Induction of Labor for Psychiatric Indications: A Case Series and Literature Review

Ethical challenges in the treatment of psychotic pregnancy denial

Background

There is a paucity of literature regarding ethical strategies for treating pregnant people with psychosis. While not uncommon, psychotic pregnancy denial is a psychotic illness in which patients have the delusion that they are not pregnant. The authors provide a literature review regarding psychotic pregnancy denial, present an unpublished case and its questions and dilemmas, and offer recommendations for resolving the ethical challenges these cases raise.

Case

A 26-year-old, single, unemployed woman of no fixed residence was admitted for suicidal ideation. She had a history of psychosis, had multiple ER visits and at least one previous hospitalization, had minimal contact with psychiatric outpatient clinics, and had been poorly compliant with treatment recommendations. She was discovered to be about 31 weeks pregnant in the emergency room. Ultrasound exams revealed no fetal anomalies. This was the patient's second pregnancy; her previous pregnancy resulted in an abortion. Her sole psychotic symptom was the delusional belief that she was not pregnant. On the rare occasions when the patient acknowledged being pregnant, she requested termination of pregnancy. Despite intensive pharmacological treatment of her psychosis, the patient continued believing that she was not pregnant and repeatedly said she would not participate in the labor and delivery process. She disagreed with the induction of labor or a cesarean section if needed. The patient developed gestational hypertension, an obstetric indication for delivery. Induction of labor was offered to avoid potentially disastrous outcomes for the pregnant woman and the fetus.

Conclusion

Psychotic pregnancy denial is potentially life-threatening. Delivery of the fetus requires carefully weighing risks and benefits and thoroughly considering the ethical framework.

Teaching points

Treatment of birthing people with psychotic denial of pregnancy is complex; it requires special clinical and ethical skills to determine the patient's level of decision-making impairment and to find a middle ground between the pregnant person's right to autonomy and the physicians' beneficence-based duties. Using a well-coordinated, interdisciplinary approach and a solid ethical framework, the decision to deliver the fetus while engaging the pregnant person, to the extent possible, in the decision-making process is essential.

Unplanned pregnancy and the association with maternal health and pregnancy outcomes: A Swedish cohort study

OBJECTIVES

Unplanned pregnancies are common and associated with late initiation and inadequate antenatal care attendance, which may pose health risks to mother and child. How pregnancy planning relates to maternal health and delivery in Sweden, a country with free antenatal care and free abortion, has not been studied previously. Our aims were to study whether pregnancy planning was associated with antenatal care utilization and pregnancy outcomes in a Swedish setting.

METHODS

Data for 2953 women, who answered a questionnaire when recruited at antenatal clinics in Sweden and later gave birth, was linked to the Swedish Medical Birth Register. The degree of pregnancy planning was estimated using the London Measure of Unplanned Pregnancy. Unplanned (comprising unplanned and ambivalent intention to pregnancy) was compared to planned pregnancy. Differences between women with unplanned and planned pregnancy intention and associated pregnancy outcomes were analyzed using Fisher's exact test and logistic regression.

RESULTS

There were 31% unplanned (2% unplanned and 29% ambivalent) pregnancies, whereas most woman (69%) reported their pregnancy to be planned. Women with an unplanned pregnancy enrolled later to antenatal care, but there was no difference in number of visits compared with planned pregnancy. Women with an unplanned pregnancy had higher odds to have induced labor (17% versus 13%; aOR 1.33 95% CI 1.06-1.67) and a longer hospital stay (41% versus 37%; aOR 1.21 95% CI 1.02-1.44). No associations were found between pregnancy planning and pregnancy-induced hypertension, gestational diabetes mellitus, preeclampsia, epidural analgesia use, vacuum extraction delivery, Caesarean section or sphincter rupture.

CONCLUSIONS

Unplanned pregnancy was associated with delayed initiation of antenatal care, higher odds for induction of labor and longer hospital stay, but not with any severe pregnancy outcomes. These findings suggest that women with an unplanned pregnancy cope well in a setting with free abortion and free health care.

