Lithium Use in Pregnancy
- The question is no longer whether to use lithium in pregnancy, but how. First-trimester exposure carries a modest, dose-dependent cardiac risk; the absolute risk stays low and the relapse risk on discontinuation is exceptionally high.
- Risk–benefit favors continuation: NNT = 3 to prevent one postpartum relapse versus NNH = 33 for any congenital anomaly. ACOG (2023) issues a Strong Recommendation against discontinuing mood stabilizers — except valproate — in pregnancy.
- Dose drives cardiac risk: at ≤ 600 mg/day the signal is statistically indistinguishable from baseline; the inflection is > 900 mg/day, where risk roughly triples.
- Levels fall most in the second trimester (↓ 36%), not the third — adjust proactively on levels, not symptoms. After delivery the pregnancy-related rise in renal clearance reverses and levels overshoot to ~9% above the pre-pregnancy baseline, so return to the preconception dose immediately.
- Highest-risk window is postpartum: reinstitute lithium within 6–12 hours of stabilization, protect sleep, and flag the chart "No NSAIDs."
Lithium management in pregnancy has evolved from cautious avoidance to a sophisticated, proactive monitoring strategy. The clinical question is no longer whether to use lithium during the perinatal period, but how to use it optimally. First-trimester exposure carries a modest, dose-dependent risk of cardiac malformations, including Ebstein anomaly, but the absolute risk remains low. The risk of maternal relapse following discontinuation, by contrast, is exceptionally high.
Meta-analytic data establish a favorable risk-benefit profile: NNT = 3 to prevent one postpartum relapse (from two small studies, N = 48; 95% CI 1–12) versus NNH = 33 for any congenital anomaly — and NNH = 71 for cardiac anomalies specifically (95% CI 48–167). ACOG (2023) issues a Strong Recommendation (Moderate-Quality Evidence) against discontinuing mood stabilizers — except valproate — during pregnancy.
Snellen and Malhi: "The aim is always to achieve the minimum effective dosage — emphasis on effective rather than minimal. Half-treatment represents the worst possible scenario, as it exposes the fetus to the risks of treatment AND maternal mental illness."
Subtherapeutic dosing provides neither adequate maternal protection nor meaningful fetal risk reduction.
Preconception Counseling
Preconception planning is the single most impactful intervention. Initiate these conversations with all women of reproductive age on lithium — well before pregnancy is contemplated.
Establish the Therapeutic Baseline Before Pregnancy
- Document the minimum effective lithium level that maintains euthymia — this becomes the pregnancy target.
- Convert to BID dosing — reduces peak concentrations without changing total daily dose.
- Target 12-hour trough: 0.6–1.0 mEq/L.
- Folic acid 5 mg/day — not the standard 0.4 mg; mitigates neural tube and cardiac risk.
- Baseline labs: creatinine, eGFR, TFTs, lithium level.
The Patient Script — Shared Decision-Making
The newest research — from a study of more than 1.3 million pregnancies — shows that the risk of heart issues for the baby is much lower than we used to think. At lower doses (600 mg/day or less), the risk is barely above the population baseline. Even at higher doses, about 97 of every 100 babies are born with a healthy heart.
The risk of a mood relapse if we stop the medication, however, is very high — roughly 70 to 90 percent. Untreated bipolar disorder during pregnancy can itself cause problems for the baby, including growth restriction and preterm birth.
Because your body clears lithium faster during pregnancy, we'll check blood levels monthly early on, then weekly toward the end. We'll also arrange a specialized ultrasound of the baby's heart around 16–20 weeks.
At delivery we'll pause the medication for a day or two for safety, then restart it right away after the baby is born — because the postpartum period is the highest-risk window for relapse. We'll also build a sleep-protection plan, because sleep loss is one of the strongest triggers for mood episodes.
Teratogenicity — What the Evidence Actually Shows
Historical Context: Why Old Estimates Were Wrong
Early registries (Schou et al., 1973; Weinstein, 1975) estimated that lithium increased the risk of Ebstein anomaly by a factor of approximately 400. Those data were fatally flawed by severe recall bias and an absence of appropriate control groups, producing a decades-long overestimation of risk that shaped clinical practice well into the 21st century.
