonal changes that occur with pregnancy, childbirth, and breastfeeding. Among the factors that can exacerbate bipolar disorder are hormonal fluctuations, various brain chemicals, sleep, nutrition, drugs and alcohol, levels of light, seasons, personal circumstances, stress, etc.. That is what makes bipolar disorder so complex to manage. But with careful management and self-awareness, it is possible to live a healthy and stable life and have children when one has bipolar disorder.

I hope this helps others who may be seeking information on medication changes postpartum, breastfeeding while on lithium, and just generally dealing with bipolar disorder and hypothyroidism postpartum.

For all the stress and sleepless nights, I've never been more grateful for anything in my life.

Is this a footnote?