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Maines E, Cardellini MC, Stringari G, Leonardi L, Piccoli G, Urru SAM, Maiorana A, Soffiati M, Franceschi R. Drug-Induced Hypoglycemia in Neonates Born to Nondiabetic Women Treated with Medications during the Pregnancy or the Labor: A Systematic Review of the Literature. Am J Perinatol 2024; 41:e2850-e2861. [PMID: 37848046 DOI: 10.1055/s-0043-1776061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
The prompt identification of at-risk newborns for drug-induced hypoglycemia can minimize the risk for adverse side effects, inappropriate investigations, and considerable unnecessary costs. Existing literature discusses drug-induced hypoglycemia, but a systematic description of neonatal hypoglycemia induced or exacerbated by maternal medications is missing. We reviewed the association between neonatal hypoglycemia and maternal medications. We systematically searched the literature according to the PICOS model on drug-induced hypoglycemia in neonates born to nondiabetic women treated with medications during the pregnancy or the labor. The main outcomes of the review were: (1) prevalence of hypoglycemia, (2) risk factors and potential confounders, (3) time at onset and severity of hypoglycemia, (4) dose-response gradient, (5) metabolic features of hypoglycemia, (6) modalities to treat hypoglycemia, and (7) quality of the studies. We included 69 studies in this review and we identified 11 groups of maternal drugs related to neonatal hypoglycemia. Results were classified for each outcome. Our review aims at supporting clinicians in the identification of the newborn at risk for hypoglycemia and in the differential diagnosis of neonatal hypoglycemia. Further studies are necessary to assess the risk of neonatal hypoglycemia associated with common maternal medications. KEY POINTS: · A systematic description of neonatal hypoglycemia induced or exacerbated by maternal medications is missing.. · In our review we identified 11 groups of maternal drugs related to neonatal hypoglycemia.. · Our review aims at supporting clinicians in the identification of the newborn at risk for hypoglycemia..
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Affiliation(s)
- Evelina Maines
- Division of Pediatrics, S. Chiara General Hospital, APSS, Trento, Italy
| | | | - Giovanna Stringari
- Division of Neonatology, S. Chiara General Hospital, APSS, Trento, Italy
| | - Letizia Leonardi
- Division of Pediatrics, S. Chiara General Hospital, APSS, Trento, Italy
| | - Giovanni Piccoli
- CIBIO - Department of Cellular, Computational and Integrative Biology, Università degli Studi di Trento, Trento, Italy
| | | | - Arianna Maiorana
- Division of Metabolism and Research Unit of Metabolic Biochemistry, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Massimo Soffiati
- Division of Pediatrics, S. Chiara General Hospital, APSS, Trento, Italy
- Division of Neonatology, S. Chiara General Hospital, APSS, Trento, Italy
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Torfs M, Hompes T, Ceulemans M, Van Calsteren K, Vanhole C, Smits A. Early Postnatal Outcome and Care after in Utero Exposure to Lithium: A Single Center Analysis of a Belgian Tertiary University Hospital. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:10111. [PMID: 36011745 PMCID: PMC9407712 DOI: 10.3390/ijerph191610111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 08/12/2022] [Accepted: 08/13/2022] [Indexed: 06/15/2023]
Abstract
Knowledge of the impact of in utero exposure to lithium during the postnatal period is limited. Besides a possible teratogenic effect during the first trimester, exposure during the second and third trimesters might lead to neonatal effects. Uniform guidelines for postnatal management of these neonates are lacking. The aim was to retrospectively describe all neonates admitted to the University Hospitals Leuven after in utero exposure to lithium (January 2010 to April 2020), and to propose a postnatal care protocol. Descriptive statistics were performed. For continuous parameters with serial measurements, median population values were calculated. In total, 10 mother-neonate pairs were included. The median gestational age was 37 (interquartile range, IQR, 36-39) weeks. Neonatal plasma lithium concentration at birth was 0.65 (IQR 0.56-0.83) mmol/L with a median neonate/mother ratio of 1.02 (IQR 0.87-1.08). Three neonates needed respiratory support, 7/10 started full enteral (formula) feeding on day 1. The median length of neonatal stay was 8.5 (IQR 8-12) days. One neonate developed nephrogenic diabetes insipidus. This study reported in detail the postnatal characteristics and short-term neonatal outcomes. A postnatal care protocol was proposed, to enhance the quality of care for future neonates, and to guide parental counselling. Future prospective protocol evaluation is needed.
