Chapter 21: Psychiatric Emergencies in Pregnancy

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.

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 rates in women.

Assessing for suicidality, or risk of harm to others (including the fetus), is of utmost importance and must be carried out in a prompt, yet professional and sensitive manner. While there are numerous suicide risk screening tools available, by far the most valuable tool one can employ involves respectful and open dialogue with the patient (and her immediate supports). A common misconception about suicide screening is that one may actually increase the risk of the patient attempting suicide (or implanting the suicidal notion into a patient’s mind) simply by inquiring about these thoughts. There is evidence to support exactly the opposite; empathic questioning of a patient about her possible thoughts of self-harm may actually alleviate some of the related emotional distress and may even serve to reduce the risk for a suicide attempt. An honest, open, and gentle probing of a patient’s thoughts and feelings about harming herself (or others) will often yield a wealth in useful information (Table 21-2).

Some women may actually experience the simple expression of their thoughts of suicide as the necessary tool to relieve their emotional tension, while others may use this as an arena to generate a heightened level of emotional support from their family or other supports. Not all women who express thoughts of suicide will go on to attempt or commit suicide; but given the potential cost is so great, each and every eruption of suicidal thinking deserves appropriate consideration.

Arrange for a safe environment! There are no limitations to when and where we may encounter a suicidal patient, but there is no reason to limit on the most basic of interventions—assure her safety. Examples of techniques that can be used to assure safety are listed in Table 21-3.

The expression of anger often follows a recognized pattern. Just as dealing with a suicidal patient can elicit strong emotional reactions within the healthcare provider, so too can the interactions with an angry, confrontational, enraged, aggressive, assaultive, or caustic patient (or family member). Being aware of this pattern can guide the healthcare provider to diffuse a potentially explosive situation. The genesis of anger must begin with a stressor. While it may not always be possible to specifically identify the particular stressor, fear is one of the painful core feelings often expressed as anger. Continuing with the explosion analogy, there is often a triggering event (such as a comment, action/inaction, or event) that will release a cascade of emotions that can become expressed as anger. Anger is a ubiquitous human emotion. Yet, the source of the anger is often difficult to clarify, as we can tend to focus more on the behavior demonstrated during the acting out phase of the anger process (Table 21-4).

When faced with an escalating situation, the initial response should be to remain calm (both emotionally and physically) and maintain good eye contact (remembering that in some cultures direct eye contact may be viewed as aggression). The patient is attempting to communicate something to you (which may not be clear to anyone, including the patient, at this point). Your job at this point, which is to gather as much data as possible, will prove fruitful toward the goal of an uneventful resolution. Some helpful steps toward understanding the patient’s needs are outlined in Table 21-5.

The following examples of techniques that can be used in these situations, as a process of deescalating a crisis situation, can be found in many counseling resources such as Behavioral Medicine: A Guide for Clinical Practice by Feldman (2007).⁶

Modeling

• Slow, steady breathing

  • Monitor the pace and tone of your voice.

• Open body language

  • Monitor your body language to avoid closed, aggressive postures. Sitting directly in front of someone can appear confrontational. Consider sitting at a 45-degree angle, or if safe, facing the same direction.

Rapport building

• Listen with attention and intention. Make empathic statements.

• “I can appreciate how you feel.”

• “It concerns me that you feel so strongly about this.” “Tell me how I can make it easier for you.”

Confrontation (difficult to do until rapport has been established)

• “You seem very angry?”

• “It’s unlike you to be like this.”

• “I get the feeling that you are upset with...”

• “What is it that’s upsetting you?”

• “What really makes you feel this way?”

Reflection, facilitation, clarification

• Do not parrot patient statements or phrases, but try to accurately reflect or rephrase what you think the patient is trying to communicate.

• “I find it puzzling that you are angry with me.” “So you feel that. . .”

• “You seem to be telling me. .” “If I understand you correctly. .” “Tell me more about this.”

• “I would like you to enlarge on this point. .it seems important.”

Searching

• “Do you have any special concerns about you or your baby’s health?”

• “Tell me more.”

• “How are things at home, work?”

• “How are you sleeping, eating?”

• “Do you have any special dreams?”

• “Can you identify anyone who has a problem like you have?”

• A past history of violence is the greatest predictor of future violence.

• Watch for premonitory signs (fist clenching, use of profanity, violence to inanimate objects, actual verbal threats).

