Lithium toxicity in a neonate

Lithium during pregnancy and after delivery: a review

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.

Long-term neurodevelopmental consequences of intrauterine exposure to lithium and antipsychotics: a systematic review and meta-analysis

Lithium and antipsychotics are often prescribed to treat bipolar disorder or psychotic disorders in women of childbearing age. Little is known about the consequences of these medications during pregnancy for the developing child. The objective of this article is to systematically review findings from preclinical and clinical studies that have examined the neurodevelopmental consequences of intrauterine exposure to lithium and antipsychotics. A systematic search was performed in Embase, Medline, Web of Science, PsychINFO, Cochrane, and Google Scholar. Clinical and experimental studies were selected if they investigated neurodevelopment of offspring exposed to lithium or antipsychotics during gestation. Quality of clinical and preclinical studies was assessed by the Newcastle-Ottawa Scale and the SYRCLE's risk of Bias tool, respectively. In total, 73 studies were selected for qualitative synthesis and three studies were selected for quantitative synthesis. Of preclinical studies, 93% found one or more adverse effects of prenatal exposure to antipsychotics or lithium on neurodevelopment or behaviour. Only three clinical cohort studies have investigated the consequences of lithium exposure, all of which reported normal development. In 66% of clinical studies regarding antipsychotic exposure, a transient delay in neurodevelopment was observed. The relative risk for neuromotor deficits after in utero exposure to antipsychotics was estimated to be 1.63 (95% CI 1.22-2.19; I2 = 0%). Preclinical studies suggest long-term adverse neurodevelopmental consequences of intrauterine exposure to either lithium or antipsychotics. However, there is a lack of high-quality clinical studies. Interpretation is difficult, since most studies have compared exposed children with their peers from the unaffected population, which did not allow correction for potential influences regarding genetic predisposition or parental psychiatric illness.

Early postnatal exposure to lithium in vitro induces changes in AMPAR mEPSCs and vesicular recycling at hippocampal glutamatergic synapses

Lithium is an effective mood stabilizer but its use is associated with many side effects. Electrophysiological recordings of miniature excitatory postsynaptic currents (mEPSCs) mediated by glutamate receptor AMPA-subtype (AMPARs) in hippocampal pyramidal neurons revealed that CLi (therapeutic concentration of 1 mM lithium, from days in vitro 4-10) decreased the mean amplitude and mean rectification index (RI) of AMPAR mEPSCs. Lowered mean RI indicate that contribution of Ca2+ -permeable AMPARs in synaptic events is higher in CLi neurons (supported by experiments sensitive to Ca2+ -permeable AMPAR modulation). Co-inhibiting PKA, GSK-3 beta and glutamate reuptake was necessary to bring about changes in AMPAR mEPSCs similar to that seen in CLi neurons. FM1-43 experiments revealed that recycling pool size was affected in CLi cultures. Results from minimum loading, chlorpromazine treatment and hyperosmotic treatment experiments indicate that endocytosis in CLi is affected while not much difference is seen in modes of exocytosis. CLi cultures did not show the high KCl associated presynaptic potentiation observed in control cultures. This study, by calling attention to long-term lithium-exposure-induced synaptic changes, might have implications in understanding the side effects such as CNS complications occurring in perinatally exposed babies and cognitive dulling seen in patients on lithium treatment.

Pharmacological treatment of unipolar depression during pregnancy and breast-feeding--a clinical overview

BACKGROUND

This overview is aimed at clinicians working with patients in the fertile age who suffer from depressive disorders. The study of adverse effects of antidepressants on the foetus is hampered by difficulty in distinguishing between the behavioural changes that are related to the disorder itself and changes that accompany its treatment with antidepressants. The current lack of solid scientific knowledge and the implications, mainly emotional, of treating pregnant or breast-feeding women often raise anxiety and cause concern among patients and clinicians.

METHODS

Currently available data are evaluated and clinical recommendations given.