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Affiliation(s)
- Marlien Torfs
- Department of Pediatrics, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Titia Hompes
- Mind-Body Research Unit, Department of Neurosciences, KU Leuven, 3000 Leuven, Belgium
- Adult Psychiatry UPC, KU Leuven, 3000 Leuven, Belgium
- L-C&Y, Child and Youth Institute, KU Leuven, 3000 Leuven, Belgium
| | - Michael Ceulemans
- L-C&Y, Child and Youth Institute, KU Leuven, 3000 Leuven, Belgium
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000 Leuven, Belgium
- Teratology Information Service, Netherlands Pharmacovigilance Centre Lareb, 5237 MH Hertogenbosch, The Netherlands
| | - Kristel Van Calsteren
- Department of Development and Regeneration, KU Leuven, 3000 Leuven, Belgium
- Department of Obstetrics and Gynecology, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Christine Vanhole
- Department of Development and Regeneration, KU Leuven, 3000 Leuven, Belgium
- Neonatal Intensive Care Unit, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Anne Smits
- L-C&Y, Child and Youth Institute, KU Leuven, 3000 Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, 3000 Leuven, Belgium
- Neonatal Intensive Care Unit, University Hospitals Leuven, 3000 Leuven, Belgium
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Sandoval Karamian AG, Mercimek-Andrews S, Mohammad K, Molloy EJ, Chang T, Chau V, Murray DM, Wusthoff CJ. Neonatal encephalopathy: Etiologies other than hypoxic-ischemic encephalopathy. Semin Fetal Neonatal Med 2021; 26:101272. [PMID: 34417137 DOI: 10.1016/j.siny.2021.101272] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Neonatal encephalopathy (NE) describes the clinical syndrome of a newborn with abnormal brain function that may result from a variety of etiologies. HIE should be distinguished from neonatal encephalopathy due to other causes using data gathered from the history, physical and neurological exam, and further investigations. Identifying the underlying cause of encephalopathy has important treatment implications. This review outlines conditions that cause NE and may be mistaken for HIE, along with their distinguishing clinical features, pathophysiology, investigations, and treatments. NE due to brain malformations, vascular causes, neuromuscular causes, genetic conditions, neurogenetic disorders and inborn errors of metabolism, central nervous system (CNS) and systemic infections, and toxic/metabolic disturbances are discussed.
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Affiliation(s)
- A G Sandoval Karamian
- Children's Hospital of Philadelphia, Division of Neurology, 3501 Civic Center Blvd Office 1200.12, Philadelphia, PA, 19104, USA.
| | - S Mercimek-Andrews
- Biochemical Geneticist, Department of Medical Genetics, University of Alberta, 8-39 Medical Sciences Building, 8613 - 144 Street, Edmonton, T6G 2H7, Alberta, Canada.
| | - K Mohammad
- Cumming School of Medicine, University of Calgary, Alberta Children's Hospital, Room B4-286, 28 Oki drive NW, Calgary, AB, T3B 6A8, Canada.
| | - E J Molloy
- Trinity College, the University of Dublin, Trinity Translational Medicine Institute, Dublin, Ireland; Children's Health Ireland at Tallaght and Crumlin & and Coombe Women's and Infants University Hospital, Dublin, Ireland; Trinity Research in Childhood Centre (TRiCC), Trinity Academic Centre, Tallaght University Hospital, Dublin 24, Ireland.
| | - T Chang
- George Washington University School of Medicine & Health Sciences, Washington, DC, 20010, USA; Neonatal Neurology Program, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20010, USA.
| | - Vann Chau
- Neurology, Neonatal Neurology Program, The Hospital for Sick Children, 555 University Avenue, Toronto ON, M5G 1X8, Canada.
| | - D M Murray
- Deptartment of Paediatric and Child Health, University College Cork, ARm 2.32, Paediatric Academic Unit, Floor 2, Seahorse Unit, Cork University Hospital, Wilton, Cork, T12 DCA4, Ireland.
| | - Courtney J Wusthoff
- Division of Child Neurology, Division of Pediatrics- Neonatal and Developmental Medicine, Stanford Children's Health, 750 Welch Road, Suite 317, Palo Alto, CA, 94304 USA.
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Poels EMP, Bijma HH, Galbally M, Bergink V. Lithium during pregnancy and after delivery: a review. Int J Bipolar Disord 2018; 6:26. [PMID: 30506447 PMCID: PMC6274637 DOI: 10.1186/s40345-018-0135-7] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 10/10/2018] [Indexed: 12/16/2022] Open
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.