• Verbally engage the patient’s threat

• Assess for access to a weapon.

• Actively respond to escalating threat behavior.

• Do not hesitate to call for security support.

• Always position yourself with an easy exit.

• If escape is not possible prepare for self-defense.

It is impossible to predict with 100% certainty when a patient will become violent. Patients with perceived injury, either physical or psychological are at increased risk for committing violence against clinicians, especially if their complaints are dismissed. A patient who remains upset, yet is responsive to your efforts, will be managed differently than a patient who continues to display escalating hostile behavior.

When the anger begins to control physical behavior (ie, agitation), a process for evaluating other potential sources is necessary to make sure that an underlying cause (intoxication, delirium, psychosis, mania, etc) is not overlooked. In cases where the patient refuses to respond, or cannot respond, further investigation is necessary. Table 21-6 describes some potential causes of agitation, while a guideline for the evaluation for causes of altered mental status is shown in Table 21-7.

Part of the goal of controlling an erupting situation is to assure the safety to the patient as well as to the staff and others in the immediate area. Given that such scenarios are often highly emotionally charged (on both sides of the bed) utilizing basic crisis management techniques must occur so as to have the greatest likelihood of a smooth resolution. Table 21-8 describes the conceptualization of managing such situations. Table 21-9 lists medications often used for treatment of the agitated patient. Rarely physical restraint becomes necessary. Guidelines for use of restraints in pregnancy are outlined in Table 21-10.

Anxiety disorders are among the most prevalent of psychiatric conditions in the general population.¹ Incidence rates have been reported as high as 18% to 28%. While there are no specific reports documenting these rates in the pregnant woman, it is suspected to at least match those of the general population.

The anxiety disorders consist of a wide range of conditions listed in Table 21-11.

The pregnant patient may present with anxiety symptoms that predate the pregnancy or are specific to her current status. This can be related to realistic, or unrealistic, fears about the pregnancy. The health of the baby is a common fear, especially when additional worry is created by definite or suspected findings on ultrasound done during the pregnancy. There is the fear of the pain of a vaginal delivery or fear of failing to accomplish a vaginal delivery resulting in a cesarean delivery. Fears related to body image issues from the effects of the pregnancy or the resulting scar from cesarean delivery can also drive up anxieties. Having a new baby at home brings on fears of adequacy as a mother and/or wife. Other psychosocial issues such as financial strain and family tensions among other children, partners, and in-laws are examples of other anxiogenic sources.

Psychiatric emergencies associated with anxiety disorders can and do exist. Emergent situations related to anxiety can present as debilitating panic attacks, although it has also been reported that symptoms of panic disorder actually improve in the pregnant woman. Emergent situations also present as noncompliance in medical care, overuse of medical care, or the use of substances (self-medicating, illicit, misuse of prescribed medications).

Also of note is that anxiety disorder symptoms can worsen simply because the pregnant woman has opted to self-discontinue medication(s) that had been previously prescribed to treat such a condition (or the treating physician has advised their discontinuation).

Anxiety may present as an internal sense of nervousness, hostility, psychomotor agitation (fidgetiness, increase in purposeless movements), somatic complaints (chest pain, shortness of breath, diaphoresis, paresthesias, nausea, and other somatic preoccupations), or overt panic attacks. A calm and gentle first approach will often allow for the establishment of a good connection with the patient (and her supports). Careful initial evaluation (a review of systems, vitals, physical examination, and evaluation of the fetal status) can help properly rule out medical causes (eg, hypoxia). A calm review of the reassuring elements of the preceding physical examination and fetal assessment along with the initiation of a basic behavioral psychotherapy technique (deep breathing exercises or serial muscle contraction/relaxation exercises) will often result in resolution of the acute anxiety symptoms.

Pharmacologic strategies should be reserved for the most acute cases when all other interventions have failed. Benzodiazepines have been shown to be effective in the short-term treatment of anxiety disorders. Given the potential effects on the neonate, caution must be used when prescribing these medications in pregnancy.

The proper selection of an anxiolytic agent will be based on the stage of pregnancy, current acuity level, and previous patient experience with the various pharmacologic options. Consultation with the pediatrician, or neonatologist, should be considered if this crisis evolves during labor.

