Pregnancy lithium treatment

Case Example A 28-year-old woman had been stable on lithium treatment for several years. When she became pregnant, her lithium was discontinued, and within a few weeks she was hospitalized for a severe exacerbation of mania unresponsive to CPZ in doses up to 1,200 mg/day. After a course of ECT she became euthymic and was adequately maintained on lower doses of CPZ (i.e., 50 to 100 mg/day) for the remainder of her pregnancy. The delivery and the immediate postpartum period went well, but lithium was not resumed because she opted to nurse her infant. Several weeks later, she was rehospitalized for an episode of depression, which also responded to a course of ECT. She then agreed to discontinue nursing her child and resume lithium. The patient was doing well at follow-up 1 year later. 

Schou M. Lithium treatment during pregnancy, delivery, and lactation an update. J Clin Psychiatry 1990 51 410-412. 

Lithium is contraindicated during pregnancy, especially the first trimester, due to congenital abnormalities, most notably of the heart. In rare situations, it may be necessary to continue lithium treatment in the pregnant patient, with dosage adjustments as necessitated by pregnancy-induced changes in kidney function. 

Initial side effects are mild and include tremor, lethargy, nausea, diarrhea, and abdominal discomfort. Lithium treatment has been associated with headache symptoms described as episodes of moderately severe, throbbing occipital pain lasting 6 to 12 hours, but these headaches are easily distinguishable from the cluster headache and disappear when lithium is withdrawn. Lithium should be administered with caution to patients with significant renal or cardiovascular disease, dehydration, pregnancy, or concomitant diuretic use. 

Electroconvulsive therapy (ECT) is used for severe mania or depression during pregnancy and for mixed episodes prior to treatment, anticonvulsants, lithium, and benzodiazepines should be tapered off to maximize therapy and minimize adverse effects. 

Both lithium and valproate are teratogenic. In this case, women thinking of having children may be advised to switch to alternate treatments before the pregnancy. 

Atypical antipsychotics may be preferable to lithium or anticonvulsants such as carbamazepine if treatment of bipolar disorder is required during pregnancy... 

Many salts of ternary acids are used in medicine. Lithium carbonate, Li2C03, has been used successfully to combat severe jet lag. Lithium carbonate is also useful in the treatment of mania, depression, alcoholism, and schizophrenia. Magnesium sulfate, MgS04, sometimes helps to prevent convulsions during pregnancy and to reduce the solubihty of toxic barium sulfate in internally administered preparations consumed before gastrointestinal X-ray films are taken. 

Clinical effects of lithium are slow in onset and may not be apparent before a week or two of daily treatment. Lithium is cleared exclusively by the kidney at a rate 20% of that of creatinine. Clearance is influenced by many factors, including renal function, serum sodium concentration, hydration state, pregnancy, and the presence of other drugs. High urinary levels of sodium inhibit renal tubular reabsorption of lithium, thus decreasing its plasma levels. By decreasing blood volume, thiazides may increase lithium plasma levels. Any drug that can cross the blood-brain barrier can cross the placental barrier The answer is (C). 

Pregnancy test before starting in women Baseline then 6-monthly eGFR, U E, TFTs, BMI EGG (if CV risk factors/PMHx) Lithium levels 3-monthly Check calcium in long-term treatment... 

---