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Affiliation(s)
- Eline M P Poels
- Department of Psychiatry, Erasmus University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Hilmar H Bijma
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Prenatal Medicine, Erasmus University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Megan Galbally
- School of Psychology and Exercise Science, Murdoch University, Murdoch, Australia
| | - Veerle Bergink
- Department of Psychiatry, Erasmus University Medical Centre Rotterdam, Rotterdam, The Netherlands. .,Department of Psychiatry and Department of Obstetrics, Gynecology and Reproductive Science, The Blavatnik Women's Health Research Institute, Icahn School of Medicine at Mount Sinai, 1425 Madison Avenue, Room L4-34, New York City, NY, 10029, USA.
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Frayne J, Nguyen T, Mok T, Hauck Y, Liira H. Lithium exposure during pregnancy: outcomes for women who attended a specialist antenatal clinic. J Psychosom Obstet Gynaecol 2018; 39:211-219. [PMID: 28617151 DOI: 10.1080/0167482x.2017.1337743] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
INTRODUCTION Lithium treatment in pregnancy represents a significant dilemma for women and treating health professionals alike. The complexity of risk-benefit analysis is impacted by limited information. METHODS A cohort study of 33 women with severe mental illness, who were prescribed lithium at any time during the pregnancy, and gave birth between December 2007 and January 2015 at a specialist antenatal clinic in Western Australia. A descriptive comparison for women who continued lithium throughout pregnancy, and those who ceased on discovery of pregnancy was undertaken examining demographic, obstetric, neonatal and psychiatric variables. RESULTS Women who were prescribed lithium, irrespective of whether they continued or discontinued the medication represented a high risk group obstetrically, with high rates of smoking overall (33%) medical comorbidities (54%) and antenatal complications (88%). Preconception counseling occurred in 33% of the cohort but increased the likelihood of continuing lithium in pregnancy (p = .007). Compared to those who ceased lithium, women who remained on lithium through the pregnancy had increased rates of fetal ultrasound abnormalities such as abdominal circumference >90th % (p = .005). Psychiatric relapses through the antenatal and immediate postpartum period appeared to be due to a combination of factors. DISCUSSION Pregnant women with severe mood disorders treated with lithium are a vulnerable, high-risk obstetric population who would benefit from preconception counseling, regular antenatal care in a tertiary center, delivery with neonatal pediatric support and experienced psychiatric management.
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Affiliation(s)
- Jacqueline Frayne
- a Department of Obstetrics and Gynaecology , Women and Newborn Health Service , Subiaco , Western Australia , Australia.,b School of Medicine, Division of General Practice , University of Western Australia , Western Australia , Australia
| | - Thinh Nguyen
- c School of Medicine, Division of Psychiatry , University of Western Australia , Western Australia , Australia.,d Peel and Rockingham Kwinana Mental Health Services , Western Australia , Australia
| | - Tabitha Mok
- e Department of Psychological Medicine , Women and Newborn Health Service , Subiaco , Western Australia , Australia
| | - Yvonne Hauck
- f Department of Nursing and Midwifery Education , Women and Newborn Health Service , Subiaco , Western Australia , Australia.,g School of Nursing, Midwifery and Paramedicine , Curtin University , Perth , Western Australia , Australia
| | - Helena Liira
- b School of Medicine, Division of General Practice , University of Western Australia , Western Australia , Australia
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Forsberg L, Adler M, Römer Ek I, Ljungdahl M, Navér L, Gustafsson LL, Berglund G, Chotigasatien A, Hammar U, Böhm B, Wide K. Maternal mood disorders and lithium exposure in utero were not associated with poor cognitive development during childhood. Acta Paediatr 2018; 107:1379-1388. [PMID: 29150869 DOI: 10.1111/apa.14152] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 06/15/2017] [Accepted: 11/13/2017] [Indexed: 11/30/2022]
Abstract
AIM This study evaluated whether maternal mood disorders (MMD), particularly bipolar disorder, and lithium treatment during pregnancy influenced the neonatal health and cognition of children born from 2006 to 2010. METHODS Our study at Karolinska University Hospital, Stockholm, Sweden, focused on women with and without mood disorders and their children. Information on pharmacotherapy, mental health, delivery and neonatal complications was retrospectively collected from electronic patient records. Children were tested in a blinded manner at four to five years of age with the Wechsler Preschool and Primary Scale of Intelligence, 3rd edition. Maternal health, child health and social situations were evaluated. RESULTS Of the 39 children, 20 were exposed to lithium and MMD during pregnancy, eight were exposed to MMD but not lithium and 11 were not exposed to MMD or lithium. The children's full scale intelligence quotient (IQ), performance IQ and verbal IQ results did not differ significantly between the groups. The processing speed quotient was significantly lower in children exposed to mood disorders, but there was a high level of missing data for this subtest. CONCLUSION This small, clinical cohort showed no significant association between mothers' prenatal exposure to lithium or mood disorders and their offspring's IQ.