Reproductive Decision-Making Capacity in Women With Psychiatric Illness: A Systematic Review

BACKGROUND

Decision-making capacity can be affected by psychiatric illness. Women who have psychiatric illness who make decisions about their reproductive health may require evaluation of their decision-making capacity.

OBJECTIVE

This article aims to characterize existing literature about capacity evaluations in women with psychiatric illness making reproductive decisions.

METHODS

We conducted a systematic review searching PubMed, EMBASE, Ovid PsycINFO, and ClinicalTrials.gov databases through July 2020. Articles were evaluated for relevance to inclusion criteria, first by title and abstract screening then by reading the full text of articles. Our inclusion criteria were case reports and studies that involved women of childbearing age with psychiatric illness making obstetrical decisions for whom decision-making capacity was evaluated. We qualitatively analyzed our data by examining themes within the studies, such as the circumstances of the referral and characteristics of reproductive decision-making. We also collected information about the clinical circumstances, such as the clinical setting (e.g., inpatient or outpatient, in primarily psychiatric or obstetric care) and who made the determination of capacity.

RESULTS

We identified 18 articles, which included 22 distinct patient cases and 27 distinct obstetrical decisions. Decisions about termination of pregnancy were most common, which were 10 of 27 decisions. Decisions about timing and mode of delivery accounted for 7 and 5 decisions, respectively. The most common psychiatric diagnosis reported was schizophrenia, which was present in 8 patients. Major depression and bipolar disorder were also frequently reported, present in 3 and 5 patients, respectively.

CONCLUSION

Patients who make health care decisions must have decision-making capacity. A patient with psychiatric illness does not inherently lack capacity, and in fact, most patients with psychiatric illness have decision-making capacity. Psychiatric illness, however, can add complexity to obstetrical medical decision-making. Reasons for this complexity include the involvement of many stakeholders, the often time-sensitive nature of these decisions, and the potentially unpredictable course of psychiatric illness. Successful management of these cases involves multidisciplinary collaboration, the use of preventative ethics through advanced care planning, and identification of a guardian or surrogate decision-maker when a patient is determined to lack decision-making capacity or for a patient who has capacity through advanced care planning.

PROSPERO REGISTRATION NUMBER

CRD42020143434.

Psychotic pregnancy denial: a review of the literature and its clinical considerations

BACKGROUND

Pregnancy denial can be broken into two major types, non-psychotic and psychotic deniers, and further classified into pervasive, affective and persistent sub-types. It can lead to increased morbidity and mortality of the mother and neonate. Psychotic pregnancy denial is rare and the medical literature existing on the subject is limited to a small number of case reports and case series. No formal recommendation exists on the clinical management of psychotic pregnancy denial in the antenatal or postpartum period. The authors provide a comprehensive review of the literature regarding psychotic pregnancy denial, present an example of an unpublished case and provide suggestions for clinical management.

CASE

A 33-year-old primigravida at 37 6/7 weeks gestation presented with new-onset psychotic pregnancy denial with no prior history of psychosis. She had a negative medical work-up for organic causes of psychosis. Using a multidisciplinary approach, the decision was made to deliver the fetus at 38 1/7 weeks via cesarean section due to concerns for patient and fetal safety. Following delivery, she was admitted to an inpatient psychiatric facility and underwent 16 bilateral electroconvulsive therapy (ECT) treatments to which she showed complete response.

CONCLUSION

Psychotic pregnancy denial is rare and potentially dangerous. Delivery prior to 39 weeks gestation is reasonable for worsening psychiatric disease but careful consideration of the risk-benefit analysis and ethical framework must be deliberated.Teaching points: In cases of worsening psychiatric disease in pregnancy, a multidisciplinary approach is necessary for comprehensive care. Psychotic denial of pregnancy leads to increased maternal and neonatal morbidity and mortality. Delivery prior to 39 weeks gestational age is reasonable to expedite psychiatric treatment.PrecisUsing a multidisciplinary approach, the decision to deliver before 39 weeks gestation is reasonable for worsening psychiatric disease.