The labor process can be very exciting yet equally distressing. If a patient’s anxiety escalates such that she can no longer be an active participant in the delivery, maintenance of a clear line of communication is essential. The patient must be aware of the situation and able to cooperate and, if needed, be able to provide competent consent in case an emergent surgical situation arises. The delivery room can quickly become filled with chaos, which can lead to a further disintegration of the patient’s ability to participate. Preexisting anxiety disorders such as posttraumatic stress disorder (PTSD) may be reactivated by the events surrounding the pregnancy.

A woman who has experienced a sexual assault may, in essence, reexperience these traumas even through relatively straightforward but nonetheless intrusive medical intervention such as a vaginal examination. PTSD symptoms have been described in women who have experienced prior pregnancy losses or other pregnancy-related traumas. PTSD also can result from unexpected emergencies occurring at the time of delivery or in the immediate postpartum period. Examples include cesarean delivery for life-threatening fetal conditions, such as cord prolapse, maternal hemorrhage, or a cesarean delivery done with inadequate anesthesia.

If possible, attempt to establish an advocate in whom the patient can harbor trust in order to maintain a necessary open line of effective communication with the healthcare team. Occasionally events can happen so quickly that the patient may lose her ability to perform properly in the delivery, in these cases using focus and direction, interaction may actually allow for one to take advantage of the heightened state of awareness that can arise in such anxiety-producing situations.

Some anxious patients will benefit by discussions that prepare them for potential complications. By knowing that there is an established plan of action to handle these unforeseeable events the patient may actually be more able to tolerate the growing anxiety and stay focused enough to allow for a good cooperation between patient and obstetrician. A debriefing session following these events will allow for the now postpartum patient to express her concerns, have questions addressed, and may even serve as a protective mechanism against acute posttraumatic stress reactions.

In summary, a close and trusting relationship with the obstetrician will prove useful to the patient, her family, and the treatment team. Preemptive strategies such as preparatory discussions about the patient’s fears, establishing how communications will be handled in the event of an unintended outcome, and even allowing for cultural and religious input (such as a prayer before the start of the procedure) can have a calming influence on not only the patient but her family and healthcare providers.

Unipolar and bipolar spectrum mood disorders typically emerge in the late teens to early twenties, which coincide with peak fertility years. There has been much work exploring the link between hormones and mood disorders with a strong focus on attempting to understand the postpartum mood state. Estimates on the incidence of postpartum mood disorders, ranging from mild and self-limited depressions (sometimes called “the baby blues") to severe depressions or manias or psychoses range from 10% to 80%. The prevalence of mood disorders during pregnancy is less clear given these conditions are still poorly recognized in the community and the psychosocial stigma associated with psychiatric conditions in general tends to keep reporting low. The incidence of depression in the general population ranges from 2% to 10% and estimates of perinatal depression have been as high as 20% to 25% in a high-risk pregnancy population.

The obstetrician or perinatologist must assess for depression as part of the regular evaluation process. Depression is often a condition intensified by psychosocial or emotional distress, thus it is not difficult to imagine that women with high-risk pregnancies will be at higher risk for developing this condition. Screening can start with as simple a question as “How has your mood been lately?” For a more formal process, the Edinburgh Postpartum Depression Scale (EPDS) is a commonly used tool,⁸ although a number of screening tools are available (and can easily be implemented into an office or hospital-based perinatal practice).

The impact of depression is far reaching. Depression can result in muted emotional responses, diminished self-care, apathy, impaired compliance, substance misuse, and suicidality. Social, cultural, and even financial issues impact how depression is identified and addressed. Depression can, for many women, imply a sense of inadequacy or incompetence as a future mother; shame readily accompanies depression and only serves to more firmly anchor this disease and make for even more resistance and difficulty in seeking out appropriate treatment.

By far, the most important tool available to the clinician is awareness. Table 21-12 describes common risk factors for perinatal depression.

Depression can present in a variety of ways. Being able to engage with the patient to gather data and offer support enhances the therapeutic relationship. This should include establishing a connection with the birth-partner and other family members/supports. These contacts can provide a wealth of information as well as allow for the further strengthening of support and comfort to the high-risk OB patient.

The presence of mania does not always signal the presence of bipolar disorder (BD). Substance-induced mania is not uncommon and is typically associated with the misuse of illicit substances such as cocaine or methamphetamine. It has also been reported in cases of overuse of prescribed stimulants such as methylphenidate and dextroamphetamine. In the absence of such illicit drug use, manic eruption is then diagnostic for BD.

