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Ask Dr Ivan 6


Lithium in Pregnancy
Resistant Bipolar Affective Disorder

What recommendations could be made to a recently married young woman who is currently stablized on LiCO3 and desires to become pregnant, especially with regard to risks vs. benefits of any treatment modality during pregnancy?

The best way to control of bipolar disorder during pregnancy depends on a number of factors. Most important are the history of prior episodes, and the past results of discontinuing lithium. For many women, prengancy is a time of improved mental functioning, while the post-partum period is often a time when depression may be a problem.

If a woman's history includes relatively few mood episodes that have been separated by long periods of euthymia, the VERY gradual discointinuation of lithium (over a couple of months) might precede attempts to become pregnancy. If prior attempts to gradually discontinue lithium have resuled in the rapid onset of a depressive or manic episode, discontinuation prior to trying to get pregnant does not make sense.

At one time it was thought that lithium was extremely toxic to the developing fetus, and that approximately 1% of babies exposed to lithium in-utero would develop severe, possibly lethal, heart defects. More recent research has determined that the risk of such defects is actually one-tenth of a percent rather than the 1% previously estimated. As the anti- convulsant drugs used as lithium alternatives can also cause severe congenital abnormalities, they cannot be considered as alternatives to lithium duing pregnancy. Four of my patients have delivered five healthy babies after taking lithium though- out their pregnancies.

Ref: Sachs GS & Cohen LS Update on pharmacologic treatment of mood disorders: Bipoolar disorder and management through preg- nancy and postpartum. Psychiat Clin N Amer 1995, 2, 21-75.

In a Bipolar patient who has failed trials with 1) Lithium Carbonate, 2) Sodium valproate, and 3) Carbamazepine for his first manic episode at age 17-----but responded nicely to ECT, what if any medications should be used for maintenance/prophylaxis in the future?

There are some people with bipolar disorder who do not respond to the usual drug treatments. While ECT may be useful in ending an episode of mania or depression, the use of ECT as a prophylactic therapy is accompanied by many difficulties.

The atypical antipsychotic medication clozapine has been used to treat some people who fail to respond to the mood regulating effects of lithium and the anticonvulsants.