surgical operations (such as Caesarean section) or bromocriptine as an alternative to, or in addition to, the postpartum trigger. Course of the illness With modern treatment, a full recovery can be expected within 6–10 weeks. After recovery from the psychosis, some mothers have depression, which can last for weeks or months. About one third have a relapse, with a return of psychotic symptoms a few weeks after recovery; these relapses are not due to a failure to comply with medication, because they were often described before pharmaceutical treatment was discovered. A minority have a series of periodic relapses related to the menstrual cycle. Complete recovery, with a resumption of normal life and a normal mother-infant relationship is the rule. Many of these mothers experience other bipolar episodes, on the average about one every six years. Although suicide is almost unknown in an acute puerperal manic or cycloid episode, depressive episodes later in life carry an increased risk, and it is wise for mothers to maintain contact with psychiatric services in the long term. In the event of a further pregnancy, the recurrence rate is high – in the largest series, about three quarters had a recurrence, but not always in the early puerperium; the recurrence could occur during pregnancy, or later in the postpartum period. Management, treatment and prevention Pre-conception counseling Women with a personal or family history of puerperal psychosis or bipolar disorder are at higher risk of a puerperal episode. The highest risk of all (82%) is a combination of a previous postpartum episode and at least one earlier non-puerperal episode. Counseling regarding risks of recurrence should be discussed with patients who have these risk factors, and may include the potential side effects to the fetus associated with certain psychiatric medications, the frequency of episode recurrence, and the risks and benefits of various treatments during pregnancy and breast-feeding. The teratogenic risks of antipsychotic agents are small, but are higher with lithium and anti-convulsant agents. Carbamazepine, an anticonvulsant, when taken in early pregnancy, has some teratogenic effects, but valproate, a different member of the anticonvulsant class, is associated with spina bifida and other major malformations, and a foetal valproate syndrome; it is not usually recommended in women who may become pregnant. More recent reviews demonstrate varying effects of different anticonvulsants (or antiepileptic medications) when given during pregnancy: the type of medication, dosage, and timing of the medication during pregnancy