Olanzapine use in a manic patient during second and third trimester pregnancy
A 31-year-old woman with a history of four psychiatric hospitalizations (for a depressive episode in 2002 and three manic episodes thereafter) visited our clinic in 2010 and began a course of valproic acid 500 mg/day and olanzapine 5 mg/day. She demonstrated stable progress and was in a euthymic state while discussing pregnancy. The clinical staff planned to taper out the mood stabilizer slowly, use only quetiapine and clonazepam just prior to pregnancy, and cease all medication by June 1, 2012. After one month, her pregnancy was confirmed.\nIn September 2012, the patient experienced nausea and vomiting and was admitted to the obstetric department for conservative care. She then complained of depressed mood, avolition, and loss of appetite in weeks 9–10 of gestation. After some time, the patient developed a manic episode with elated mood, decreased need for sleep, talkativeness, hyperactivity, and distractibility, at which time she was admitted to the inpatient psychiatric department (January 2013).\nAfter hospitalization, the clinical team decided to control the patient’s symptoms by close monitoring without pharmacotherapy. However, due to her persistent irritability and violent behavior, it was decided that overall harm to the fetus from the disorder exceeded that from pharmacotherapy. Electroconvulsive therapy, which the clinical team considered as the first-line treatment, was not carried out due to her family’s refusal. Therefore, a course of olanzapine, which was shown to be effective in previous years, was reinstituted at week 25 of gestation with a dose of up to 7.5 mg/day. However, she was discharged early, even with symptom persistence, due to the family’s demands. Despite using a 7.5 mg/day dose of olanzapine, she was readmitted in March 2013 (week 33 of gestation) for persecutory delusions and delusions of infidelity in addition to manic symptoms.\nDespite amelioration of the delusions after taking olanzapine up to 20 mg/day, the patient still continued to show irritability and behavioral disturbances. Therefore, during week 35 of gestation, her medication was switched from olanzapine to quetiapine. Her sleep duration lengthened and she showed some improvements in irritability and hyperactivity afterwards with 800 mg/day of quetiapine, but still appeared to be talkative and sometimes temperamental. She was found to have oligohydramnios on follow-up sonogram, and emergency cesarean section was carried out at week 37 of gestation. The patient experienced no postsurgical complications, and the newborn’s Apgar score was 9. The baby was deemed to be healthy by the pediatrician and there were no congenital malformations.\nBeginning the day after surgery, the patient was started on valproic acid 1,000 mg/day and quetiapine 800 mg/day and showed improvement in her irritability, loss of impulse control, and distractibility. After agreeing not to breastfeed, the valproic acid was increased to 1,500 mg/day based on blood levels of 44.53 μg/mL while taking 1,000 mg/day. She tolerated the medication even after quetiapine was increased to_1,200 mg/day; she showed stable progress and was discharged on the 59th inpatient day.