The Modern Evidence: 1.3 Million Pregnancies
Patorno et al. (2017), NEJM — a cohort of 1,325,563 Medicaid pregnancies; 663 with first-trimester lithium exposure. Overall, cardiac malformations occurred in 2.41% of lithium-exposed infants versus 1.15% of unexposed infants (adjusted RR 1.65; 95% CI 1.02–2.68). The risk is clearly dose-dependent:
| Daily Lithium Dose | Cardiac aRR | 95% CI | Interpretation |
|---|---|---|---|
| ≤ 600 mg/day | 1.11 | 0.46–2.64 | Minimal — not statistically significant |
| 601–900 mg/day | 1.60 | 0.67–3.80 | Moderate — not statistically significant |
| > 900 mg/day | 3.22 | 1.47–7.02 | Significant — intensify fetal surveillance |
| Overall (any dose) | 1.65 | 1.02–2.68 | Overall cardiac malformation risk |
aRR = adjusted risk ratio. All right-ventricular outflow tract obstruction (RVOTO) defects in lithium-exposed infants occurred at doses > 600 mg/day.
- RVOTO defects (the category that includes Ebstein anomaly): 0.60% in exposed infants vs. 0.18% in unexposed (aRR 2.66; 95% CI 1.00–7.06). The cohort did not report a separate Ebstein-specific count — the number of events was too small to disclose.
- Any congenital malformation (Munk-Olsen et al., 2018): Absolute risk 7.4% exposed vs. 4.3% unexposed. Neonatal readmission within 4 weeks: 27.5% vs. 14.3%.
For women maintained on ≤ 600 mg/day, cardiac malformation risk is statistically indistinguishable from baseline. The inflection point is > 900 mg/day, where risk roughly triples. This does not contraindicate higher-dose lithium when clinically necessary — it warrants more intensive fetal surveillance.
Absolute Risk — RVOTO Defects vs. Ebstein Anomaly
A precision point that matters at the bedside: Patorno tracked RVOTO defects — the broad category that includes Ebstein anomaly — not Ebstein anomaly in isolation. The figures below should be read accordingly.
| Measure | Risk |
|---|---|
| RVOTO defects — lithium-exposed (first trimester) | 0.60% (≈ 6 per 1,000) |
| RVOTO defects — unexposed | 0.18% — aRR 2.66 (95% CI 1.00–7.06) |
| Ebstein anomaly — general population | ≈ 1 in 20,000 live births (published estimates range ~1 in 14,000 to ~1 in 200,000) |
| Lithium-exposed infants without an RVOTO defect | > 99% |
The often-quoted "~20-fold increase in Ebstein anomaly" is an unadjusted crude prevalence ratio and should not be cited alongside the adjusted RVOTO risk ratio of 2.66. No Ebstein-specific absolute risk for lithium-exposed infants can be derived from the Patorno cohort, as those events were too few to report.
Spontaneous Abortion
Meta-analytic data suggest an increased risk (OR 3.77; 95% CI 1.15–12.39). However: when matched for underlying mood disorder, the association loses statistical significance. The finding is preliminary and should not, on its own, drive a discontinuation decision.
Clinical Features of Ebstein Anomaly — When to Suspect
| Age at Presentation | Typical Finding | Frequency |
|---|---|---|
| Fetus | Abnormal routine prenatal scan | 86% |
| Neonate | Cyanosis | 74% |
| Infant | Heart failure | 43% |
| Child | Incidental murmur | 63% |
| Adolescent / Adult | Arrhythmia | 42% |
Diagnostic Study of Choice
Fetal echocardiography (transthoracic 2D + Doppler) is the gold standard. FDA recommendation: fetal echocardiogram at 16–20 weeks gestation for all women with first-trimester lithium exposure.
Pharmacokinetics — Trimester-Specific Clearance
Lithium is renally eliminated exclusively. Pregnancy-related changes in GFR produce predictable, trimester-specific fluctuations in serum levels that require proactive dose management — adjustments anticipated from levels, not reactive responses to symptoms.