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Affiliation(s)
- L Forsberg
- Department of Pediatrics; Karolinska University Hospital; Stockholm Sweden
- Department of Clinical Science, Intervention and Technology (CLINTEC); Division of Pediatrics; Karolinska Institutet; Stockholm Sweden
| | - M Adler
- Affective disorder Outpatient Clinic; Psychiatric Clinic Southwest; Stockholm Sweden
- Department of Clinical Neuroscience; Karolinska Institutet; Stockholm Sweden
| | - I Römer Ek
- Affective disorder Outpatient Clinic; Psychiatric Clinic Southwest; Stockholm Sweden
| | - M Ljungdahl
- Affective disorder Outpatient Clinic; Psychiatric Clinic Southwest; Stockholm Sweden
| | - L Navér
- Department of Pediatrics; Karolinska University Hospital; Stockholm Sweden
- Department of Clinical Science, Intervention and Technology (CLINTEC); Division of Pediatrics; Karolinska Institutet; Stockholm Sweden
| | - LL Gustafsson
- Department of Laboratory Medicine; Division of Clinical Pharmacology; Karolinska Institutet; Stockholm Sweden
| | - G Berglund
- Department of Psychologists; Karolinska University Hospital Huddinge; Stockholm Sweden
| | - A Chotigasatien
- Department of Anesthesiology; Karolinska University Hospital; Stockholm Sweden
| | - U Hammar
- Institute of Environmental Medicine; Unit of Biostatistics; Karolinska Institutet; Stockholm Sweden
| | - B Böhm
- Department of Women's and Children's Health; Karolinska Institutet; Stockholm Sweden
| | - K Wide
- Department of Pediatrics; Karolinska University Hospital; Stockholm Sweden
- Department of Clinical Science, Intervention and Technology (CLINTEC); Division of Pediatrics; Karolinska Institutet; Stockholm Sweden
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Smith B, Dubovsky SL. Pharmacotherapy of mood disorders and psychosis in pre- and post-natal women. Expert Opin Pharmacother 2017; 18:1703-1719. [DOI: 10.1080/14656566.2017.1391789] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Beth Smith
- Department of Psychiatry, State University of New York at Buffalo, Buffalo, NY, USA
| | - Steven L. Dubovsky
- Department of Psychiatry, State University of New York at Buffalo, Buffalo, NY, USA
- Departments of Psychiatry and Medicine, University of Colorado, Denver, CO, USA
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Oyebode F, Rastogi A, Berrisford G, Coccia F. Psychotropics in pregnancy: Safety and other considerations. Pharmacol Ther 2012; 135:71-7. [DOI: 10.1016/j.pharmthera.2012.03.008] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2012] [Accepted: 03/06/2012] [Indexed: 10/28/2022]
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van der Lugt NM, van de Maat JS, van Kamp IL, Knoppert-van der Klein EAM, Hovens JGFM, Walther FJ. Fetal, neonatal and developmental outcomes of lithium-exposed pregnancies. Early Hum Dev 2012; 88:375-8. [PMID: 22000820 DOI: 10.1016/j.earlhumdev.2011.09.013] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2011] [Revised: 09/14/2011] [Accepted: 09/27/2011] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Many women with a bipolar disorder are of reproductive age and will need to continue lithium treatment during pregnancy. The teratogenic and perinatal effects of lithium are known, but not the long-term effects of lithium on neurodevelopment of the children. This study investigates growth, neurological, cognitive and behavioral development of children exposed to lithium in utero. METHOD In an observational retrospective cohort study 15 children who were exposed to lithium in utero were investigated at 3-15 years of age. Neurological development was tested using the Hempel or Touwen examination. Cognitive development was assessed with the Bayley Scales of Infant Development III, Wechsler Preschool and Primary Scale of Intelligence or the Wechsler Intelligence Scale for Children. Parents completed the Child Behavior Checklist to assess behavioral development and a standard questionnaire about general development of the child since birth. RESULTS One child had signs of a minor neurological dysfunction, but without further clinical implications. The results of the cognitive tests were within normal limits, although most children had lower scores on the performance IQ subtest. Growth, behavior and general development were within the normal range. CONCLUSIONS Continuing lithium therapy during pregnancy did not cause adverse effects on growth, neurological, cognitive and behavioral development of exposed children.