Mania refers to an escalated mood state and is characterized by an elated, expansive, or irritable mood, a diminished need for sleep, heightened impulsivity and recklessness, feelings of grandiosity, racing thoughts and rapid, hyperverbal, or pressured speech. Manic episodes can emerge spontaneously or in the face of heightened emotional distress. Psychotic symptoms can co-occur with mania (as well as with depression) and can lead to serious complications including violence and other dangerous behavior. Common management strategies when faced with a manic pregnant patient include assurance of safety and well-being to the mother and fetus and prompt initiation of psychiatric care. Gather collaborative data paying attention to the current medication regimen (if known) as well as previous history of violence or other unsafe acting out behaviors.

While a common response to the occurrence of a pregnancy in women on antidepressant medication is to immediately discontinue the medication, this has been associated with poorer outcomes including exacerbations of the mood disorder. In a paper by Einarson (2001), over 70% of women abruptly discontinued use of antidepressants either because of fear of teratogenicity or on the advice of their physician.⁹ Nearly 30% of these women experienced a worsening of their mood disorder resulting in suicidal ideation with 10% requiring psychiatric hospitalization. The consideration to use medications to treat a mood disorder, especially during pregnancy, is a complex one that has implications to maternal and fetal well-being. Initiation of any psychotropic agent should never be done in unilaterally and proper informed consent must occur. This discussion includes an explanation of known potential side effects, the FDA pregnancy category rating, any known teratogenic issues (such as the incidence of facial clefts) as well as any special precautions related to pregnancy (monitoring of lithium levels especially around the time of parturition).

Antidepressant medications are commonly used to treat unipolar depression. The selective serotonin reuptake inhibitors (SSRIs) are typically well tolerated and have high efficacy rates, thus having become the preferred first-line agent for many clinicians working with patients with depression. There are numerous anecdotal reports of medications of this class being used to treat depression during pregnancy. Recent reports suggest that the SSRI paroxetine may be associated with higher rates of ventricular septal defects in infants with first trimester in utero exposure while other reports fail to find a similar association.^10,11 The decision to treat a pregnant woman with any psychotropic agent must take into account the potential adverse effects of in utero exposure weighed against the potential for psychiatric suffering (and its associated ill effects including the heightened potential for suicide and neonaticide). Thorough and repeated discussions with the pregnant patient and her pregnancy partner (including family if indicated), which includes accurate documentation of these meetings should be a standard part of any such intervention. Consultation with a psychiatrist familiar with and skilled at working with the gravid patient is preferred, but often such clinicians are not available in the community or the patient (or family) declines such encounters.

Side effects of the antidepressants can include nausea/gastrointestinal (GI) distress, headache, dizziness, tremulousness, diminished appetite, insomnia or hypersomnia, and sexual dysfunction. The serotonin syndrome is a rare clinical entity that can be seen with the use of serotonergic antidepressants. It can occur in patients who, unbeknownst to the clinician, are concomitantly on other serotonergic agents (ie, St. John’s wort or even meperidine). The clinical presentation can range from very mild to quite severe and typically includes fever, skin flushing, agitation/restlessness or alterations in mental status, diaphoresis, GI cramping with diarrhea, hyperreflexia, rigors, autonomic instability, seizures, and gait disturbances. Supportive care is the treatment of choice.

Electroconvulsive therapy is a viable alternative particularly in cases that involve significant melancholia with poor self-care or refusal to eat or drink. It may also prove useful with patients who are actively suicidal or psychotic. Special considerations for the administration of this modality are described in Table 21-13. Anderson (2009) reported on a review of 339 cases of electroconvulsive therapy (ECT) in pregnancy.^12,13 In the 339 cases reviewed, there were 25 adverse fetal events and 20 adverse maternal events. Of the 25 fetal events, 11 (3.2%) were thought to be related to ECT. The most common was transient fetal bradycardia or deceleration, which occurred in 8 (2.7%) of cases. The other fetal events included one fetal death following an episode of status epilepticus, one first trimester miscarriage 24 hours after ECT, and one case of multiple brain infarcts after multiple ECT courses. Of the maternal adverse events, 18 (5.3%) were thought to be related to ECT. Uterine contraction or preterm contraction was the most common event and occurred in 12 (3.5%) of cases. Other complications thought to be related to ECT included status epilepticus, hematuria, miscarriage, vaginal bleeding, abdominal pain, and placental abruption. Where efficacy data were available, the results were similar to ECT in the nonpregnant patient with at least partial response reported in 84% of those treated for depression and in 61% of those treated for schizophrenia. Additionally, the response to ECT occurred more rapidly compared to antidepressant medication.

