Psychiatric disorders in women of child-bearing years are common, given that the majority of psychiatric conditions occur during this stage of life. Pregnancy, and the events surrounding this unique life experience, is filled with significant emotional and psychological 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 and must be addressed in a thoughtful and cohesive manner.
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 are often confronted with behaviors that can quickly devolve into crisis situations. The most empiric goal of obstetric medicine, to assure the well-being of the mother and baby, requires a structured, cohesive, and organized schema for identifying and managing these patients.
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
In this chapter, we hope to provide clear and easy-to-follow guidelines for triaging psychiatric emergencies that arise in pregnancy, including preexisting psychiatric conditions, those with new symptoms/behaviors, as well as those caused by other medical conditions (ie, delirium or intoxication). Approaches to the patient at risk for harming themselves or others and the agitated or irritable 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 the gravid patient 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 However, suicide and homicide have been reported to be the fourth and fifth leading causes of death among women of reproductive age in the United States.5 About 5% of all female suicides occur during the child-bearing years with 2% of suicides in this group by women who were pregnant.
Suicide was the third most frequent cause of death among both early and late postpartum women behind natural causes and injuries, accounting for approximately 20% of postpartum deaths. The late postpartum group had the highest proportion of deaths attributable to suicide (7.0%) among the four groups, pregnant, early postpartum (pregnant within 42 days of death), late postpartum (pregnant within 43 days to 1 year of death), and nonpregnant/nonpostpartum women.6 Rates of suicide also increases with first trimester miscarriage or termination (Table 21-1).7
TABLE 21-1Suicide After Pregnancy5