Trimester-Specific Level Changes
Wesseloo et al. (2017); N = 113 pregnancies, 1,101 lithium measurements:
| Period | Mean Level Change | 95% CI | Clinical Action |
|---|---|---|---|
| First trimester | ↓ 24% | 15–35% | Begin monthly monitoring; anticipate dose increase |
| Second trimester (nadir) | ↓ 36% | 27–47% | Highest risk of subtherapeutic levels — act proactively |
| Third trimester | ↓ 21% | 13–30% | Weekly monitoring from 34 weeks |
| Postpartum | ↑ 9% above baseline | 2–15% | Reduce to preconception dose immediately |
Clark et al. (2022): Lithium elimination clearance increased by an average of 63.5% by the third trimester, with mood symptoms worsening as serum levels declined. Clearance returned to non-pregnant baseline at 4–9 weeks postpartum.
The greatest drop in lithium levels occurs in the second trimester (36% reduction), not the third. Clinicians who wait until the third trimester to increase doses may leave patients subtherapeutic during a critical window. Adjust proactively, based on levels — not on symptoms alone.
Dosing Strategy
- Target 12-hour trough: 0.6–1.0 mEq/L (establish before pregnancy in a stabilized patient).
- Lowest clinically effective dose — emphasis on "effective" over "lowest."
- Split to BID dosing — reduces peak concentrations without changing total daily dose.
- Avoid sodium restriction and diuretics throughout pregnancy.
- Avoid NSAIDs — raise lithium levels 25–40%; use acetaminophen.
Converting from once-daily to twice-daily dosing reduces peak lithium concentrations without changing total daily dose. This reduces fetal exposure to concentration spikes while maintaining therapeutic trough levels. Do this before conception whenever possible.
Phase-by-Phase Clinical Management
Renal Clearance Phase
- Monitoring: serum lithium + creatinine monthly
- Fetal surveillance: fetal echo 16–20 weeks; anatomy ultrasound at 20 weeks
- Dose: increases frequently required (24–36% level reduction)
- Alert: hyperemesis gravidarum → altered plasma volume → check levels with prolonged vomiting
- Supplementation: folic acid 5 mg/day
High-Sensitivity Phase
- Monitoring: weekly levels from 34 weeks until delivery
- Level status: ~21% below non-pregnant baseline
- Preeclampsia: alters GFR → reassess dosing; may require reduction
- Polyhydramnios: may signal fetal renal effects → reduce dose and investigate
- Oligohydramnios: may reflect fetal nephrotoxicity → urgent evaluation
Delivery — The "Labor Hold" Protocol
Rapid vascular volume contraction combined with a sudden drop in GFR can cause lithium levels to spike acutely. The Labor Hold is non-negotiable. Aggressive intrapartum hydration is mandatory.
| Step | Action |
|---|---|
| On admission | Measure maternal lithium concentration immediately |
| Scheduled delivery (induction or C-section) | Decrease or discontinue lithium 24–48 hours before (FDA label: 2–3 days) |
| Spontaneous labor | Suspend lithium immediately at onset of labor or on admission |
| Intrapartum | Oral and/or IV fluids throughout; avoid sodium restriction; check levels at any sign of toxicity |
| Cord blood (at delivery) | Send lithium level, TSH, free T4, glucose, hepatic function |
| Neonatology team | Alert before delivery; monitor for "floppy baby syndrome" up to 14 days |
Evolving Evidence on the Labor Hold
Imaz et al. (2024): A 12-hour pre-delivery discontinuation was associated with only slight maternal lithemia fluctuations (~0.20 mEq/L) and a low 6% early postpartum relapse rate. The VA/DoD (2023) cites recent studies suggesting no clear association between neonatal lithium levels and short-term neonatal outcomes. The FDA label and most expert consensus still recommend the hold; the duration is reasonably debated.
Postpartum — Stabilization and Relapse Prevention
The postpartum period carries a 25–50% risk of postpartum psychosis in women with bipolar disorder — roughly a 100-fold increase over the general population. Do not delay lithium reinitiation.
| Timeframe | Action |
|---|---|
| At delivery | Measure lithium level before and 24 hours after delivery |
| Weeks 1–2 postpartum | Twice-weekly levels; restart at preconception dose; target 0.8–1.0 mmol/L; no NSAIDs |
| Weeks 3–8 postpartum | Weekly → biweekly monitoring; titrate to maintenance; clearance normalizes at 4–9 weeks |
| Ongoing | Implement sleep-protection plan; document early warning signs with patient and family |
Lithium levels rise approximately 9% above non-pregnant baseline in the immediate postpartum period. Failing to reduce the dose back to the preconception level after delivery is a common — and dangerous — error. Restart at the preconception dose and titrate based on twice-weekly levels.
