Chapter 5 114 can be considered a strength rather than a limitation because neonates born after an uncomplicated pregnancy would also not be monitored. It can therefore be argued that potentially missed anomalies were clinically insignificant and would have skewed the results towards an overestimation of adverse outcomes in lithium-exposed neonates compared to the reference group. Interpretation Similar admission rates between lithium and non-lithium exposed neonates seem to contradict previously described increased admissions to a neonatal ward with monitoring after lithium exposure due to floppy infant syndrome, cardiac arrhythmia, thyroid disorder, congenital malformations and Ebstein anomaly7. However, our relatively high overall admission rate to a neonatal ward with monitoring of 19% may be related to the BD status of the mother more than to lithium exposure to the neonate. This is argued by comparable admission rates between lithium-exposed neonates and neonates born to mothers with BD in previous study samples5. Our findings showed lower absolute rates of (re)admission to a neonatal ward with monitoring in both groups compared to the previously described 27.5% in lithium-exposed neonates in the study of Munk-Olsen et al. (2018). As the reason for (re)admission is not described in the study of Munk-Olsen, we are unable to interpret this difference in (re)admission rate within the first 28 days of life. In our study, neonates with severe adverse outcomes were identified immediately postpartum in the delivery rooms or the maternity ward and not through preventative admission to a neonatal ward with monitoring. More importantly, none of the lithium-exposed neonates who were not initially admitted to a neonatal ward with monitoring, suffered any adverse outcomes within the first 28 days postpartum. For these neonates, rooming-in with the mother on a maternity ward without monitoring was safe and, according to earlier research, beneficial for parental mental health and parent-infant bonding14,15,19,20. As for the possible lithium-related admission to the neonatal ward with monitoring, an atrial flutter was observed in a lithium-exposed neonate at 37 + 3 weeks’ gestation. A previous case was described in 198321, with toxic lithium levels of 1.5 mmol/l, compared to 0.42 mmol/l in our case. Nowadays lithium levels are routinely checked in the last weeks before delivery, thus toxic lithium levels are rare. Whether this atrial flutter was a result of lithium toxicity or a congenital condition, is unclear. With no significant risk of neonatal complications in lithium-exposed newborns, our study, except for their finding of lower Apgar scores, is in accordance with a recent cohort study8. Obstetric vulnerability in our sample of women with BD was marked by higher levels of caesarean section22, gestational diabetes23, and hypertensive disorders24. This is in line with findings of various studies, who previously described high risk obstetric profiles of women with BD11,25. Maternal obesity, high prenatal stress levels, smoking
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