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Abstract
INTRODUCTION Untreated bipolar disorder during pregnancy leads to detrimental repercussions on the mother-infant pair's health. Despite different drugs having been proposed as mood stabilizers, lithium remains the first-choice agent for preventing mood changes. AREAS COVERED Analyzing up-to-date information on the reproductive safety of lithium and providing practice guidelines to optimize its use during pregnancy. EXPERT OPINION Findings from prospective and case-control studies confirm an increased, specific risk of Ebstein's anomaly (4.45-7.6/1000 live births), although lower than that previously reported. A potential increase in the risk of neural tube defects should also be taken into consideration. Moreover, several perinatal complications may occur, and even in the presence of relatively low infant serum levels, in the case of drug exposure during late pregnancy. Despite such concerns, lithium should still be considered the first-choice agent for treating bipolar disorder in pregnancy. Indeed, the U.S. FDA recently issued a new warning regarding the reproductive safety of antipsychotics. Moreover, the risk of fetal valproate/carbamazepine syndrome (and the confirmed neurodevelopmental teratogenicity of valproate) contraindicates the use of both medications, whereas the use of lamotrigine is limited by efficacy concerns. However, women who need lithium treatment during pregnancy should be carefully monitored: a strict gynecologic and psychiatric surveillance and, probably, preconception folate supplementation is highly advisable. Moreover, delivery should be programmed in Neonatal Intensive Care Units to ensure optimal management of potential iatrogenic perinatal complications.
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Affiliation(s)
- Salvatore Gentile
- Department of Mental Health ASL Salerno, Mental Health Center, Salerno, Italy.
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Spezielle Arzneimitteltherapie in der Schwangerschaft. ARZNEIMITTEL IN SCHWANGERSCHAFT UND STILLZEIT 2012. [PMCID: PMC7271212 DOI: 10.1016/b978-3-437-21203-1.10002-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
Drugs are the most frequent cause of hypoglycaemia in adults. Although hypoglycaemia is a well known adverse effect of antidiabetic agents, it may occasionally develop in the course of treatment with drugs used in everyday clinical practice, including NSAIDs, analgesics, antibacterials, antimalarials, antiarrhythmics, antidepressants and other miscellaneous agents. They induce hypoglycaemia by stimulating insulin release, reducing insulin clearance or interfering with glucose metabolism. Several drugs may also potentiate the hypoglycaemic effect of antidiabetic agents. Administration of these agents to individuals with diabetes mellitus is of most concern. Many of these drugs, and depending on clinical setting, may also induce hyperglycaemia. Drug-induced hepatotoxicity and nephrotoxicity may lead in certain circumstances to hypoglycaemia. Some drugs may also induce hypoglycaemia by causing pancreatitis. Drug-induced hypoglycaemia is usually mild but may be severe. Effective clinical management can be handled through awareness of this drug-induced adverse effect on blood glucose levels. Herein, we review pertinent clinical information on the incidence of drug-induced hypoglycaemia and discuss the underlying pathophysiological mechanisms, and prevention and management.
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Affiliation(s)
- Chaker Ben Salem
- Department of Clinical Pharmacology, Faculty of Medicine of Sousse, and Medical Intensive Care Unit, Sahloul University Hospital, Sousse, Tunisia.
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Ward S, Wisner KL. CEU; Collaborative Management of Women with Bipolar Disorder During Pregnancy and Postpartum: Pharmacologic Considerations. J Midwifery Womens Health 2010; 52:3-13. [PMID: 17207745 DOI: 10.1016/j.jmwh.2006.09.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Bipolar disorder is a chronic condition characterized by periods of mania, depression, or mixed states (co-occurring mania and depression). The postpartum period is associated with a high risk for symptom relapse or intensification, which can be reduced with the use of medications. Abrupt discontinuation of these medications increases the probability of relapse, which is associated with high-risk behaviors, significant family dysfunction, and suicide. Drugs used to treat patients with bipolar disorder vary in teratogenic potential. Although first trimester lithium use is associated with Ebstein's anomaly, the risk was overestimated in the past. Valproate and its derivatives and carbamazepine are human teratogens. Lamotrigine does not negatively impact major reproductive outcomes, but the data are limited. Typical antipsychotic medications are relatively well studied and the data do not identify major morphologic teratogenicity. There are fewer studies of newer atypical antipsychotic medications, and registries have been developed to collect prospective data. Clinical management of bipolar disorder during pregnancy, postpartum, and lactation requires a careful balancing of maternal and fetal risks and benefits. Communication and careful comanagement between the obstetric and psychiatric team is essential when treating women with bipolar disorder during the reproductive years.
