Lithium Use in Pregnancy and the Risk of Cardiac Malformations

Abstract

To the Editor: Patorno et al. (June 8 issue) 1 provided information on the risk of cardiac malfor-mation in infants exposed to lithium during the first trimester of pregnancy. The risk is higher than in nonexposed infants or in infants exposed to lamotrigine, but the association is of a smaller magnitude than previously reported. We emphasize that these findings do not imply or support the idea that lithium treatment should be discontinued in women who are pregnant or planning a pregnancy or that lithium treatment should be avoided in women of child-bearing age. If properly managed, lithium is the most effective prophylactic treatment option for bipolar disorder, both in and outside the perinatal period, and it has a side-effect profile that is more favorable than usually assumed. 2,3 The increased risk of cardiac malformation presented in this research needs to be weighed against the high risk of a postpartum recurrence of bipolar disorder in women who do not receive treatment (in a recent meta-analysis, the risk was found to be 66% [95% confidence interval, 57 to 75] 4), as well as against the risks associated with alternative perinatal treatment options, such as lamo-trigine 3 or the combined use of antipsychotics and antidepressants. 5 No potential conflict of interest relevant to this letter was reported. 1. Patorno E, Huybrechts KF, Bateman BT, et al. Lithium use in pregnancy and the risk of cardiac malformations. N Engl J Med 2017; 376: 2245-54. 2. Geddes JR, Miklowitz DJ. Treatment of bipolar disorder. Lancet 2013; 381: 1672-82. 3. Wesseloo R, Liu X, Clark CT, Kushner SA, Munk-Olsen T, Bergink V. Risk of postpartum episodes in women with bipolar disorder after lamotrigine or lithium use during pregnancy: a population-based cohort study. J Affect Disord 2017; 218: 394-7. 4. Wesseloo R, Kamperman AM, Munk-Olsen T, Pop VJ, Kush-ner SA, Bergink V. Risk of postpartum relapse in bipolar disorder and postpartum psychosis: a systematic review and meta-analysis. Am J Psychiatry 2016; 173: 117-27. 5. Tosato S, Albert U, Tomassi S, et al. A systematized review of atypical antipsychotics in pregnant women: balancing between risks of untreated illness and risks of drug-related adverse effects.