A 7-year-old boy is evaluated for fatigue. For the last year, he has been avoiding any significant outdoor activities with his peers due to poor energy and shortness of breath. He also describes occasional pounding in the chest. Physical examination shows a holosystolic murmur best heard at the lower sternal border. Echocardiography reveals apical displacement of the tricuspid valve leaflets, decreased right ventricular volume, and atrialization of the right ventricle. Moderate to severe tricuspid regurgitation is also present. If this patient's diagnosis is due to a side effect of a drug taken during pregnancy, his biological mother most likely had which of the following conditions?

Question

A 7-year-old boy is evaluated for fatigue.  For the last year, he has been avoiding any significant outdoor activities with his peers due to poor energy and shortness of breath.  He also describes occasional pounding in the chest.  Physical examination shows a holosystolic murmur best heard at the lower sternal border.  Echocardiography reveals apical displacement of the tricuspid valve leaflets, decreased right ventricular volume, and atrialization of the right ventricle.  Moderate to severe tricuspid regurgitation is also present.  If this patient's diagnosis is due to a side effect of a drug taken during pregnancy, his biological mother most likely had which of the following conditions?

Quizplus · Accepted Answer

11ec160b_3c49_987f_9249_af8f89169b09_MD0001_00 In patients with bipolar disorder, lithium is used to treat acute mania, hypomania, and bipolar and unipolar depression. Long-term treatment may also reduce the risk of suicide attempts and deaths. Lithium is potentially teratogenic; in utero exposure is associated with Ebstein's anomaly in infants. Ebstein's anomaly is characterized by apical displacement of the tricuspid valve leaflets, decreased volume of the right ventricle, and atrialization of the right ventricle. (Choice A) Alcohol use during pregnancy may result in fetal alcohol syndrome, which is characterized by dysmorphic facies, growth retardation, and central nervous system abnormalities. (Choice C) Prenatal cocaine use increases the risk of preeclampsia, spontaneous abortion, fetal demise, and placental abruption. (Choice D) Atrial and ventricular septal defects are the most common congenital cardiac anomalies in patients with Down syndrome. (Choice E) Seizures are not associated with major fetal malformations, but antiepileptic drugs (AEDs) significantly increase the risk of neural tube, renal, skeletal, and cleft palate abnormalities. Although AEDs also increase the risk of congenital heart defects, they are not associated with Ebstein's anomaly. (Choice F) Gestational diabetes is associated with fetal macrosomia, caudal regression syndrome, hypoglycemia, hypocalcemia, and hypertrophic cardiomyopathy. (Choice G) Untreated maternal hypothyroidism in pregnancy is associated with obstetric complications and cognitive impairment in offspring. (Choice H) Opioid use may cause neonatal withdrawal symptoms (irritability, diarrhea, vomiting) after delivery. Opioid dependence increases the risk of multiple obstetric complications but not major cardiac defects. (Choice I) Schizophrenia and antipsychotics are not associated with the development of major fetal malformations. Educational objective: Lithium is commonly used to treat bipolar disorder. Its use during pregnancy is associated with Ebstein's anomaly, which is characterized by apical displacement of the tricuspid valve leaflets, decreased right ventricular volume, and atrialization of the right ventricle. __________ References: When lithium hurts: a look at Ebstein anomaly. (http://www.ncbi.nlm.nih.gov/pubmed/23269033) Pregnancy outcome following in utero exposure to lithium: a prospective, comparative, observational study. (http://www.ncbi.nlm.nih.gov/pubmed/24781368) Use and safety of antipsychotic drugs during pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/19461391)

A 7-Year-Old Boy Is Evaluated for Fatigue