Lithium during pregnancy and after delivery: a review

Abstract

Lithium is an effective treatment in pregnancy and postpartum for the prevention of relapse in bipolar disorder. However, lithium has also been associated with risks during pregnancy for both the mother and the unborn child. Recent large studies have confirmed the association between first trimester lithium exposure and an increased risk of congenital malformations. Importantly, the risk estimates from these studies are lower than previously reported. Tapering of lithium during the first trimester could be considered but should be weighed against the risks of relapse. There seems to be no association between lithium use and pregnancy or delivery related outcomes, but more research is needed to be more conclusive. When lithium is prescribed during pregnancy, lithium blood levels should be monitored more frequently than outside of pregnancy and preferably weekly in the third trimester. We recommend a high-resolution ultrasound with fetal anomaly scanning at 20 weeks. Ideally, delivery should take place in a specialised hospital where psychiatric and obstetric care for the mother is provided and neonatal evaluation and monitoring of the child can take place immediately after birth. When lithium is discontinued during pregnancy, lithium could be restarted immediately after delivery as strategy for relapse prevention postpartum. Given the very high risk of relapse in the postpartum period, a high target therapeutic lithium level is recommended. Most clinical guidelines discourage breastfeeding in women treated with lithium. It is highly important that clinicians inform and advise women about the risks and benefits of remaining on lithium in pregnancy, if possible preconceptionally. In this narrative review we provide an up-to-date overview of the literature on lithium use during pregnancy and after delivery leading to clinical recommendations.

The Skeletal-Protecting Action and Mechanisms of Action for Mood-Stabilizing Drug Lithium Chloride: Current Evidence and Future Potential Research Areas

“…A case report reported that a 31-year-old Caucasian woman with bipolar disorder type I manifested a cutaneous adverse reaction after treated with Li 2 CO 3 (Pinna et al, 2017). Some clinical cohort studies also indicated the association between lithium treatment and congenital malformation, raising the concern about the possible teratogenicity of lithium exposure during the first trimester (Poels et al, 2018).…”

Methods and considerations concerning cardiac output measurement in pregnant women: recommendations of the International Working Group on Maternal Hemodynamics

“…The amounts of lithium used to calibrate LiDCOplus are very low, especially when compared with standard therapeutic doses in pregnant women with bipolar disorders; however, lithium can cross the placenta freely. Two recent meta‐analyses addressed the long‐term neurodevelopment outcomes in offspring with in‐utero exposure to lithium. While preclinical data in animals suggest a potential adverse effect, clinical data in humans, although limited to 97 children, seem reassuring.…”

Prescribing for pregnancy: managing prescribing for women with mental health diagnoses

“…It has been suggested that an increase in the prevalence of Ebstein’s anomaly may be associated with maternal mental illness itself rather than lithium exposure 17. Later in the pregnancy lithium use may be associated with polyhydramnios due to fetal polyuria, third trimester ultrasound scanning should be considered 18…”