SHORT COMMUNICATION

Post-abortion mania

Verinder Sharma & Christina Sommerdyk & Sapna Sharma

Received: 21 November 2012 /Accepted: 20 January 2013 /Published online: 5 February 2013# Springer-Verlag Wien 2013

Abstract We describe case histories of three women withpost-abortion mania, including two women who underwenta change in diagnosis from bipolar II to bipolar I disorderand another woman who had no prior history of psychiatricdisturbance. It is argued that the study of post-abortionmania should provide an opportunity to better understandthe aetiology of puerperal mania.

Keywords Abortion . Mania . Diagnostic switch

Introduction

Various female reproductive events including menarche,menstruation, and childbirth are associated with increasedrisk of mood episodes in women with bipolar disorder;however, little is known about the impact of abortion onthe course of bipolar disorder. There are anecdotal reports ofan association between abortion and acute mania or cycloidpsychosis. In his authoritative book, Motherhood and MentalHealth, Brockington (1996) referenced at least 30 psychoticepisodes following abortion, including a case described

by Esquirol in 1819. The clinical presentation of post-abortionpsychosis is similar to that of puerperal psychosis in that theonset of an episode is typically within 2 weeks of thesereproductive events. Mahé et al. (1999) described thecase of a woman with five term pregnancies and twoabortions (one therapeutic) in whom each event wasfollowed by an episode of psychotic mania. There areno studies that have systematically examined the linkbetween abortion and mania among women with bipolardisorder, but there are conflicting data on the link betweenabortion and psychiatric illness in general. A Danishstudy (David 1985) reported higher risk of psychiatrichospitalization after abortion, but a recent population-based cohort study from Denmark reported similar risksof readmission for women with bipolar disorder beforeand after abortion (Munk-Olsen et al. 2012). In ourperinatal clinic, we have encountered several cases ofwomen with the onset of mania after abortion. Thispaper describes three such cases and discusses theimportance of studying post-abortion mania to enhanceour understanding of the aetiology of postpartum maniaand psychosis.

Case reports

Patient I This is a 33-year-old married woman with a 15-yearhistory of bipolar II disorder. Her hypomanic episodeswere infrequent and brief and had never lasted for morethan 4 days. However, during the early course of thedisorder, she had required frequent hospital admissionsfor recurrent episodes of depression. There was nohistory of psychotic features or substance use disorder.There was a history of treated hypothyroidism. Familyhistory was significant for major depressive disorder andbipolar disorder. Her mood had been stable with no

V. SharmaDepartment of Psychiatry, Western University, London, Ontario,Canada

V. Sharma : C. SommerdykPerinatal Clinic, St. Joseph’s Health Care, London, Ontario,Canada

V. Sharma : S. SharmaDepartment of Obstetrics and Gynaecology, University of WesternOntario, London, Ontario, Canada

V. Sharma (*)Regional Mental Health Care London, 850 Highbury Avenue,London, Ontario N6A4H1, Canadae-mail: vsharma@uwo.ca

Arch Womens Ment Health (2013) 16:167–169DOI 10.1007/s00737-013-0328-0

mood episodes for at least four years on quetiapine 300 mgonce daily. She had unsuccessfully attempted to taper offquetiapine to have a drug-free pregnancy.

She was not aware of her pregnancy at the time she had aspontaneous abortion at 10 weeks gestation. Within 1 weekof the miscarriage, she began to lose sleep and quicklydeveloped symptoms of mania including pressured speech,distractibility, rapidly alternating periods of elation and crying,psychomotor agitation, grandiosity, and auditory and visualhallucinations. The diagnosis was changed to bipolar Idisorder-mixed episode and the quetiapine dose wasoptimized to 400 mg. She was hospitalized involuntarilyas her condition continued to worsen and she developedbizarre delusions, including a belief that she was a birdand could fly. Her thyroid functioning, assessed beforeand after hospitalization, was in the normal range. Theepisode resolved following the addition of lithium 900 mg tothe existing quetiapine 400 mg, and she has not had arecurrence of mania in 4 years. She has decided not tohave any children.

Patient II This is a 25-year single mother of two childrenwith a 6-year history of bipolar II disorder. Her illness beganwith a depressive episode after the birth of her first child,followed by a recurrence 2 years later when her second childwas born. She was hospitalized on both occasions. Therewas no history of psychotic features accompanying depres-sive episodes or substance use disorder. Physically, therewas no history of any major physical illnesses. In spite oftrials of multiple antidepressants, she had continued tostruggle with depression and occasional brief episodes ofhypomania following her last discharge from hospital.Following the discontinuation of antidepressants andinitiation of lithium 1,200 mg once daily and aripiprazole4 mg once daily, there was sustained symptomatic and func-tional improvement for a few years.

