|
Lithium in pregnancy, childbirth and afterwards
Please give feedback on this information
Copyright note for Mind factsheets: Both individuals and organisations are welcome to print and photocopy any complete factsheet from the 'Information' section of Mind's website. Organisations are free to distribute them to service users and colleagues, but must ensure they always use the latest version of the factsheet, as available on the website, at the time of distribution.
Prescribing lithium to pregnant women and mothers
As a general rule all drugs are best avoided in pregnancy unless essential, so as to minimise any risk to the developing and newborn infant. Lithium is no exception to this, although the risks are not now considered to be as great as was once thought. For a few women, lithium maintenance treatment may be thought to be essential.
Lithium is given as a preventive treatment to help reduce the recurrence of manic-depressive episodes. Its potential benefits need to be weighed up very carefully against the risks associated with its use in pregnancy, especially at certain stages of pregnancy, during childbirth and while breast-feeding.
What are the possible risks during pregnancy?
There is a risk of malformation of the heart in the developing infant when lithium is taken during pregnancy, especially during the first three months. Lithium should be particularly avoided in this period if possible.
Lithium is also associated with a higher than expected frequency of still-births and deaths soon after birth. If lithium is given in late pregnancy there is risk of dangerous levels of lithium in mother and infant, as the way in which lithium is cleared from the body alters suddenly at childbirth.
If lithium is to be taken at any stage of pregnancy, careful monitoring of lithium levels is most important if toxic effects are to be avoided.
What if I'm taking Lithium and want to become pregnant?
Planned pregnancy
If, after discussion with your doctor, you decide to come off lithium, this should be done gradually over six to eight weeks. Afterwards it is advisable to wait a few weeks before trying to conceive, to make sure that you do not get any recurrence of the manic-depressive symptoms on stopping the lithium.
I'm on lithium and I've discovered that I'm pregnant. What should I do?
You should discuss the problem with your doctor. If it is early in pregnancy and your doctor feels that it is appropriate, you might stop taking lithium immediately.
If you have been pregnant for some time without realising it, you should discuss with your doctor whether you should have an ultrasound scan. This can usually identify any possible problems in your baby's development.
What if it is thought essential to continue with lithium during pregnancy?
If your doctor thinks it is necessary for you to continue with the lithium treatment, then he or she may need to adjust your dose. For example, the kidneys clear lithium from the body differently during pregnancy, so your dose may need to be increased to cope with this.
During the first half of pregnancy, blood lithium levels should be checked monthly; towards the end this should be done weekly. It may also be better to split the total daily dose into three or more odses a day, so that the level of lithium in your blood does not reach such high peaks as it does if you take larger doses less often.
In late pregnancy it is very important that the doctor who is prescribing and monitoring your lithium treatment consults closely with the obstetrician responsible for your baby's delivery.
Childbirth
In childbirth the way that the body clears lithium alters suddenly. If you have continued taking lithium during pregnancy, some doctors may prefer to withdraw lithium treatment gradually in the weeks leading up to the estimated date of delivery, in order to minimise the risk of toxic effects in both the mother and the child. Others may prefer to continue with lithium treatment until the date the baby is due or until labour begins. They may want to continue with lithium as long as possible as a protective factor against the risk of serious mental illness (puerperal or postnatal psychosis).
Lithium should be stopped as soon as labour begins. The obstetrician will need to carefully check your fluid and salt balance and the level of lithium in the blood.
After childbirth
For those who have already had a manic-depressive episode there is a significant risk of serious mental illness (puerperal psychosis) during the weeks after the birth. Because of this, lithium is often started again as a preventive measure a few days after childbirth. Frequent monitoring of the level of lithium in the blood will be needed at this time to achieve a therapeutic dose. Continuing use of the drug would need to be reviewed in the normal way at the end of the period of risk.
Breast-feeding
You should not breast-feed while taking lithium, as lithium passes into the breast milk in sufficient amounts to be dangerous to the baby.
Are there alternatives to lithium in pregnancy?
If possible drugs should be avoided in pregnancy, especially newer drugs as their safety has not yet been proven. The anti-epileptic medicines, carbamazepine and valproate, which are also used as alternatives to lithium, should not be taken during pregnancy because they pose risks to the developing infant.
If drug treatment is considered to be essential, then antidepressants or antipsychotic drugs may be prescribed instead. The type of drug given would depend on the pattern of your manic depression and your symptoms. The following information indicates particular risk periods associated with these alternative drugs.
Tricyclic antidepressants given in late pregnancy have been associated with withdrawal symptoms in newborn babies. Irritability, muscle spasms, restlessness, sleeplessness, fever and fits have been reported.
One anti-psychotic drug, prochlorperazine (Stemetil), is associated with malformations in the developing baby when given during the first three months of pregnancy. The use of anti-psychotic drugs in late pregnancy may cause temporary reactions in newborn infants. Extrapyramidal or Parkinson's reactions have occasionally been reported. These include muscular rigidity, involuntary movements and shaking. If long-acting drugs are taken they take time to clear from the body. The last dose should be taken six to eight weeks before the expected birth.
For further information about these drugs see Mind's booklets Making sense of antidepressants, Making sense of antipsychotics, Making sense of lithium, and Making sense of coming off psychiatric drugs, and Mind's factsheet Alternatives to lithium.
Further information
You should be able to get further information from your doctor regarding any drug you are advised to take during pregnancy. It is very important to discuss all aspects of your drug treatment and any concerns you may have with your doctor, obstetrician, midwife and pharmacist.
You could also discuss the issues with a pharmacist on the psychiatric medication helpline: 020 7919 2999 (Monday-Friday 11am-5pm).
Full information about all licensed drugs can also be found on the electronic Medicines Compendium: emc.medicines.org.uk
Sources
British National Formulary 51, March 2006.
Kelwyn Williams and Sarah Oke, 2000, Lithium and pregnancy , Psychiatric Bulletin, 24, 229-231.
emc.medicines.org.uk
Katherine Darton
Mind Information Unit, May, 2006.
|