The anticonvulsant mood stabilizer medications (valproic acid, carbamazepine, oxcarbazepine, lamotrigine, etc) are commonly used by psychiatrists to treat bipolar spectrum mood disorders.^14,15 While generally very effective, their use in pregnancy has now been studied very closely (in both epileptic and bipolar patients where it is felt, by the physician, patient, and her supports, necessary for use of one of these medications during pregnancy) to watch for teratogenic effects. Valproic acid and carbamazepine, for example, have been associated with facial cleft anomalies and neural tube defects and other features (Table 21-14). The risk of neural tube defects is even higher when valproate is used in combination with other anticonvulsant agents. Additional folic acid supplementation to women taking such medications given the known link between these medications in folic acid metabolic pathways has been recommended. However, the specific folic acid dose is still undetermined with recommendations from various experts ranging from 1 to 4 mg daily. Vitamin K supplementation of 20 mg daily (at 36 weeks’ gestation) has also been suggested by some clinicians for patients on carbamazepine. To date, lamotrigine has been shown to have the lowest incidence of anomalies to babies exposed in utero. When it is decided to embark on the use of an antiepileptic drug to treat a bipolar spectrum mood disorder, striving for the lowest effective dose with a single agent is still the preferred approach. The North American Pregnancy AED Registry has compiled this data in an attempt to monitor the safety of these medications in pregnancy.

Lithium use has historically been avoided during pregnancy due to its link with Ebstein anomaly. Lithium, a well-respected mood stabilizer, has been shown to provide mood stabilization, alleviation of depressive symptomatology, and reduction of suicidality. Although not typically used in the acute or emergent situation, lithium is the only agent shown to reduce suicidality in bipolar patients and should receive appropriate consideration for its use.¹⁶ Further observation has shown that this fear may be overstated especially if the exposure occurs after the first trimester. The risk ranges from 1:1000 to 1:20,000. Lithium, however, is not completely innocuous. Given the everchanging fluid balance states of the pregnant woman, serum lithium levels can fluctuate rapidly, especially around the time of delivery. Other factors associated with lithium toxicity are listed in Table 21-15.

Lithium can also be associated with neonatal complications (Table 21-16). The maternal and neonatal complications of lithium therapy can be reduced by avoiding those factors associated with lithium toxicity, monitoring serum levels during the pregnancy (ideally a 12-hour trough level), discontinuing the medication at delivery (or 48 hours in advance of a scheduled delivery), and reinstitution of the medication at a lower dose after delivery. Table 21-17 outlines a basic guideline for management of the pregnant patient taking lithium.

Psychosis is a mental disturbance in which there is a loss of contact with reality evidenced by hallucinations, delusions, or thought disorganization.¹⁷ Psychotic disorders range from primary thought disorders (such as schizophrenia or schizoaffective disorder) to secondary disorders (due to a mood disorder or substance induced). Table 21-18 describes the salient features of psychosis. Although denial of pregnancy is not unique to the psychotic patient, it is a fascinating phenomenon that can occur in the patient with psychosis and can have serious implications to the mother, fetus, and family. Denial of pregnancy is associated with unexpected delivery of a viable fetus in 1:2455 pregnancies; denial of pregnancy until formally diagnosed at 20 weeks in 1:475; and unexpected delivery at home in 1:9821. Complications seen can include insufficient prenatal care, alcohol or substance exposure, prematurity, longer NICU stays, breech presentations, deliveries outside of a typical medical setting, and, in extreme cases, neonaticide with either unintentional drowning of the neonate who is delivered into a toilet or a panic-stricken mother dissociates and kills the neonate out of distress. Risk of intrauterine growth restriction is increased 2-fold while the risk of stillbirth is quadrupled. Issues associated with denial include personally, socially, or culturally driven pressures, which make the pregnancy unacceptable. These types of nonpsychotic denials of pregnancy are more commonly seen in unmarried, teenaged, or emotionally immature mothers. Other issues seen in pregnancies where the mother is psychotic include a higher risk for maternal smoking, unplanned pregnancies, pregnancy termination, sexually transmitted diseases, and difficulty parenting and maintaining custody of the newborn.

