What to do for a patient 11 weeks pregnant who ingested 11 Wellbutrin (bupropion) tablets?

Emergency Management of Bupropion Overdose in Pregnancy

This patient requires immediate emergency department evaluation with continuous cardiac monitoring, seizure precautions, and obstetric consultation, as bupropion overdose can cause life-threatening seizures and cardiac dysrhythmias, with the first priority being maternal stabilization to protect both mother and fetus.

Immediate Actions Required

Emergency Department Transfer

• Transport immediately to the emergency department for evaluation and monitoring, as ingestion of 11 tablets (likely 1650-3300 mg depending on formulation) significantly exceeds the therapeutic dose and poses serious risk 1, 2
• Seizures occur in approximately 30% of bupropion insufflation overdoses at median doses of 1500 mg, with median onset at 7 hours (range 2-21.5 hours) after exposure 2, 3
• Fatal outcomes have been reported with 23 g ingestions, with death occurring from recurrent seizures and hypoxia 1

Critical Monitoring Parameters

• Continuous cardiac monitoring for dysrhythmias, as bupropion overdose can cause cardiac arrest 1
• Seizure precautions with IV access and benzodiazepines readily available 1, 2
• Tachycardia is present in 95% of patients who develop seizures and serves as an important warning sign 3
• Monitor for "jittery"/anxious/agitated behavior, as 83% of patients who developed seizures or out-of-hospital adverse events exhibited these symptoms 2

Time-Sensitive Interventions

• Observation period of at least 8-12 hours is essential, as delayed seizures can occur up to 21.5 hours post-ingestion 2
• Consider activated charcoal if presenting within 1-2 hours of ingestion, though this must be weighed against aspiration risk 2
• Do NOT induce vomiting due to rapid onset seizure risk 4

Pregnancy-Specific Considerations

Maternal-Fetal Risk Assessment

• Maternal stabilization is the absolute priority, as maternal seizures and hypoxia pose the greatest threat to fetal well-being 1
• At 11 weeks gestation, the patient is in the first trimester when organogenesis is occurring 5
• Bupropion exposure in the first trimester has been associated with small absolute increases in cardiovascular malformations (left ventricular outflow tract obstruction and ventricular septal defects, adjusted OR 2.9) and possible diaphragmatic hernia risk (aOR 2.77), though absolute risks remain low 5

Obstetric Consultation

• Obtain obstetric consultation for fetal monitoring once maternal condition is stabilized 5
• Document fetal heart tones if gestational age permits
• Discuss pregnancy continuation and enhanced prenatal surveillance given first-trimester exposure 5

Clinical Management Algorithm

Dose-Related Risk Stratification

• Moderate outcome risk: The reported dose of 11 tablets likely represents 1650-3300 mg (assuming 150-300 mg tablets), which exceeds the 900 mg threshold where seizure risk increases 2
• Patients with moderate outcomes (seizures) had mean doses of 1250 mg compared to 694 mg in those with no effect/minor outcomes 2

Symptom Monitoring Sequence

1. Tachycardia/palpitations - Present in 95% of patients who seize 3
2. Agitation/jitteriness/anxiety - Key harbinger of severe effects 2
3. Seizures - Typically self-limited but can be recurrent 1, 3
4. Cardiac dysrhythmias - Rare but potentially fatal 1

Treatment Interventions

• Benzodiazepines are the primary treatment for seizures if they occur 2
• Supportive care with IV fluids and electrolyte monitoring 1
• Avoid medications that lower seizure threshold 4

Critical Pitfalls to Avoid

• Do not discharge early: Delayed seizures can occur beyond 8 hours, and one case reported seizure at 21.5 hours post-ingestion 2
• Do not assume absence of early symptoms means safety: Patients can deteriorate rapidly 1
• Do not crush or manipulate extended-release formulations if attempting gastric decontamination, as this accelerates drug release 4
• Do not focus solely on fetal concerns: Maternal stabilization must take precedence, as maternal death or severe morbidity guarantees fetal loss 1

Post-Acute Management

If Patient Survives Acute Phase

• Enhanced prenatal monitoring including fetal growth surveillance, blood pressure checks, and appropriate weight gain assessment 5
• Detailed fetal anatomy ultrasound at 18-20 weeks to evaluate for cardiac defects and diaphragmatic hernia 5
• Psychiatric evaluation once medically stable to address underlying issues leading to overdose 4

Counseling Points

• Risk-benefit discussion regarding pregnancy continuation, acknowledging that while there is a small increased risk of specific malformations, the absolute risk remains relatively low 5, 6
• Confounding by indication cannot be ruled out in outcome studies 5, 6

The immediate priority is emergency department evaluation with continuous monitoring for at least 8-12 hours, seizure precautions, and maternal stabilization, followed by obstetric consultation for pregnancy-specific management once the acute overdose is addressed 1, 2, 3.