Part 21 (2/2)

Molindone is an indole derivative that is not related chemically to the phenothiazines, butyrophenones, or thioxanthenes, but is an effective antipsychotic drug. No studies have been published of birth defects in newborns that were exposed to molindone in in utero utero, and no studies in animals evaluating its teratogenic effects are available.

LITHIUM SALTS AND BIPOLAR TREATMENT.

Bipolar disorder is treated with mood stabilizers (lithium, anticonvulsants, antipsychotics) with an adjuvant antidepressant if necessary. Lithium is effective in the prophylaxis and treatment of affective psychiatric disorders.

Of all the psychotropic agents currently available, lithium has received the greatest attention as a possible teratogen. Cardiovascular system anomalies, particularly Ebstein's anomaly, have been reported to be increased among the infants of mothers that received lithium carbonate during the first trimester (Nora et al et al., 1974), but the question of the magnitude of these risks has been questioned (Cohen et al et al., 1994). Ebstein's anomaly is induced between weeks 2 and 6 postconception.

Three congenital anomalies were reported among 60 infants exposed to lithium in in utero utero. This is no different from the incidence in the general population (Schou and Amidsen, 1971). Among 50 women who reportedly received lithium during gestation, one infant had myelomeningocele, one had unilateral hernia, and none had congenital heart defects (Cunniff et al et al., 1989). No maternal history of lithium ingestion was found among 40 infants with Ebstein's anomaly and in 44 with tricuspid atresia (Kallen, 1971).

The risk of Ebstein's anomaly and other birth defects was reevaluated, and the risk of cardiac anomalies appears to be much less than estimated in previous studies (Cohen et al et al., 1994; Miller, 1994a, 1996). The early recommendation that women who take lithium salts during early gestation should undergo prenatal diagnosis with fetal echocardiography (Allan et al et al., 1982) is still valid (Yonkers et al et al., 2004). The risk of birth defects a.s.sociated with lithium was probably overestimated in the past (Yonkers et al et al., 2004). The risk is 'likely to be weak if it exists' and the 'data certainly do not support the 30-fold increased risk of Ebstein's anomaly suggested by the Register of Lithium Babies' (Moore, 1995). Nonetheless, first-trimester exposure to lithium is an indication for a fetal echocardiogram, targeting the competence and function of the tricuspid valve.

194.

Psychotropic use during pregnancy Table 10.3 Lithium exposure during first trimester and congenital anomalies Exposed Non-heart Heart Lithium exposure during first trimester and congenital anomalies Exposed Non-heart Heart Ebstein's anomalies anomalies anomaly N.

n/N %.

n/N %.

n/N %.

Cohort studies Background 35/1000 3.5.

8/1000 0.8.

1/20 000 0.005.

Weinstein (1980) 225.

7/225.

3.1.

18/225 8.0.

6/225.

2.7.

Jacobsen et al. (1992) 138.

3/138.

2.2.

0/138.

0.

1/138a 0.8.

Kallen and Tandberg 59.11/59.

18.6.

4/59.

6.8.

0/59.

0.

(1983).

Ebstein's anomaly Unaffected control Lithium exposure Lithium exposure Yes No Yes No Casecontrol studies Kallen (1988) 69.0.

128.

0.

Edmonds and Oakley 34.0.

34.0.

(1990).

Zalzstein et al. (1990) 59.0.

168.

0.

Correa-Villasenor et al. 44 0.

3572.

0.

(1994).

aThe case of Ebstein's anomaly was a therapeutic abortion.

Adapted from Yonkers et al., 1998.

No increase in physical or mental anomalies was found in a follow-up study of 60 school-aged children that were exposed to lithium in utero in utero (Schou, 1976) (Schou, 1976) . . Lithium toxicity, including cardiac, hepatic, and neurological abnormalities, has been reported in newborns of mothers who took lithium salts at term (Morrell Lithium toxicity, including cardiac, hepatic, and neurological abnormalities, has been reported in newborns of mothers who took lithium salts at term (Morrell et al et al., 1983; Woody et al et al., 1971). Diabetes insipidus and polyhydramnios are also complications attendant to lithium-exposed pregnancies.

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