Within a week of a therapeutic abortion at 10 weeksgestation for an unplanned pregnancy, she developed a fullblown manic episode for the first time. The symptomsexperienced included decreased sleep requirement, eupho-ria, over talkativeness, risk-taking behavior, grandiosity, andincreased level of energy. Her family members noted amarked change in her behavior and urged her to seekprofessional help. According to her mother, the manicepisode had lasted 2 weeks by the time she was seen inconsultation. With optimization of aripiprazole dose to8 mg and continued treatment with lithium (lithiumlevel 0.81 mmol/l), the manic symptoms subsided within afew weeks. She has not had a recurrence of mania sincethat time.

Patient III This is a 23-year-old, physically healthy marriedwoman with no children. She experienced her first episode

of depression following a spontaneous abortion that wasself-remitting. Subsequently, she developed a mixed episodeimmediately following surgical management of an ectopicpregnancy. At that time, she was at 7 weeks gestational age.The mixed episode was characterized by symptoms ofsadness, crying spells, belligerence, distractibility, overtalka-tiveness, flight of ideas, decreased sleep requirement,paranoia, and grandiosity. The manic symptoms resolvedquickly following treatment with lorazepam 2 mg, butshe continued to struggle with depression for 2 months.Her mood was euthymic during her third pregnancy, but had apostpartum episode of depression that lasted 3 months.All of her pregnancies were planned. There was no personalhistory of substance use disorder, but family history waspositive for postpartum psychosis, bipolar disorder, andcompleted suicide. We cannot rule out the possibilitythat general anesthetics or surgery may have been con-tributing factors to her psychosis.

Discussion

These cases add to the scant literature on post-abortion mania.Patients I and II had a history of hypomania, but experiencedtheir only episodes of mania immediately following sponta-neous or therapeutic abortion. The association of mania withabortion may have been purely coincidental and the unintend-ed nature of pregnancies may have confounded the effect ofabortion on the mental health of these women; however, priorto the abortion, they both had had prolonged periods ofeuthymia. Furthermore, there was no evidence of treatmentnonadherence around the time of abortions. These cases alsosuggest that the post-abortion period may be a time of in-creased risk for conversion of bipolar II to bipolar I disorder.Bipolar II disorder is generally considered a fairly stablediagnosis, but there are reports of a switch to bipolar I disorderover the course of the illness (Goldberg et al. 2001). Childbirthappears to be associated with a switch in diagnosis of majordepressive disorder to bipolar disorder, but there no data onconversion of bipolar II to bipolar I disorder after delivery orafter abortion (Sharma et al. 2013).

Individual predisposition and estrogen withdrawalhave been hypothesized to play a causal role in bothpost-abortion psychosis (Mahé and Dumaine 2001) andpuerperal psychosis. Although there are no studies onthe incidence of post-abortion mania, it is considerablyless common than postpartum psychosis. This suggeststhat the risk of psychosis may be proportional to thedegree of the drop in estradiol levels associated withcessation of pregnancy (Guillaume et al 1990). The caseof patient II is unique as both of her deliveries werefollowed by depressive episodes while her isolated

168 V. Sharma et al.

manic episode occurred post-abortion. Although thedrop in estradiol postpartum exceeds that which occursin the first trimester, patient II did not have a manicepisode in the postpartum period. In patient III, theoccurrence of a mixed episode following therapeuticabortion marked the onset of bipolar disorder; however,there was no recurrence after a full-term pregnancy.Women with ectopic pregnancies have lower levels ofestradiol than those seen in normal pregnancy at similargestational age. This suggests that in addition to estradiolwithdrawal and individual predisposition, other factorsmust be considered in the etiology of post-abortion psychosis.Decreased sleep requirement was an early symptom inall our cases, yet it is unknown whether sleep loss, acommon precipitant of mania (Plante and Winkelman 2008)and postpartum psychosis (Sharma and Mazmanian 2003),plays a causal role.

These cases illustrate the importance of providing closemonitoring and treatment of emergent manic symptomsfollowing abortion in women with personal or family histo-ries of bipolar disorder. We hope that our cases will spurinterest among researchers to study the effect of abortion onthe course of bipolar disorder.

Conflict of interest The authors report no conflict of interest.

References

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Sharma V, Xie B, Campbell K, Penava D, Hampson E, & Pope C(2013) A prospective study of diagnostic conversion of majordepressive disorder to bipolar disorder in pregnancy and postpar-tum. Bipolar Disord (in press)

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