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Affiliation(s)
- Sheila Ward
- Department of Obstetrics, Gynecology & Women's Health, University of Louisville School of Medicine, Louisville, KY 40292, USA.
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Huffman JC, Alpert JE. An approach to the psychopharmacologic care of patients: antidepressants, antipsychotics, anxiolytics, mood stabilizers, and natural remedies. Med Clin North Am 2010; 94:1141-60, x. [PMID: 20951275 DOI: 10.1016/j.mcna.2010.08.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The number of safe and effective medication treatments for psychiatric illness has expanded substantially over the past 10 to 15 years. Knowing when and how to prescribe psychotropics--and knowing which medication to prescribe--can be challenging, but with knowledge of some basic principles, this task can be performed adeptly by physicians of all specialties. In this article, the authors discuss basic principles of psychopharmacology and outline an approach to using several commonly prescribed classes of medications.
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Affiliation(s)
- Jeff C Huffman
- Harvard Medical School, 260 Longwood Avenue, Boston, MA 20115, USA.
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Chopra S, Suri V, Aggarwal N, Rohilla M, Vijayvergiya R, Keepanasseril A. Ebstein's anomaly in pregnancy: Maternal and neonatal outcomes. J Obstet Gynaecol Res 2010; 36:278-83. [DOI: 10.1111/j.1447-0756.2009.01130.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Abstract
One of the least-developed areas of clinical pharmacology and drug research is the use of medication during pregnancy and lactation. This article is the first in a two-part series designed to familiarize physicians with many aspects of the drugs they commonly prescribe for pregnant and breast-feeding women. Almost every pregnant woman is exposed to some type of medication during pregnancy. Although the majority of pregnant and breast-feeding women consume clinically indicated or over-the-counter drug preparation regularly, only few medications have specifically been tested for safety and efficacy during pregnancy. There is scant information on the effect of common pregnancy complications on drug clearance and efficacy. Often, the safety of a drug for mothers, their fetuses, and nursing infants cannot be determined until it has been widely used. Absent this crucial information, many women are either refused medically important agents or experience potentially harmful delays in receiving drug treatment. Conversely, many drugs deemed "safe" are prescribed despite evidence of possible teratogenicity. Novel research and diagnostic applications evolving from the opportunities presented by the advances in genomics and proteomics are now beginning to affect clinical diagnosis, vaccine development, drug discovery, and unique therapies in a modern diagnostic-therapeutic framework-part of the new scientific field of theranostics. This review critically explores a number of recently raised issues in regard to the use of several classes of medications during gestation and seeks to provide a general and concise resource on drugs commonly used during pregnancy and lactation. It also seeks to make clinicians more aware of the controversies surrounding some drugs in an effort to encourage safer prescribing practices through consultation with a maternal-fetal medicine specialist and through references and Web sites that list up-to-date information.
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Abstract
Cluster headache is a rare disorder in women, but has a serious impact on the affected woman's life, especially on family planning. Women with cluster headache who are pregnant need special support, including the expertise of an experienced headache centre, an experienced gynaecologist and possibly a teratology information centre. The patient should be seen through all stages of the pregnancy. A detailed briefing about the risks and safety of various treatment options is mandatory. In general, both the number of medications and the dosage should be kept as low as possible. Preferred treatments include oxygen, subcutaneous or intranasal sumatriptan for acute pain and verapamil and prednisone/prednisolone as preventatives. If there is a compelling reason to treat the patient with another preventative, gabapentin is the drug of choice. While breastfeeding, oxygen, sumatriptan and lidocaine for acute pain and prednisone/prednisolone, verapamil, and lithium as preventatives are the drugs of choice. As the individual pharmacokinetics differ substantially, adverse drug effects should be considered if unexplained symptoms occur in the newborn.