Neonatal Care — Toxicity Monitoring
Placental Passage
Lithium crosses the placenta completely. The mean umbilical-cord-to-maternal intrapartum lithium ratio is approximately 1.10 (SD 0.17) — fetal exposure essentially equals maternal levels at delivery.
Cord Blood Workup at Delivery
- Lithium level
- TSH and free T4
- Glucose
- Hepatic function panel
Recognizing Neonatal Toxicity — "Floppy Baby Syndrome"
Infants with cord blood concentrations > 0.64 mEq/L are at increased risk. In the Imaz et al. (2024) cohort, 56% of neonates had transient acute complications; hypotonia was most frequent (mean lithemia 0.178 mEq/L higher in affected neonates; p = 0.028).
| System | Signs |
|---|---|
| Neuromuscular | Hypotonia ("floppy baby"), poor suck/feeding, lethargy, depressed reflexes |
| Respiratory | Respiratory distress, cyanosis, apnea, lower Apgar scores |
| Cardiac | Bradycardia |
| Endocrine / Renal | Neonatal diabetes insipidus (polyuria), transient hypothyroidism |
Neonatal Clearance
- Neonatal half-life: 68–96 hours — dramatically longer than in adults.
- Toxic signs may persist for up to 14 days (per FDA label).
- Most cases are self-limiting with supportive care: hydration, thermoregulation, and respiratory support as needed.
Neonatal lithium clearance is dramatically slower than adult clearance. Even after a brief peripartum hold, cord blood levels may be clinically significant. Alert neonatology before delivery, and monitor the infant for up to 14 days for delayed-onset toxicity.
Critical Drug–Drug Interactions
Standard obstetric and postpartum orders can inadvertently precipitate lithium toxicity. The following interactions require active flagging in the medical record.
| Agent | Effect on Lithium | Magnitude | Management |
|---|---|---|---|
| NSAIDs (ibuprofen, naproxen) | Reduce renal clearance | +25–40% in levels | Use acetaminophen — flag chart "No NSAIDs" |
| Thiazide diuretics | Sodium depletion → retention | +40% in levels | Avoid during pregnancy and postpartum |
| Magnesium sulfate (preeclampsia) | Additive neuromuscular blockade | Synergistic | Monitor levels; observe for enhanced neuromuscular depression |
| ACE inhibitors / ARBs | Reduce GFR → retention | Significant | Avoid; if needed, monitor closely |
| Preeclampsia (disease state) | Alters GFR | Variable | Reassess dosing; may require reduction |
| Acute blood loss | Reduces plasma volume | Variable | Can spike levels — check promptly |
Ibuprofen 600 mg q6h — standard post-cesarean analgesia — can raise maternal lithium levels 25–40% within days. Flag the chart explicitly: "No NSAIDs — Lithium Patient." Prescribe acetaminophen as first-line analgesic.
Long-Term Neurodevelopmental Outcomes
Poels et al. (2018) systematic review identified three clinical cohort studies of intrauterine lithium exposure — all three reported normal neurodevelopment in exposed offspring.
Haskey & Galbally (2017) systematic review found no adverse neurodevelopmental outcomes associated with lithium exposure, in clear contrast to valproate's confirmed dose-dependent cognitive harm.
Limitations: Most studies compared exposed children with unaffected populations, without correction for genetic predisposition or parental psychiatric illness. The clinical signal is reassuring, but long-term surveillance remains appropriate and the evidence base is narrower than the headline conclusion suggests.
Lithium: No demonstrated neurodevelopmental teratogenicity in clinical studies to date.
Valproate: Confirmed, dose-dependent adverse effects on cognitive development (IQ reduction, autism spectrum disorder, ADHD).
There is no clinical scenario in bipolar disorder where valproate should be the first-line choice for a woman who may become pregnant.
Alternatives & Mood Stabilizer Selection
Based on ACOG (2023), VA/DoD (2023), and Bergink et al. (2025):
Bipolar I Disorder (Mania-Predominant)
- First-line: Lithium — gold standard; strongest evidence for postpartum relapse prevention (NNT = 3).
- Alternative: Quetiapine or olanzapine — reasonable perinatal safety data; note metabolic risks (gestational diabetes, weight gain).
- Avoid: Valproate (FDA Black Box Warning) and carbamazepine (neural tube defects, fetal carbamazepine syndrome).
