Treatment and outcomes of psychotic patients during pregnancy and childbirth

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 The authors provide a literature review regarding psychotic pregnancy denial, present an unpublished case and its questions and dilemmas, and offer recommendations for resolving the ethical challenges these cases raise.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.

Antipsychotic Use in Pregnancy: Patient Mental Health Challenges, Teratogenicity, Pregnancy Complications, and Postnatal Risks

Pregnant women constitute a vulnerable population, with 25.3% of pregnant women classified as suffering from a psychiatric disorder. Since childbearing age typically aligns with the onset of mental health disorders, it is of utmost importance to consider the effects that antipsychotic drugs have on pregnant women and their developing fetus. However, the induction of pharmacological treatment during pregnancy may pose significant risks to the developing fetus. Antipsychotics are typically introduced when the nonpharmacologic approaches fail to produce desired effects or when the risks outweigh the benefits from continuing without treatment or the risks from exposing the fetus to medication. Early studies of pregnant women with schizophrenia showed an increase in perinatal malformations and deaths among their newborns. Similar to schizophrenia, women with bipolar disorder have an increased risk of relapse in antepartum and postpartum periods. It is known that antipsychotic medications can readily cross the placenta, and exposure to antipsychotic medication during pregnancy is associated with potential teratogenicity. Potential risks associated with antipsychotic use in pregnant women include congenital abnormalities, preterm birth, and metabolic disturbance, which could potentially lead to abnormal fetal growth. The complex decision-making process for treating psychosis in pregnant women must evaluate the risks and benefits of antipsychotic drugs.

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.

Safety of Psychotropic Medications During Pregnancy

Risks, benefits, alternatives, and appropriateness of psychotropic medications, including risks of no treatment, are discussed for antidepressants, mood-stabilizing medications, anxiolytic/sedative hypnotic medications, stimulants, and medication-assisted treatment of substance use disorders. Early screening, diagnosis, and intervention prior to and/or during pregnancy often reduce morbidity and mortality of mental health disorders for mothers and infants.

Pedagogical Implications of Partnerships Between Psychiatry and Obstetrics-Gynecology in Caring for Patients with Major Mental Disorders

OBJECTIVE

Because there are no formal reviews, the authors set out to identify and describe programs that serve female patients with major mental disorders by integrating mental health care with services in obstetrics and gynecology and to describe the pedagogical implications of those programs.

METHOD

The authors searched PubMed for all articles describing a program in which psychiatry was formally integrated with obstetric or gynecological services, other than standard consultation-liaison programs, in the care of patients with major mental disorders. The search terms used included interdisciplinary, interprofessional, integrated, collaborative care, psychiatry, and obstetrics-gynecology or psychosomatic obstetrics-gynecology.

RESULTS

The authors found six distinct integrated programs. These included family planning clinics that were integrated into inpatient psychiatry services; inpatient and outpatient psychiatry services for pregnant mentally ill women in close collaboration with obstetric services; a day hospital for pregnant women with psychiatric disorders in an obstetric setting; an interdisciplinary training site providing care for predominantly depressed, low-income, and minority women; a primary care HIV service for women integrated with departments of obstetrics-gynecology and psychiatry; and an obstetrics-gynecology clinic-based collaborative depression care intervention for socially disadvantaged women. Residents' involvement was described in four of the programs.

CONCLUSIONS

These innovative and integrated programs potentially enhance the care of vulnerable and culturally diverse women with major mental disorders. The authors discuss how these programs may contribute to the education of residents in psychiatry and obstetrics-gynecology.

Professionally responsible intrapartum management of patients with major mental disorders

Pregnant women with major mental disorders present obstetricians with a range of clinical challenges, which are magnified when a psychotic or agitated patient presents in labor and there is limited time for decision making. This article provides the obstetrician with an algorithm to guide professionally responsible decision making with these patients. We searched for articles related to the intrapartum management of pregnant patients with major mental disorders, using 3 main search components: pregnancy, chronic mental illness, and ethics. No articles were found that addressed the clinical ethical challenges of decision making during the intrapartum period with these patients. We therefore developed an ethical framework with 4 components: the concept of the fetus as a patient; the presumption of decision-making capacity; the concept of assent; and beneficence-based clinical judgment. On the basis of this framework we propose an algorithm to guide professionally responsible decision making that asks 5 questions: (1) Does the patient have the capacity to consent to treatment?; (2) Is there time to attempt restoration of capacity?; (3) Is there an opportunity for substituted judgment?; (4) Is the patient accepting treatment?; (5) Is there an opportunity for active assent?; and (6) coerced clinical management as the least worst alternative. The algorithm is designed to support a deliberative, clinically comprehensive, preventive-ethics approach to guide obstetricians in decision making with this challenging population of patients.

Delusional denial of pregnancy as a special form of Cotard's syndrome: case report and review of the literature

The following case report describes a pregnant woman who was convinced that her pregnancy was non-existent despite being in an advanced stage of clinically obvious pregnancy. The nosologically unspecific syndrome of denial of pregnancy is discussed by reviewing the literature. Based on the existing literature it will be explained why this specific syndrome is considered to indicate a special form of Cotard's syndrome.

