Dr. Hale and other lactnetters:

I'd appreciate input on the following.

I am caring for a pregnant woman who has definite bipolar disorder.  She
was off all meds during the first trimester, but was severely depressed
and suicidal.  I felt she needed to be on meds, but she had had previous
manic episodes with poor judgement, etc, when on antidepressants alone.
After consultation with a psychiatrist, we first tried a low dose of
desipramine, but she quickly developmed dysphoric symptoms and was
concerned about becoming manic.  We reveiwed the literature, and found
support for "absolutely necessary" use of lithium after the first
trimester.  The patient is back on a minimal dose of lithium, just enough
to keep symptoms under control.  Her level is 0.3-0.4 (Therapeutic
.5-1.5).  She notices the baby seems to move less vigorously when she's
using the Lithium, so stopped it on her own for a few weeks, but quickly
felt severely depressed again.  (She's very bright, a student and
mom of a 4 year old, and has great insight into her illness).

She was off meds through her first pregnancy and breastfed her daughter
for about 3 months then weaned so she could resume her lithium.  She and
I are wondering about what she should do this time--this baby's already
had lithium exposure in utero.  How "absolute" is the contraindication to
lithium use in breastfeeding?  I think she'll be able to make a good
decision for herself with adequate information, and I want to support her
decision.  She would really like to breastfeed, but wants to do what's
best for the baby and herself.

BTW, Dr. Hale, your book has *finally* been ordered (I convinced the
residency coordinator that I don't want an *additional*  copy of Briggs....).

--
Anne Montgomery, M.D.
[log in to unmask]
St.Peter Hospital Family Practice Residency
525 Lilly Road NE
Olympia, WA  98506
360/493-4040