Bipolar II Disorder (Depression-Predominant)
- First-line: Lamotrigine — preferred for bipolar II; low teratogenic risk. Note: pregnancy-related clearance increases substantially (up to ~330%), often requiring a 2–3× dose increase across pregnancy.
- Alternative: Quetiapine or lurasidone.
- Consider lithium if lamotrigine is ineffective, or in any patient with a personal or family history of postpartum psychosis.
Patients Already Stable on Lithium
ACOG (2023): "For individuals taking medications at the time of pregnancy who are clinically stable, it is preferable to continue the same regimen rather than switch medications."
Safety Hierarchy for Bipolar Disorder
| Mood Stabilizer | Relative Safety in Pregnancy | Key Concern |
|---|---|---|
| Lamotrigine | Most favourable | Requires 2–3× dose increase during pregnancy |
| Lithium | Favourable with monitoring | Dose-dependent cardiac risk; intensive monitoring required |
| Quetiapine | Reasonable | Metabolic complications (gestational diabetes) |
| Carbamazepine | Use with caution | Neural tube defects; fetal carbamazepine syndrome |
| Valproate | AVOID | FDA Black Box; confirmed cognitive teratogenicity |
The Perinatal Bipolar Relapse Prevention Plan
Based on Bergink et al. (2025). A written plan must be created collaboratively with the patient, family, and entire care team — and documented in the medical record before delivery.
- Maintenance treatment during pregnancy — medication choice, dose, monitoring schedule, contingency plans for dose adjustments.
- Preferred mode of delivery — planned induction vs. spontaneous labor; implications for lithium hold timing; communication plan with L&D team.
- Medication immediately after delivery — restart timing (within 6–12 hours), target level (0.8–1.0 mmol/L), monitoring frequency.
- Feeding plan — breastfeeding vs. bottle-feeding; risks and benefits discussed; monitoring plan if breastfeeding (see separate Breastfeeding chapter).
- Sleep-protection strategies — who takes night feeds; minimum 4–6 hours of consolidated sleep as the target; backup plans.
- Early warning signs and intervention plan — insomnia, racing thoughts, irritability, decreased need for sleep, grandiosity; emergency contacts; threshold for hospitalization; PRN medications.
Sleep protection is not a lifestyle recommendation — it is a medical intervention. Sleep deprivation is a primary driver of mania, and the postpartum period combines maximal circadian disruption with the highest biological vulnerability for relapse.
A patient on optimal lithium sleeping 2 hours a night is at higher relapse risk than a patient on suboptimal levels sleeping 6 hours a night.
The relapse-prevention plan must address both pillars: pharmacological prophylaxis and protected sleep.
International Guideline Concordance & Discordance
Understanding where guidelines agree — and where they diverge — is essential for informed clinical decision-making and for medicolegal documentation.
| Guideline | Position on Lithium | Peripartum Hold | Fetal Echo | Key Recommendation |
|---|---|---|---|---|
| ACOG (2023) | Continue; do not discontinue | 24–48h before scheduled delivery, or at onset of labor | Yes | Strong Rec, Moderate Evidence |
| VA/DoD (2023) | Benefits likely outweigh harms | FDA recommends 48–72h; recent studies question this | Yes (16–20 wks) | Lowest effective dose; account for BD severity |
| FDA Label | Continue if benefits outweigh risks | Decrease or discontinue 2–3 days prior | Yes (16–20 wks) | Serum monitoring required throughout |
| NICE (UK) | Avoid where possible (esp. T1) | Not specified | Yes if exposed | Use alternatives where feasible |
| Bergink et al. (2025) | Gold standard for BD | Written perinatal plan addressing delivery mode | Yes | 6-point written relapse-prevention plan |
| Fornaro et al. (2020) | Not an absolute contraindication | Case-by-case; prompt resumption | Yes | NNT = 3 vs. NNH = 33 |
ACOG (US, 2023): Strong Recommendation — do not discontinue lithium during pregnancy.
NICE (UK): Recommends avoiding lithium in pregnancy where possible.
This divergence reflects different weighting of the same evidence base. For clinicians practicing in the US, ACOG's position represents the current standard of care.
The Peripartum Hold — Points of Ongoing Debate
- FDA label: decrease or discontinue 2–3 days before delivery.