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Affiliation(s)
- T P Jürgens
- Department of Neurology, University of Regensburg, Regensburg, Germany
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20
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Abstract
The effect of various antipsychotics during pregnancy has repeatedly been studied, but for most atypical antipsychotics, only little information is available. We identified from the Swedish Medical Birth Register 2908 women who had reported the use of any antipsychotic or lithium in early pregnancy and studied malformation rates with data also from the Register of Congenital Malformations and the Hospital Discharge Register. Comparisons were made with all births (n = 958,729) after adjustment for some confounders. Risks were expressed as odds ratios (ORs). Most women had used dixyrazine or prochlorperazine mainly because of nausea and vomiting in early pregnancy. Seventy-nine women had used lithium, and these outcomes are reported separately. Hence, the main analysis was restricted to 570 women (576 infants) using other antipsychotics. There was a statistically significant increase in the risk for a congenital malformation-after exclusion of some common and minor conditions, the OR was 1.52 (95% confidence interval, 1.05-2.19). Exclusion of infants exposed to anticonvulsants reduced the OR only slightly. Most of the increased risk was caused by cardiovascular defects, mainly atrium or ventricular septum defect. No certain drug specificity was found. Except for an increased risk for congenital malformations, a nearly doubling of the risk for gestational diabetes and a 40% increased risk for cesarean delivery was noted. Because there seems to be little drug specificity, it is possible that underlying pathology or unidentified confounding explains the excess risk.
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21
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Prenatal diagnosis of Ebstein’s anomaly using spatio-temporal image correlation (STIC) and inversion mode. Arch Gynecol Obstet 2008; 278:387-91. [DOI: 10.1007/s00404-008-0597-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2007] [Accepted: 02/04/2008] [Indexed: 11/27/2022]
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22
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Menon SJ. Psychotropic medication during pregnancy and lactation. Arch Gynecol Obstet 2007; 277:1-13. [PMID: 17710428 DOI: 10.1007/s00404-007-0433-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2007] [Accepted: 07/30/2007] [Indexed: 10/22/2022]
Abstract
Despite the traditional notion that pregnancy is a time of joy and emotional well being, evidence suggests that it does not protect women against mental illness. Untreated mental illness carries wide-ranging repercussions for mother, child and family that often outweigh those associated with treatment. Clinical management is complex, involving competing risks to mother and offspring; the challenge lies in effectively treating mental illness, whilst minimising exposure of the child to harmful medication. The paucity of robust published evidence on which to base the principles of psychiatric care further compounds the issue. Pregnancy significantly affects plasma drug levels and immature foetal/neonatal physiology renders the child prone to damage from pharmacological agents, all of which cross the placenta/enter breast-milk to varying degrees. Risks include teratogenicity, obstetrical complications, perinatal syndromes, and long-term behavioural problems. Despite evidence that some psychotropic drugs may be safe during pregnancy, knowledge regarding the risks of antenatal exposure to medications remains far from complete. The pregnant or breastfeeding woman requires an individualised risk-benefit analysis with regard to the commencement or continuance of psychotropic medication. If treatment is deemed necessary, monotherapy at the lowest possible dose should be prescribed. More robust safety data is available for older psychotropic drugs, which should be employed in preference to newer agents with unestablished safety profiles. Pregnant/breastfeeding women should also be educated with regard to early detection of signs of drug toxicity in both themselves and their babies. Despite shared responsibility, the ultimate decision with regard to reasonable risk, and what constitutes it, rests with the informed patient. Close psychiatric monitoring and coordinated multidisciplinary care with the obstetrician and paediatrician combine with such informed patient choices to comprise the components of a holistic model of care, targeted at optimizing the complex management of women with psychiatric illness during pregnancy.
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Affiliation(s)
- Sharmila J Menon
- Royal Glamorgan Hospital, Pontypridd & Rhondda NHS Trust, Llantrisant, UK.
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23
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Misiuta IE, Saporta S, Sanberg PR, Zigova T, Willing AE. Influence of retinoic acid and lithium on proliferation and dopaminergic potential of human NT2 cells. J Neurosci Res 2006; 83:668-79. [PMID: 16408307 DOI: 10.1002/jnr.20718] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Our laboratory is working with the human NTera2/D1 (NT2) cell line, which has properties similar to those of progenitor cells in the central nervous system (CNS). These neural-like precursor cells can differentiate into all three major lineages, neurons, astrocytes, and oligodendrocytes. The pure neuronal population, hNT neurons, possess characteristics of dopamine (DA) cells. First, we analyzed whether the retinoic acid (RA)-treated hNT neurons and the NT2 precursor cells expressed two transcription factors required for development of the midbrain DA neurons. We report that NT2 cells endogenously expressed Engrailed-1 and Ptx3, whereas RA-treated hNT neurons did not express Engrailed-1 or Ptx3. Next we examined the influence of lithium treatment on Engrailed-1 and Ptx3 as well as another critical transcription factor, Nurr1. Previous research has shown that lithium can mimic the Wnt pathway, which is important for the induction of these transcription factors. Finally, we investigated the effect of lithium treatment on the viability and proliferation of NT2 cells, because lithium has been shown to stimulate neurogenesis in adult neural precursors. Lithium treatment increased the viability and proliferation of NT2 cells. The expression of transcription factors essential for the induction and maintenance of the DA phenotype was not increased in NT2 after lithium treatment. We conclude that the NT2 cell line is an excellent in vitro model system for studying the influence of pharmalogical agents on proliferation, differentiation, and apoptosis of a human neural progenitor cell line.
