Pharmacologic management of acute mania in pregnancy

Mania is a psychiatric illness that often requires immediate intervention, and the pregnant manic patient presents a therapeutic dilemma. Use of psychotropic medications during pregnancy may cause three complications: teratogenesis, neonatal toxicity, and behavioral toxicity. The literature contains few well-controlled studies for psychotropic medications in bipolar or other psychiatric populations and those often lack a control group or do not consider confounding factors such as other drug use. Pharmacologic alternatives include antipsychotics, lithium, carbamazepine, and benzodiazepines. Although studies and case reports describe fetal malformations in infants exposed in utero to psychotropic medications, the data are conflicting as to the nature of anomalies and risk of their occurrence. Malformations can occur in almost every organ system; however, the cardiovascular type are of major concern after lithium exposure during the first trimester and oral clefts after benzodiazepine exposure. Antipsychotic exposure can produce extrapyramidal symptoms in the neonate and lithium has been associated with neonatal cyanosis, lethargy, flaccidity, and non-toxic goiter. A neonatal abstinence syndrome has occurred after maternal benzodiazepine consumption. Behavioral toxicity is more difficult to assess, as long-term follow-up is needed. To date, evidence for behavioral toxicity in children exposed to lithium or antipsychotics in utero is lacking. Few specific guidelines for using psychotropic medications in an acutely manic pregnant patient exist. Current symptoms, past response, and the stage of gestation all must be considered. Complete elimination of symptoms may not be the goal. A team approach is essential in treatment of such a complex and challenging patient.