- ACOG (2023): hold 24–48 hours before scheduled delivery, or at onset of spontaneous labor — framed as expert opinion.
- VA/DoD (2023): cites recent studies questioning whether the hold is always necessary.
- Imaz et al. (2024): a 12-hour hold was associated with ~0.20 mEq/L fluctuation and a 6% early postpartum relapse rate.
Consensus regardless of hold protocol: aggressive intrapartum hydration and immediate postpartum lithium reinitiation are not in dispute.
Master Monitoring & Action Table
| Stage | Monitoring | Action / Target | Rationale |
|---|---|---|---|
| Pre-conception | Baseline labs | Establish therapeutic level; folic acid 5 mg/day; convert to BID dosing; baseline renal function + TFTs | Optimize dosing; mitigate cardiac/neural tube risk |
| Trimester 1 | Monthly levels + creatinine | Lowest effective dose; plan fetal echo at 16–20 weeks; check levels with hyperemesis | Dose-dependent cardiac risk; 24% level reduction |
| Trimester 2 | Monthly levels + creatinine | Anticipate dose increase; fetal echo 16–20 weeks; anatomy US at 20 weeks | Nadir of levels (36% reduction) |
| Trimester 3 (from 34 wks) | Weekly levels | Adjust dose to maintain therapeutic range; monitor amniotic fluid status | 21% level reduction; prepare for delivery |
| Delivery (admission) | Immediate level check | Hold lithium 24–48h before scheduled delivery or at onset of labor; aggressive IV/oral hydration; cord blood labs; alert neonatology | Prevent toxicity during vascular volume shifts |
| Postpartum Weeks 1–2 | Twice-weekly levels | Restart at preconception dose within 6–12h; target 0.8–1.0 mmol/L; no NSAIDs | 25–50% PP psychosis risk; levels rise 9% |
| Postpartum Weeks 3–8 | Weekly → biweekly | Titrate to maintenance; implement sleep-protection plan; monitor early warning signs | Clearance normalizes at 4–9 weeks postpartum |
EMR Documentation Template
Copy and complete in the patient's medical record:
- Indication: Bipolar Disorder Type [I / II]. Current status: [Stable / Euthymic / Symptomatic].
- Current regimen: Lithium [dose] mg [frequency]. Preconception therapeutic level: [X] mEq/L.
- Discussed dose-dependent cardiac malformation risk (aRR 1.11 at ≤ 600 mg/day; aRR 1.60 at 601–900 mg/day; aRR 3.22 at > 900 mg/day) vs. high relapse risk (20–70% during pregnancy; 25–50% postpartum psychosis).
- NNT for relapse prevention = 3 (two studies, N = 48; 95% CI 1–12); NNH for any congenital anomaly = 33; NNH for cardiac anomalies = 71.
- Patient [consents / declines] continuation.
- Target lithium level: [X] mEq/L. Dose split to BID: [Yes / No].
- Ordered: fetal echocardiography at 16–20 weeks GA.
- Ordered: detailed fetal anatomy ultrasound at 20 weeks GA.
- Ordered: folic acid 5 mg daily.
- Monthly serum lithium + creatinine (Trimesters 1–2).
- Weekly serum lithium from 34 weeks until delivery.
- Twice-weekly levels for the first 2 weeks postpartum.
- Hold lithium 24–48 hours prior to induction/C-section, or at onset of active labor / on admission.
- Aggressive IV / oral hydration during labor.
- NO NSAIDs — acetaminophen only — CHART FLAGGED.
- If magnesium sulfate required: monitor lithium levels; observe for neuromuscular depression.
- Cord blood: lithium level, TSH, free T4, glucose, hepatic function.
- Alert neonatology: lithium-exposed infant; monitor for floppy baby syndrome up to 14 days.
- Resume lithium at preconception dose within 6–12 hours of medical stabilization.
- Target level: 0.8–1.0 mmol/L for first month postpartum.
- Monitor twice-weekly × 2 weeks, then weekly × 4 weeks.
- Sleep-protection plan: [Partner / family / night nurse for nighttime feeds — documented].
- Feeding plan: [See Breastfeeding chapter — decision documented].
- Patient and family educated on signs of mania / psychosis (insomnia, racing thoughts, irritability, grandiosity, decreased need for sleep).
- Emergency contacts provided. Threshold for hospitalization discussed.
