A 29-year-old woman, gravida 1 para 0, at 11 weeks gestation is brought to the emergency department by her husband who says she has been acting "bizarrely and out of control" for the past 8 days. The patient reported to her husband, "I am the smartest graduate in America right now. This new company I am working on will rocket to the top." She has not slept in 4 days and spends most of the night writing plans for a company that will sell baby shoes. The patient quit her job suddenly yesterday and began shopping online for luxury baby clothes and furniture despite the couple's financial difficulties. Psychiatric history is remarkable for 3 similar episodes that required hospitalization. The patient's husband says that she has been relatively stable since discharge from her last hospitalization 2 years ago. She took lithium until 5 months ago, when she asked to discontinue it due to the adverse effects of weight gain and hand tremors and to her desire to start a family. Physical examination is normal. Mental status examination shows loud, pressured speech and rapid shifts in mood and affect. The patient starts to cry when discussing her grandmother's death 6 months ago and then bursts into laughter after making an inappropriate joke. She has no suicidal or homicidal ideation. She tells the doctor, "My baby is going to be a king and a prince of the weak, like Moses." Which of the following is the most appropriate treatment recommendation for this patient?

Question

A 29-year-old woman, gravida 1 para 0, at 11 weeks gestation is brought to the emergency department by her husband who says she has been acting "bizarrely and out of control" for the past 8 days.  The patient reported to her husband, "I am the smartest graduate in America right now.  This new company I am working on will rocket to the top."  She has not slept in 4 days and spends most of the night writing plans for a company that will sell baby shoes.  The patient quit her job suddenly yesterday and began shopping online for luxury baby clothes and furniture despite the couple's financial difficulties.  Psychiatric history is remarkable for 3 similar episodes that required hospitalization.  The patient's husband says that she has been relatively stable since discharge from her last hospitalization 2 years ago.  She took lithium until 5 months ago, when she asked to discontinue it due to the adverse effects of weight gain and hand tremors and to her desire to start a family.  Physical examination is normal.  Mental status examination shows loud, pressured speech and rapid shifts in mood and affect.  The patient starts to cry when discussing her grandmother's death 6 months ago and then bursts into laughter after making an inappropriate joke.  She has no suicidal or homicidal ideation.  She tells the doctor, "My baby is going to be a king and a prince of the weak, like Moses."  Which of the following is the most appropriate treatment recommendation for this patient?

Quizplus · Accepted Answer

Explanation: This patient suffers from bipolar I disorder and is currently experiencing an acute manic episode (lack of sleep, grandiose delusions, pressured speech, increased spending, impulsivity, and impaired judgment). First-line treatments for mania include lithium, anticonvulsant mood stabilizers, and antipsychotic medications. The first-generation antipsychotic haloperidol is a safe and effective treatment for pregnantpatients with bipolarmania. This is due largely to its favorable reproductive safety profile, demonstrated over a long period on the market. Haloperidol has efficacy equal to that of second-generation antipsychotics for mood stabilization in bipolar disorder. Second-generation antipsychotics (eg, quetiapine, risperidone, olanzapine) can also be considered. The anticonvulsant mood stabilizers carbamazepine and valproate should be avoided in the first trimester as they have an increased risk of major congenital malformations such as neural tube defects (Choices B and E). Lithium has an increased relative risk of Ebstein anomaly, but the absolute risk is considered to be low. It can therefore be considered for use in severe mania in pregnancy. Any medication initiated during pregnancy has risks and benefits, and it is essential that the physician present all options to the patient once her condition is stabilized and she can consider the risks/benefits to make an informed decision regarding maintenance treatment. (Choice A) Electroconvulsive therapy is a relatively safe, efficacious treatment for severe manic episodes in pregnant patients. However, it is generally reserved for patients whose condition is unresponsive to antipsychotics or lithium treatment or who are at imminent risk to themselves or their fetus (eg, suicidal, homicidal, not eating or drinking). (Choice D) Lamotrigine is approved for use in the maintenance phase of bipolar disorder. It takes many weeks to titrate to effect and is not suitable for acute mania, as in this patient. Initial studies suggest that it may be safe to use in pregnancy. Educational objective: Haloperidol is a safe and effective treatment for severe bipolar mania during pregnancy. Other treatment options include lithium and second-generation antipsychotics. Valproate and carbamazepine should be avoided. Electroconvulsive therapy is effective but typically reserved for treatment-resistant cases and for those at imminent risk to themselves or their fetus. References: ACOG practice bulletin: clinical management guidelines for obstetrician-gynecologists number 92, April 2008 (replaces practice bulletin number 87, November 2007). Use of psychiatric medications during pregnancy and lactation. (http://www.ncbi.nlm.nih.gov/pubmed/18378767) Bipolar disorder in pregnancy and postpartum: principles of management. (http://www.ncbi.nlm.nih.gov/pubmed/26781551) Antipsychotic use in pregnancy and the risk for congenital malformations. (http://www.ncbi.nlm.nih.gov/pubmed/27540849)

A 29-Year-Old Woman, Gravida 1 Para 0, at 11 Weeks Gestation