Lithium and elective CS

Gabrielle Morris

32yo lady G1P0, booked for elective CS. Recent diagnosis of congenital diaphragmatic hernia in the foetus. Highly stressful for mother. Mother on lithium.

Background

  • BPAD – On 900mg SR Li

Issues

  • Perioperaive lithium management
    • Psychiatrist recommended reducing dose to half throughout perioperative period
    • Patient would prefer to maintain current dose
    • Conflicting international and local guidelines about perioperative management

Discussion

  • Narrow therapeutic range for lithium 
  • Unknown (amongst our group) what the implications of perinatal physiology changes may be
  • Acknowlegement of maternal wishes in terms of risk of destabilization of mental health due to perinatal stress

Plan

  • ECG, EUC, TFTs
  • Discuss with neuropsych pharmacist
  • Update:
    • Discussed with neuropsych pharmacist and the consultant psychiatric representative for perinatal and infant mental health from community liaison psychiatry
    • Post-deliver physiology changes mean a return to pre-pregnancy levels is recommended after birth
    • High risk period for toxicity
    • Withhold dose the day before surgery
    • Lithium levels 8-12hrs post dose (regardless of daily or BD dosing) on day 1
    • Avoid dehydration, prioritise sleep
    • CL psych review while in hospital. Remain inpatient for 5/7
    • Breastfeeding contraindicated