Review Question - QID 100625

This infant is suffering from Ebstein's abnomaly, often linked to the use of lithium during pregnancy. Lithium is commonly used for the treatment of bipolar disorder.

Ebstein's anomaly is one of the major cyanotic heart lesions and is characterized by apical displacement of the tricuspid valve leaflets, decreased right ventricular volume, and atrialization of the right ventricle. The resultant tricuspid regurgitation results in the enlarged v wave. Echocardiography shows a delayed closure of the displaced tricuspid valve (tricuspid regurgitation).

Ward and Zamorski discuss the risks and benefits of psychiatric medicines during pregnancy. While patients who have experiences 2 or more episodes of mania are recommended to continue lifetime mood stablizer therapy, lithium, valproic acid, and carbamazepine are all known teratogens. First trimester lithium exposure is associated with a tenfold increase in Ebstein's anomaly.

Lleewelllyn et al. review the use of lithium during lactation. Lithium is excreted in human breast milk and will result in elevated serum levels in nursing infants. This can result in electrocardiogram abnormalities and hypotonia. Breastfeeding is therefore recommended against in women taking lithium.

Incorrect Answers:
Answer 1: The most common therapy for depression is a serotonin-reuptake inhibitor. These medications are not associated with Ebstein's anomaly or other congenital malformations.
Answer 2: Mothers with hyperthyroidism must continue their thyroid supplementation during pregnancy. This is not associated with Ebstein's anomaly or other congenital malformations when taken appropriately.
Answer 3: Mothers who are insulin-dependent diabetics must continue therapy during pregnancy. Insulin requirements can fluctuate during pregnancy, so careful monitoring is required. Insulin therapy is not associated with Ebstein's anomaly.
Answer 5: Antihypertensives associated with developmental defects include angiotensin-converting enzyme inhibitors (ACE inhibitors). These medications can cause major congenital malformations, stillbirths, and neonatal deaths. Reported fetal abnormalities include renal dysplasia, oligohydramnios, intrauterine growth retardation, pulmonary hypoplasia, patent ductus arteriosus, and incomplete ossification of the skull.