Article

Lithium Placental Passage and Obstetrical Outcome: Implications for Clinical Management During Late Pregnancy

Harvard University, Cambridge, Massachusetts, United States
American Journal of Psychiatry (Impact Factor: 13.56). 12/2005; 162(11):2162-70. DOI: 10.1176/appi.ajp.162.11.2162
Source: PubMed

ABSTRACT Lithium has been used during pregnancy for more than four decades, but quantification of fetal lithium exposure and clinical correlations of such exposure are limited. The study objectives were to 1) quantify the rate of lithium placental passage, 2) assess any association between plasma concentration of lithium at delivery and adverse perinatal events, and 3) determine whether lithium concentrations can be reduced by briefly suspending therapy proximate to delivery.
Maternal blood and umbilical cord blood were obtained at delivery for assay of lithium concentrations, and obstetrical outcome data were collected prospectively for 10 participants. These data were combined with results from MEDLINE and PsycINFO searches that identified 32 cases in which maternal lithium was administered throughout delivery. Statistical analysis of the pooled data was conducted.
The ratio of lithium concentrations in umbilical cord blood to maternal blood (mean=1.05, SD=0.13) was uniform across a wide range of maternal concentrations (0.2-2.6 meq/liter). Significantly lower Apgar scores, longer hospital stays, and higher rates of CNS and neuromuscular complications were observed in infants with higher lithium concentrations (>0.64 meq/liter) at delivery. Withholding lithium therapy for 24-48 hours before delivery resulted in a 0.28 meq/liter reduction in maternal lithium concentration.
Lithium completely equilibrates across the placenta. Higher lithium concentrations at delivery are associated with more perinatal complications, and lithium concentrations can be reduced by brief suspension of therapy proximate to delivery. Treatment guidelines are proposed to improve neonatal well-being when lithium use is indicated in late pregnancy.

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    • "Reduce maternal lithium dose to preconception amount immediately after delivery (Newport et al. 2005). "
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    • "Adverse perinatal outcomes are more extensive in the setting of higher lithium concentrations at delivery. Lithium delivery concentrations can be significantly reduced at delivery without compromising pharmacotherapeutic efficacy by briefly withholding lithium therapy [7]. The risk of lithotoxicity can be minimized by close and careful monitoring of lithium treatment. "
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    • "In order to avoid the toxic effects of high blood levels of Li due to a sudden fall in vascular volume, the dose of Li must be reduced by 50%-75% (Yonkers et al. 2004). Li levels in the umbilical cord are the same as maternal serum levels (Newport et al. 2005); therefore, blood levels of Li must be monitored closely, both during gestation and after birth. In cases of prolonged labor the administration of intravenous fluid can be considered in order to achieve adequate hydration. "
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