Neonatal admission after lithium use in pregnant women with bipolar disorders 105 Background Lithium is the preferred treatment for pregnant women with bipolar disorders (BD), as it is most effective in preventing postpartum relapse1,2. Although it has been prescribed during pregnancy for decades, the safety for neonates and obstetric outcomes are a topic of ongoing scientific debate3. Previous research has yielded contradicting outcomes. Various cohort studies and systematic reviews (with meta-analyses) have found no increased risk in obstetric outcomes such as hypertensive disorders of pregnancy and gestational diabetes in women with BD with versus without lithium use4-8. Yet, some studies have suggested a small increased risk of spontaneous abortion, preterm birth, and increased birthweight after maternal lithium use3,9. Others described an association of BD with adverse obstetric and pregnancy outcomes such as increased risk of caesarean section, small- or large for gestational age neonates and preeclampsia10,11. Moreover, previous research has reported an association between lithium and congenital malformations3,7,12, lower Apgar scores8,13 neonatal readmission within 28 days postpartum5. Although reasons for admission of lithiumexposed neonates were not available, the authors suggested that admissions were the result of increased vigilance towards neonates exposed to lithium, neonatal withdrawal syndrome and vulnerability of neonates due to impaired maternal mental health. Most guidelines and hospitals preventatively admit neonates to monitor their condition postpartum10,11. However, admission to a neonatal ward with monitoring may also have adverse consequences. It can lead to increased feelings of parental stress, and a negative effect on early mother-infant attachment, which is especially important for patients who are already vulnerable for mental health disorders14,15. Preferably, admission to a neonatal ward with monitoring for lithium- exposed neonates should be evidence-based. As also mental health disorders may impact obstetric outcomes it is important to differentiate lithium-related adverse outcomes from adverse outcomes related to the mental disorder. The aim of the current study is to validate previous findings on neonatal outcomes after lithium exposure by comparing (re)admission rates in neonates born to women with BD with versus without lithium exposure. Moreover, we aim to elucidate the reasons for admissions in neonates born to women with BD. Methods Participants and eligibility criteria Methods were reported according to the STROBE checklist (https:// www. equat or- netwo rk. org/ repor ting- guidelines/ strobe/) for reporting observational cohort
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