New-onset psychosis in pregnancy is uncommon and should initiate a thorough workup for organic causes before concluding that it is a primary psychiatric condition. This workup would be akin to that performed when evaluating other alterations in mental status. This would also include engagement with the psychiatric team. This may include transfer to an inpatient psychiatric unit.

The treatment for psychosis will involve the use of antipsychotic medications. As noted previously, no medications in this class are specifically approved for use during pregnancy. Haloperidol remains the antipsychotic with the most extensive reproductive safety data, therefore it is typically used to manage new-onset psychosis during pregnancy.¹⁸ Benzodiazepines can be useful in the treatment of psychotic agitation; however, these agents provide no antipsychotic benefit and can, in some cases, worsen the psychosis through disinhibition and further disorganization of thought. In patients with existing psychosis, already on another neuroleptic that has shown efficacy, continuation of that agent would likely be preferred. As with treating mood disorders, the potential costs and benefits should be explored and properly documented.

Antipsychotic side effects can include the extrapyramidal syndrome (pseudoparkinsonism), akathisia, dystonias, tardive dyskinesia (TD), and, in more extreme cases, the neuroleptic malignant syndrome. These symptoms can be very distressing to patients. Pseudoparkinsonism may present as bradykinesia, rigidity, tremor, and masked fascies. This is typically managed by lowering the dose of the offending agent and/or institution of the anticholinergic agent benztropine 1 mg po bid or trihexyphenidyl 5 mg po tid.

Akathisia is the subjective sense of restlessness which can mimic worsening agitation. It is not difficult for the less-enlightened clinician to mistake akathisia for agitation and attempt to treat this with more of the causative agent. While anticholinergics may offer some benefit, along with cessation of the neuroleptic, β-blockers (such as low-dose propranolol 10 mg tid) are the preferred intervention.

Dystonic reactions can be severe, painful, disfiguring, and frightening to the patient, family, and staff. Laryngospasm can be life threatening while an occulogyric crisis can end in blindness due to retinal ischemia caused by kinking of the retinal artery that runs through the optic nerve when the eye is dramatically deviated beyond its typical range of motion. Dislocations and even fractures have been reported. Diphenhydramine 50 mg or lorazepam 2 mg intramuscularly is the treatment of choice and usually results in a satisfactory relief of the spasm. OnabotulinumtoxinA has also been used to treat dystonic reactions of the sternocleidomastoid muscle.

Tardive dyskinesia (TD) is a permanent movement disorder that is associated with longer-term use of antipsychotic medications. It is more commonly seen in the muscles of the mouth and face but any skeletal muscle group can be afflicted. Abrupt cessation of the neuroleptic can actually result in an unmasking of the TD while an increase in the dose may conceal the movement disorder temporarily. There does appear to be a lower incidence of TD with the newer atypical antipsychotics, but even so the risk is not zero. An effective treatment for this horrible disorder remains elusive.

The neuroleptic malignant syndrome (NMS) is a potentially lethal condition that is, functionally, a systemic dystonic reaction. The incidence of NMS has been reported to be as high as 0.5% to 1% of all patients on neuroleptics with a reported mortality rate approaching 5%. It is more commonly seen with the older conventional high-potency agents such as haloperidol or fluphenazine. The onset is usually shortly after the onset of neuroleptization and may be more frequent in the neuroleptic-naïve patient. The classic presentation consists of alterations in mental status, muscle rigidity (stove-pipe rigidity), and hyperpyrexia. Autonomic instability and derangements in laboratory studies such as leukocytosis, elevations in CPK levels, and even thrombocytopenia can be seen. In pregnancy, this can be confused with thrombotic thrombocytopenic purpura (TTP) or maternal infection/sepsis.

A history of neuroleptic use should create high level of clinical suspicion in patients presenting with these symptom clusters. Intervention will include supportive care (hydration, electrolyte stabilization, cooling, airway protection, etc) and immediate cessation of any neuroleptics. In theory, dantrolene and bromocriptine can reverse these clinical syndromes; however, there is little evidence to support this. These patients are critically ill and should be treated as such. This will include prompt transfer to an intensive care environment as well as fetal monitoring as indicated based on gestational age. Lorazepam has been shown to offer some relief of the rigidity.