RESULTS AND CONCLUSIONS

Citalopram and sertraline can be used during pregnancy, while some controversy remains over in utero exposure to paroxetine and fluoxetine, which might be associated with an increased risk of foetal cardiovascular malformation. Less data is available concerning fluvoxamine and escitalopram use but current data does not indicate a specific risk. Citalopram, paroxetine and sertraline can be used during breast-feeding, while fluoxetine probably should be avoided. Nortriptyline, amitriptyline and clomipramine can be used during pregnancy and lactation, although data are more abundant for SSRI treatment. Venlafaxine can be used during pregnancy, while caution is advised during breast-feeding. Other antidepressants should be avoided because of lack of data on their effect. A strongly indicated lithium therapy should be continued. Close monitoring of lithium levels throughout pregnancy is mandatory, as is detailed foetal echocardiography in weeks 18-22 of gestation. Lithium should not be used during breast-feeding. Electroconvulsive therapy (ECT) is a valid option if indicated, both during pregnancy and breast-feeding.

Lithium in pregnancy: the need to treat, the duty to ensure safety

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.

Risk of drug-induced congenital defects

Defects attributable to drug therapy represent about 1% of congenital defects of known aetiology. This means that a precautionary attitude and correct use of drugs in fertile, and especially pregnant, women is a feasible form of prevention. Drugs currently in use with proven teratogenic effect number approximately 25, but new pharmaceutical drugs are constantly in preparation. Recognition of a drug-induced teratogenic effect is a complex procedure taking into account not only experimental animal data but also experience in humans. Considering that 40% of pregnancies are not planned, it follows that any drug with known or suspected teratogenic potential must be used only under strict medical control. Also, adequate knowledge on potential teratogenicity of a drug permits modification of therapy before conception. It goes without saying that any drug should be used during pregnancy only if it is essential, and it would be prudent to use only those where adequate information is provided and prior clinical experience is available. Teratology Information Services can assist both physicians and patients when any doubt exists.

Neonatal toxicity and transient neurodevelopmental deficits following prenatal exposure to lithium: Another clinical report and a review of the literature

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.

Lethargy in a newborn: lithium toxicity or lab error?

Lithium medication during pregnancy is uncommon and the problems of a neonate who has been exposed to lithium represents a rare situation in neonatology. The clinical presentation and management of a newborn whose mother received lithium during pregnancy is presented. The newborn manifested a four day course of lethargy with unexplained high lithium levels in the adult toxic range. The infant improved clinically under intravenous hydration therapy, nevertheless lithium serum levels increased again and we did not know for certain if our clinical instinct or the actual figures were correct. Finally we noticed that our confusion had resulted from test tubes containing lithium heparine.

Case report and review of the perinatal implications of maternal lithium use

The purpose of this study was to review the use of lithium in pregnancy and its effects on the neonate. This was a case study and review of the published literature. Lithium is commonly used in the treatment of psychiatric disorders, specifically bipolar depression. Bipolar disorders that require treatment with lithium demand special consideration when the woman becomes pregnant. Reported neonatal problems with maternal lithium therapy include Ebstein's anomaly, poor respiratory effort and cyanosis, rhythm disturbances, nephrogenic diabetes insipidus, thyroid dysfunction, hypoglycemia, hypotonia and lethargy, hyperbilirubinemia, and large-for-gestational-age infants. Lithium can have adverse effects on the fetus and newborn infant, but data suggest normal behavioral patterns in childhood.

Lithium During Pregnancy : Drug Effects and Their Therapeutic Implications

Lithium is used as a primary treatment or augmentation therapy for several psychiatric conditions, such as bipolar depression, mania and unipolar depression. For many patients with bipolar disorder, it is the most effective mood stabiliser.More than half of the patients maintained on lithium are women, and many are of reproductive age. An unknown proportion of women who are receiving lithium maintenance therapy become pregnant, posing numerous clinical issues for the obstetrician, psychiatrist and patient. The specific problems associated with lithium exposure vary during different stages of gestation. The risk of the serious heart defect, Ebstein's anomaly, exists if the drug is taken during weeks 2 to 6 post-conception; risks of fetal/neonatal complications occur if lithium is taken during the second and third trimesters.Given the effects of lithium on the conceptus, potentially safer alternatives may be required. The best case scenario is to counsel fecund women who require lithium to plan pregnancy, allowing for a temporary change in treatment regimen during the period of embryogenesis. If lithium therapy is reinstituted during the second and third trimesters, fetal monitoring for altered renal and endocrine function is important. Lithium requirements usually increase in the third trimester, but should be decreased in the peripartum period to avoid drug toxicity in the neonate and mother. Ultimately, the risk/benefit considerations must guide clinicians and patients in the decision to use lithium during pregnancy.