- PRN medications: [specify].
References
- Patorno E, Huybrechts KF, Bateman BT, Cohen JM, Desai RJ, Mogun H, Cohen LS, Hernandez-Diaz S. Lithium use in pregnancy and the risk of cardiac malformations. N Engl J Med. 2017;376(23):2245–2254.
- Munk-Olsen T, Liu X, Viktorin A, Brown HK, Di Florio A, D'Onofrio BM, et al. Maternal and infant outcomes associated with lithium use in pregnancy: an international collaborative meta-analysis of six cohort studies. Lancet Psychiatry. 2018;5(8):644–652.
- Fornaro M, Maritan E, Ferranti R, Zaninotto L, Miola A, Anastasia A, et al. Lithium exposure during pregnancy and the postpartum period: a systematic review and meta-analysis of safety and efficacy outcomes. Am J Psychiatry. 2020;177(1):76–92.
- American College of Obstetricians and Gynecologists Committee on Clinical Practice Guidelines — Obstetrics. Treatment and management of mental health conditions during pregnancy and postpartum: ACOG Clinical Practice Guideline No. 5. Obstet Gynecol. 2023;141(6):1262–1288.
- Department of Veterans Affairs / Department of Defense. VA/DoD Clinical Practice Guideline for the Management of Bipolar Disorder. Published May 2023.
- U.S. Food and Drug Administration. Lithium Carbonate Prescribing Information. DailyMed; updated 2022.
- Wesseloo R, Wierdsma AI, van Kamp IL, Munk-Olsen T, Hoogendijk WJG, Kushner SA, Bergink V. Lithium dosing strategies during pregnancy and the postpartum period. Br J Psychiatry. 2017;211(1):31–36.
- Clark CT, Newmark RL, Wisner KL, Stika C, Avram MJ. Lithium pharmacokinetics in the perinatal patient with bipolar disorder. J Clin Pharmacol. 2022;62(11):1385–1392.
- Imaz ML, Torra M, Langohr K, et al. Peripartum lithium management: early maternal and neonatal outcomes. J Affect Disord. 2024;366:326–334.
- Poels EMP, Schrijver L, Kamperman AM, et al. Long-term neurodevelopmental consequences of intrauterine exposure to lithium and antipsychotics: a systematic review and meta-analysis. Eur Child Adolesc Psychiatry. 2018;27(9):1209–1230.
- Haskey C, Galbally M. Mood stabilizers in pregnancy and child developmental outcomes: a systematic review. Aust N Z J Psychiatry. 2017;51(11):1087–1097.
- Bergink V, Suleiman M, Hennen MA, Robakis T. Management of bipolar disorder in pregnancy and postpartum: a clinician's guide. CNS Drugs. 2025;39(8):763–777.
- Diav-Citrin O, Shechtman S, Tahover E, et al. Pregnancy outcome following in utero exposure to lithium: a prospective, comparative, observational study. Am J Psychiatry. 2014;171(7):785–794.
- Viguera AC, Nonacs R, Cohen LS, Tondo L, Murray A, Baldessarini RJ. Risk of recurrence of bipolar disorder in pregnant and nonpregnant women after discontinuing lithium maintenance. Am J Psychiatry. 2000;157(2):179–184.
- Viguera AC, Whitfield T, Baldessarini RJ, Newport DJ, Stowe Z, Reminick A, Zurick A, Cohen LS. Risk of recurrence in women with bipolar disorder during pregnancy: prospective study of mood stabilizer discontinuation. Am J Psychiatry. 2007;164(12):1817–1824.
- Newport DJ, Viguera AC, Beach AJ, Ritchie JC, Cohen LS, Stowe ZN. Lithium placental passage and obstetrical outcome: implications for clinical management during late pregnancy. Am J Psychiatry. 2005;162(11):2162–2170.
- Jones I, Chandra PS, Dazzan P, Howard LM. Bipolar disorder, affective psychosis, and schizophrenia in pregnancy and the post-partum period. Lancet. 2014;384(9956):1789–1799.
- Wesseloo R, Kamperman AM, Munk-Olsen T, Pop VJM, Kushner SA, Bergink V. Risk of postpartum relapse in bipolar disorder and postpartum psychosis: a systematic review and meta-analysis. Am J Psychiatry. 2016;173(2):117–127.
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