Abuse of drugs in pregnancy continues to be a significant problem. The problem involves inappropriate use of over-the-counter medications, abuse and diversion of prescribed medication, and abuse of both legal (alcohol and tobacco) and illegal substances (illicits). Overall exposure of illegal substances is 11% with higher and lower incidences varying as much as 4.3% to 30% in different areas across the nation.^19,20 Maternal psychosocial effects include poverty, lack of prenatal care, unwanted pregnancy, sexually transmitted diseases, poor nutrition, physical abuse, stress, depression, and lack of social support. The treatment of chronic substance abuse is beyond the scope of this chapter. Many of these agents, however, have acute effects resulting in symptoms of agitation, delirium, and psychosis, which will be the focus of this section.

As outlined in the algorithm for altered mental status (Fig. 21-1), the initial workup includes a detail substance exposure history including both prescribed, over-the-counter, and illicit substances. Often the patient is unable to provide a coherent story, so information from others accompanying the patient may be necessary. Details of the amount of drug used needs to be specified clearly. The consequences, medically, to a patient who states that she only drinks a glass of vodka daily is entirely different if the glass is only a small tumbler mostly filled with ice compared to a full 16-oz glass. Also, multiple agents may be used which further complicates the workup and treatment.

After a detailed history, evaluation with laboratory studies to confirm both the type of exposure and to assess the pathophysiologic effects is necessary. Urine drug screen, serum drug levels, and targeted functional tests of the potential organs affected should be done.

Drugs with significant behavioral effects include alcohol, phencyclidine (PCP), opioids, cocaine, and methamphetamine. Methamphetamine, particularly, has been associated with paranoid psychosis, delusions, hallucinations, and suicidal ideation.

Newer synthetic drugs of abuse are gaining popularity with certain individuals, in part, to their being more easily accessible, being perceived as both “legal and harmless.” Synthetic marijuana (sometimes referred to as “spice”) and “bath salts” (synthetic amphetamines) can produce euphoria as well as full-blown psychosis and agitation. These substances may not be detectable on readily available toxicology screens, and in the absence of reliable witnesses, or admission of use by the patient, use of these substances must also be considered in the patient presenting with acute onset of agitation or psychosis.

With the exception of fetal alcohol syndrome, none of the illicit agents have been associated with a consistent pattern of anomalies. The vasoconstrictive agents, cocaine and methamphetamine have been associated with anomalies presumed to be the result of loss of circulation to the developing organ that subsequently develops abnormally. But, no consistent pattern of anomalies has emerged. Careful ultrasound of the potential organs affected should be done.

While laboratory studies are processed, assessing and treating the patient’s behavior should be done as described in the section on the agitated patient. Drugs with significant behavioral effects include alcohol, phencyclidine, and methamphetamine are the only agents to consistently be associated with reducing fetal growth and premature labor and delivery. Cocaine and methamphetamine may also increase the risk of placental abruption.

Long-term effects of prenatal exposure to illicit substances have not shown the profound developmental effects once feared. However, subtle developmental effects have been demonstrated and there is still much to be learned about the impact on societal resources for large populations. These risks, however, do not compare currently with the known developmental risks of alcohol and tobacco exposure. Both of these are common agents associated with multiple substance exposure.

Heavy alcohol use results in fetal alcohol syndrome which is characterized by pre- and postnatal growth restriction, cranial dysmorphology, and cognitive deficits. Prenatal smoking is also related to intrauterine growth restriction (IUGR) and behavioral problems during childhood.

Fetal assessment during pregnancy, when careful substance use history indicates exposure, includes

• Cessation of substance use, education, and counseling

• Careful pregnancy dating

• Detailed anatomic evaluation by ultrasound at 18 to 20 weeks gestation

• Serial ultrasound assessment of fetal growth

• Antepartum fetal assessment if IUGR is demonstrated

• Prompt response to indicators of acute changes in the pregnancy such as placental abruption

Neonatal evaluation includes

• Careful physical examination for features associated with substance exposure, for example, fetal alcohol syndrome

• Structured observation for evidence of withdrawal with treatment as needed

• Careful assessment of the neonatal home environment with appropriate family education

• Scheduled developmental follow-up

The postpartum period has been shown to be a time of heightened risk for mood and psychotic disorder eruption. Around 400 BC, Hippocrates described the relationship between mental illness and the postpartum period. Diagnosis and treatment will follow the same pattern as in assessing patients in other phases of life. However, a heightened level of mindfulness is necessary, particularly in women with a preexisting psychiatric condition. This mandates good communication with and education of the patient and her family to report any changes in mood or cognition.