Treating recurrent affective disorders during and after pregnancy. What can be taken safely?

Since pregnancy and the time thereafter is a precarious period for women with recurrent affective disorders and their offspring, it is important to determine the risk of various treatments for such disorders. This review assesses the risk to the fetus, the perinatal risks for mother and infant, the risks associated with treatment during the puerperium and breastfeeding, and the risks to the later development of the child. This review considers treatment with lithium, tricyclic antidepressants (TCAs), selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors (SSRIs), monoamine oxidase inhibitors, other antidepressants, and the anticonvulsants carbamazepine and valproic acid (sodium valproate). According to available evidence, use of lithium, TCAs and SSRIs is justified during and after pregnancy if treatment is required; no prophylactic treatment has a lower risk: benefit ratio. The review provides guidelines for the use of these drugs.

Maternally-mediated developmental lithium toxicity in the mouse

1. Breast fed maternally-mediated developmental LiCl toxicity was determined in mice offspring as a function of offspring's gender and duration of maternal intake of LiCl (1 mEq). 2. The female offspring were more sensitive than the males to major organ weight changes by maternal exposure to LiCl. 3. Maternal intake of LiCl from preconception until weaning of the nurslings induced offspring hepatic alcohol dehydrogenase and heart lactate dehydrogenase in both sexes which was isoenzyme specific for the latter. 4. The offspring also showed induction of liver aldehyde dehydrogenase but only as consequences of postnatal exposure to LiCl. 5. The results indicate offspring developmental toxicity as a consequence of maternal exposure to Li salts and breast feeding.

Aberrant parenting and delayed offspring development in rats exposed to lithium

Natural lithium (Li) salts, including those used routinely in manic depressive illness, consist of two stable nonradioactive isotopes: lithium-7 (Li-7) (92.6%) and lithium-6 (Li-6) (7.4%). Female rats (3 months old) were treated with either Li-7 chloride or Li-6 chloride or were untreated prior to and during gestation and lactation. Birth weights were lower for Li-treated animals than for normal pups. Maternal behavior of all Li-treated mothers was altered. Li-7 mothers ignored their pups and nursed them infrequently. Li-6 mothers groomed and nursed their pups more often than normal mothers. All pups showed delays in development, especially in the maturation of depth perception. Although Li-6-treated dams were over-protective mothers, their offspring showed longer developmental delays than those of Li-7-treated offspring.

Lithium and the neonate: developmental and metabolic aspects

The interrelationship between lithium salts, which has been used in clinical trials of alcoholism, and ethanol, which evoke fetal alcohol syndrome by chronic use, was studied. This was made by evaluating the effect of prenatal and postnatal exposure to LiCl on ethanol and acetaldehyde metabolizing enzymes in the newborn mouse. The three Li-treatment regimens made consisted of acute and short-term prenatal exposure to LiCl in addition to postnatal exposure until weaning of the neonates. The weaned mice were then kept on water for a subsequent two weeks prior to sacrifice. The effects of LiCl, given in drinking fluid, on body weight, selected organ weights, hepatic alcohol dehydrogenase, aldehyde dehydrogenase and heart lactate dehydrogenase of the offspring were determined. Prenatal and postnatal ingestion of LiCl by the nursing mother resulted in decreased brain weight of offspring from both sexes. Concomitantly, there was a reduction in female but not male kidney weight. A marked decrease in the testis weight also occurred. The Li-treatment induced both neonatal hepatic alcohol dehydrogenase and heart lactate dehydrogenase in both sexes. Conversely, an inhibition of hepatic mitochondrial aldehyde dehydrogenase, for the enzyme with the apparent high Km, was determined in the male offspring. Maternal postnatal ingestion of LiCl decreased brain and spleen weights from corresponding control of neonatal male and female, respectively. This Li-treatment also induced hepatic neonatal alcohol dehydrogenase in both sexes. The results suggest that maternal ingestion of LiCl may interfere in brain development.(ABSTRACT TRUNCATED AT 250 WORDS)