Review Question - QID 103738

The patient is presenting with signs and symptoms of an acute manic episode given her decreased need for sleep, hypersexuality, talkativeness, and grandiosity. Haloperidol is used as a first-line therapy in pregnant patients with this disorder.

Mania presents with DIG FAST: distractibility, indiscretion, grandiosity, flight of ideas, activity increase, sleep decreased, and talkativeness. Patients presenting with an acute manic episode under normal circumstances can be treated with either lithium, valproic acid, carbamazepine, or antipsychotics. In a pregnant patient presenting with acute mania, it is preferable to use haloperidol as a first-line agent, followed by atypical antipsychotics, since neither of these therapies is associated with any major birth defects. If refractory to these medications, electroconvulsive therapy can be trialed.

Incorrect Answers:
Answer 1: Electroconvulsive therapy has minimal systemic side effects (only amnesia in the mother) and could be trialed in a severely symptomatic patient who is pregnant with bipolar disorder. Generally, this is not a first-line therapy and would be indicated after multiple first-line agents have failed.

Answer 2: Fluoxetine is an SSRI that is contraindicated in mania or bipolar disorder as it could worsen the patient's mania. Generally, patients with mania require mood stabilizers.

Answer 4: Lithium is generally avoided in pregnancy as it can cause Ebstein anomaly. It is the first-line agent in non-pregnant patients and is mortality lowering.

Answer 5: Valproic acid is a mood stabilizer that could be used in mania; however, in pregnancy, it could cause spina bifida. Valproic acid is associated with the highest incidence of spinal abnormalities in the newborn among the anti-epileptics.

Bullet Summary:
Haloperidol and other antipsychotics are the first-line treatment for mania in pregnancy.