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Affiliation(s)
- I E Misiuta
- Center of Excellence for Aging and Brain Repair, University of South Florida, Tampa, Florida, USA
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24
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Spezielle Arzneimitteltherapie in der Schwangerschaft. ARZNEIVERORDNUNG IN SCHWANGERSCHAFT UND STILLZEIT 2006. [PMCID: PMC7271219 DOI: 10.1016/b978-343721332-8.50004-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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25
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Abstract
The management of psychotropic medications during pregnancy and lactation involves a difficult and complex decision for both patient and provider, particularly due to the many unknown effects medication may have on the infant. Available studies concerning use of psychotropic medications in pregnant and lactating women are limited and there are no universal guidelines. This article reviews the literature on the use of psychotropic drugs, including antidepressants, mood stabilizers, antipsychotics, and benzodiazepines, in pregnant and breast-feeding women and presents relevant data on teratogenic effects, neonatal toxicity, perinatal syndromes, and neurobehavioral sequelae.
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Affiliation(s)
- Audrey E Jain
- Walter Reed Army Medical Center, Washington, DC 20307-5001, USA
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26
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Dodd S, Berk M. The pharmacology of bipolar disorder during pregnancy and breastfeeding. Expert Opin Drug Saf 2005. [DOI: 10.1517/14740338.3.3.221] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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27
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Kozma C. Neonatal toxicity and transient neurodevelopmental deficits following prenatal exposure to lithium: Another clinical report and a review of the literature. Am J Med Genet A 2005; 132A:441-4. [PMID: 15633173 DOI: 10.1002/ajmg.a.30501] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
I report the case of an infant girl who was exposed to lithium during gestation and her follow-up at the age of 1 year. She presented with transient neurodevelopmental deficits including lethargy, hypotonia, and poor oral feeding ability in the neonatal period. She required supportive treatment and made gradual improvement in neurologic functioning. On examination at the age of 1 year, physical findings and psychomotor development were normal. The English literature from 1978 to 2004 is reviewed. A total of 30 patients who were exposed to lithium during gestation with adequate clinical description were identified. A significant number of these babies presented with neurodevelopmental deficits and depressed neurological status including hypotonia, respiratory distress syndrome, cyanosis, lethargy, and weak suck and Moro reflexes in the neonatal period. The majority of these abnormalities resolved and most babies made full recovery. Other abnormalities were structural as well as functional involvement of the cardiovascular system, macrosomia, prematurity, jaundice, diabetes insipidus, and involvement of the thyroid gland. While the use of lithium during pregnancy does not appear to significantly increase the risk of congenital anomalies, it is frequently associated with perinatal complications and reversible neonatal toxicity. Suggested guidelines for appropriate monitoring of infants and breast-feeding of exposed babies are presented. In addition, prenatal surveillance of women with bipolar disorders who are being treated with lithium is briefly discussed.
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Affiliation(s)
- Chahira Kozma
- Department of Pediatrics, Georgetown University Medical Center, Washington, District of Columbia, USA.
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28
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Abstract
Treating women with psychiatric disorders during pregnancy is a challenge for numerous reasons. Balancing the risks and benefits of symptoms and treatments is particularly important during pregnancy because both medication and maternal illness may have adverse effects on the fetus. Communication of options in the management of psychiatric disorders in pregnancy is vital to optimal treatment. One barrier to effective communication has been a paucity of research from which clinicians can draw information, particularly in the area of pharmacological treatment. However, emerging evidence points to the low risk of many psychotropic medications during pregnancy. Uncertainty must not prevent frank risk-benefit discussions from occurring between treating physicians and their pregnant patients. Psychiatrists can prepare themselves for management decisions by reviewing the current literature.
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Affiliation(s)
- A D Cott
- Department of Psychiatry, Johns Hopkins University, Baltimore, Maryland 21287, USA.
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29
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Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2003; 12:73-88. [PMID: 12616852 DOI: 10.1002/pds.787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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