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Mandy Adams
Mandy Adams is a 25 year old who has a history of bipolar affective disorder, she is 38 weeks pregnant. Prior to becoming pregnant she had been taking Lithium 300mg daily which she stopped before she became pregnant, as she didnt want to harm her baby. Her psychiatrist convinced her to recommence this in the 3rd trimester as she was beginning to develop features of hypomania, the Lithium improved these symptoms. She is now admitted acutely psychotic to the AMU. She is febrile although able to give a reasonable history, although her speech is rapid and copious. Her pulse rate 75bpm regular BP 145/95 mmHg. Her husband is with her and says that until 2 days before she was her normal self. She does not smoke, has not been drinking alcohol and does not take any recreational drugs and has NKDA
Medications
Lithium (Priadel) 300mg tablets 1 OD (at night), Ferrous Sulphate 200mg tablets TDS Folic acid 400 micrograms tablets OD.
Admission Investigations
HB 11.9 g/dl Normal MCV 94 fl Normal WCC 14.5 x109/L with a neutrophil leucocytosis Raised Platelets 367 x109/L Normal Ur 12.2 mmol/L Raised Sodium 130 mmol/L Low Cr 120 umol/L Normal Potassium 3.4 mmol/L Borderline/Low CRP 39 mg/L Raised (Mild inflammation)
clearance of lithium
2. A lithium level subsequently comes back as low 0.3mmol/L (normal range 0.6 1.2 mmol/L). What are you going to do? The therapeutic range for lithium is between 0.6-1.2mM
1. Exclude infection Investigate and begin appropriate antimicrobials 2. Correct U&Es 3. Increase lithium dose The BNF recommends increasing the dose to 400mg during the second and third trimester
4. Lithium follows 1st order pharmacokinetics, taking this into consideration what dose might be appropriate for this patient.
1st Order Pharmacokinetics: Elimination of the drug is directly proportional to its plasma concentration. Its dependent on its half life. First order implies no matter how much drug is given it will be eliminated by 50% by its first half life. It can therefore take several days before the plasma concentration of lithium remains stable within the therapeutic range. Serum concentration monitoring should be available. Should be between 0.4-1 mmol/L - check it 12 hours after a dose on days 4-7 of treatment, then every week until dosage remains constant for 4 weeks. Then check every 3 months.
5. What significance does this BP measurement have in this patient? What further investigations need to be carried out now?
Normal blood pressure during pregnancy is 140/85 mm Hg. Ms Adams is 145/95 mm Hg and is mildly high There is a risk of pre-eclampsia or gestational diabetes, thus urinalysis is required to test for glucose, protein and ketones Ms Adams blood pressure and urine must be monitored frequently throughout the rest of her pregnancy
Admit to hospital
Treat
NO
At each visit
Blood tests
6. Mrs Adams wants to breast feed, what advice should you give to her regarding this?
Avoid breastfeeding whilst taking Lithium as it is present in the breast milk and their is a risk of toxicity in the infant.