Chapter 21: Psychiatric Emergencies in Pregnancy

INTRODUCTION

Psychiatric disorders in women of childbearing years are common, given that the vast majority of psychiatric conditions declare themselves during this stage of life. Pregnancy, and the events surrounding this unique life experience, is filled with significant emotion and psychologic stress. Even in cases where the pregnancy is planned, these stresses affect all involved, including the pregnant mother, her husband/birth-partner, family, friends, and healthcare providers.

What constitutes a psychiatric emergency? Psychiatric presentations can occur in a variety of ways and obstetricians and obstetric staff caring for high-risk pregnant patients (and their families) are often confronted with behaviors that can quickly devolve into crisis situations. While each obstetric clinician will have their own set of personal reactions to various disruptive behaviors or personality types, the common thread for all of these providers comes from the most empiric goal of obstetric medicine—to assure the well-being of the mother and baby. Therefore, a more structured, cohesive, and organized schema for identifying and managing these patients is necessary.

Although much has been written regarding women’s mental health issues and psychiatric complications during pregnancy, it is scattered among a variety of subspecialty resources.¹ Postgraduate training programs in obstetrics offer very little in the way of formal education in this arena.²

Over the remainder of this chapter, we hope to provide clear and easy-to-follow guidelines for problem solving and triaging psychiatric emergencies that arise in pregnancy, including preexisting psychiatric conditions, those with new symptoms/behaviors, as well as those caused by other medical interventions (ie, delirium). Approaches to the patient at risk for harming themselves or others and the agitated or angry patient will be discussed. The use of psychotropic medications and specific nonpharmaceutical treatments in pregnancy will also be reviewed.

DANGER TO SELF OR OTHERS

Perhaps the most anxiety-generating crisis in gravid patients is the patient who threatens to harm herself, her baby, or those around her. A patient’s allusion to suicide is sometimes the only cue for an emergent psychiatric consultation request.³ Suicide is the 11th leading cause of death in the United States.⁴ About 5% of all female suicides occur during the childbearing years. Additionally, nearly 2% of completed suicides in this group were by pregnant women. Rates of suicide increased with first trimester miscarriage or termination (Table 21-1).

Despite previous beliefs, women are just as likely to complete a suicide attempt as their male counterparts thus indicating an increase in suicide completion ...