The risk factors for postpartum depression (PPD) are similar to those listed on the mood disorders; see Table 21-12. Postpartum blues can occur in as many as 50% to 70% of postpartum women but symptoms are usually mild and resolve spontaneously within the first 1 to 2 weeks. In patients where symptoms persist beyond 2 weeks, or if the severity escalates quickly, a more thorough evaluation is indicated. Evaluation for suicidality or thoughts to harm the baby, or others, must occur.

Differing from PPD, postpartum psychosis can evolve quickly (typically within the first few days postpartum) and is a true psychiatric emergency! The psychotic symptoms may not necessarily differ from symptoms seen in other life stages; however, careful evaluation as to the theme or content of the psychosis is vital. Risk factors for postpartum psychosis include a previous history of postpartum psychosis, family history of psychosis, and a history of bipolar disorder (100 × risk). Often the neonate is actively included within the psychotic process, therefore increasing the risk for infanticide, which has been reported to occur in up to 4% of patients with postpartum psychosis. Despite the apparent certainty as to the accuracy of the diagnosis of a postpartum mood or psychotic state, a thorough organic workup (as noted above) is indicated.

Treatment is similar to treatments in the antepartum period; however, given the high potential for lethality, prompt psychiatric hospitalization may be indicated in cases that involve suicidal or homicidal thoughts. The mother’s desire to continue with breast-feeding must be addressed especially in cases where psychotropic medications are indicated. In patients with milder forms of a postpartum mood disorder, psychotherapy such as interpersonal or cognitive-behavioral has been demonstrated to improve outcomes. However, in cases with greater symptom severity, psychotropic medications are usually necessary. Electroconvulsive therapy has been shown to provide rapid and effective relief from symptoms and is considered, by some, as first line in treating postpartum psychosis or conditions that include suicidal or homicidal ideations.

Obsessive compulsive disorder (OCD) may be present in all phases of the pregnancy including the postpartum period. Sichel et al described the postpartum onset of OCD.²¹ This condition may be confused with postpartum psychosis given the distressing (ego-dystonic) and intrusive obsessions, which may be violent in nature and include fears of intentional or accidental injury or death to the neonate. This condition is more common than initially recognized. Patients may not seek help because of the shame associated with extreme nature of their symptoms. A thoughtful and nondismissive evaluation is necessary to distinguish postpartum OCD from postpartum psychosis.

Upon delivery, 20% to 30% of neonates exposed to SSRIs may experience what has been described as a neonatal adaptation disorder. This disorder generally is self-limited and resolves in about 2 weeks. More common symptoms include tremors, jitteriness, feeding problems, fussiness, irritability, hyperreflexia, and sleep disturbances. The more severe symptoms of seizures, hyperpyrexia, dehydration, and respiratory distress requiring intubation are rarely encountered.

Careful documentation is a significant component of the care provided to the patient with psychiatric or behavioral problems. Accurate recording of the elements of care are necessary whether the patient is seen for preconceptional counseling, care during the antepartum period, during labor and delivery, or in the postpartum period. Elements to be included in the documentation are described in Table 21-19.

Gather collaborative data whenever possible. Patients may consciously or unconsciously not provide all of the pertinent information to you. Additionally, having the perspective of someone else who is close to the patient may shed a new light on the situation. Always screen for suicidality or thoughts to harm others when evaluating a patient with a mood or psychotic disorder.

The interpersonal relationship you have with your patient can prove invaluable especially when the time comes to inquire about delicate or sensitive information. A patient who trusts her doctor will be more open to engaging with her when rough times come.

• Do not underestimate the power of being kind and empathic.

• Screen for substance abuse.

• Ask about access to guns just as you would inquire about smoking or wearing seat belts. It’s important information to have, so gather it.

• Be really sure that the patient and her supports/family understand the important points about psychotropic medications you may prescribe to her; make sure they have adequate time to ask questions.

• Use psychiatric consultants.

• Document your rationale for doing something.

• Rely on your countertransference feelings—if you are uncomfortable or uneasy with a particular situation it’s probably for a good reason. Seek advice.