Fertility and pregnancy in women with psychotic disorders

The majority of women with psychotic disorders have children but their pregnancies are at an increased risk of obstetric and psychiatric complications. This paper reviews research into the fertility of women with psychosis and complications occurring during their pregnancies and in the postpartum period. Mesh terms were used to search electronic databases (Medline, Embase, Psychlit and the Cochrane database of systematic reviews). Recent studies have confirmed earlier findings of a low fertility in women with schizophrenia, though fertility is less affected by mood disorders. Psychotic relapse during pregnancy is rare but women with a history of mood disorders (affective psychoses) are at high risk of postpartum relapse. There is a high risk of obstetric complications, mixed evidence of stillbirths and neonatal deaths and there is some weaker evidence of an association with sudden infant death syndrome. A significant proportion of mothers with psychotic disorders have parenting difficulties and lose custody of their infant. Close liaison between all health professionals during pregnancy and postpartum is essential for optimal management of these high risk pregnancies.

Use of Antipsychotics in the Management of Schizophrenia during Pregnancy

The rapid development of pharmacotherapy has resulted in a growing clinical importance for the treatment of the increasing number of women with schizophrenia during pregnancy. An evolving database on reproductive health safety factors for women with schizophrenia has begun to be of assistance in optimising clinical benefits for women with childbearing potential. Given the prevalence of antipsychotic use during pregnancy in women with schizophrenia, it is important for the clinician to have a prepared approach to the administration of these agents. In general, the use of psychotropic medication during pregnancy is indicated when risk to the fetus from exposure to this medication is outweighed by the risks of untreated psychiatric illness in the mother. The preponderance of evidence from registries to large health surveys indicate that treatment with antipsychotic medication confers either no or a small nonspecific risk for organ malformations. According to the relevant literature published on the safety of antipsychotic medication during pregnancy, the findings are encouraging; however, the currently available data are very limited. Until there are more controlled prospective data on the impact of drugs on fetal and later development, the clinician will continue to work in a state of potential uncertainty, weighing partially estimated risks against managing individual clinical problems. The aim for the clinician should be to provide the best information available regarding the scope of possible risks associated with the treatment of schizophrenia during pregnancy. On the basis of the available data, generalisation is impossible and recommendations should be made on a drug-by-drug basis. The risks and benefits must always be carefully weighed for each patient on an individual basis. Only a woman who is well enough to acknowledge her pregnancy and her mental illness can effectively weigh the relative and partially unknown risks of treatment with antipsychotic medication against the highly probable risks of illness exacerbation if untreated.

Ethical challenges of decision making with pregnant patients who have schizophrenia

OBJECTIVE

Because there is a dearth of literature, we developed an ethical framework to guide decision making about the management of pregnancy of patients with schizophrenia.

STUDY DESIGN

We review pertinent literature on schizophrenia and pregnancy, including information on maternal and fetal risks and outcomes, and relate this information to ethical concepts.

RESULTS

The ethical framework has five components: the concept of chronically and variably impaired autonomy, assisted decision making, surrogate decision making, strategies for dealing with the physician's feelings in response to these patients, and the concept of the fetus as a patient. We apply this ethical framework to clinical challenges of decision making during pregnancy with this patient population.

CONCLUSIONS

The preventive ethics strategies of assisted and surrogate decision making can be used to prevent ethical conflicts in decision making about the management of pregnancy of patients with schizophrenia. These preventive ethics strategies should contribute significantly to reducing the vulnerability of these patients and therefore to enhancing their autonomy in the physician-patient relationship.

Psychopharmacology in pregnancy

Clinicians are confronted with challenging situations when working with women who are pregnant and have a co-existing mental illness. A risk benefit assessment is helpful when identifying possible care interventions. Psychopharmaceutical intervention is a consideration when nonpharmacological interventions are ineffective or inappropriate. Informed consent based on known and unknown risks to the mother and fetus should be obtained. Literature and case reports are contradictory and not conclusive about the risks of medications used for psychiatric illnesses. This article reviews the literature and provides clinical guidelines for antipsychotic medications, antidepressant medications, mood stabilizing medications, and antianxiety medications.

Obstetric complications in women with schizophrenia

It is not known whether schizophrenic women have increased incidence of complications during pregnancy and delivery. Data from the Danish Medical Birth Register were used to compare 2212 births to 1537 schizophrenic women in Denmark with a random sample of all deliveries in Denmark during 1973-1993 (122931 births to 72742 women). The schizophrenic women had fewer antenatal care visits. They were at lower risk of pre-eclampsia, but tended to have lower Apgar scores. There were no other differences in the incidence of specific complications such as placenta previa, placental abruption, and abnormal fetal presentation. Schizophrenic women were at increased risk of interventions such as Cesarean section, vaginal assisted delivery, amniotomy, and pharmacological stimulation of labor. There were no important differences between the deliveries to schizophrenic women who gave birth before and after their first admission to a psychiatric department. These results show no evidence that schizophrenic women have a greater frequency of specific obstetric complications than non-schizophrenic women. Nevertheless, they are at increased risk for interventions during delivery.

Sequelae of abortion and relinquishment of child custody among women with major psychiatric disorders

A growing number of women with major psychiatric disorders frequently consider the choice of abortion or relinquishment of the custody of children. Psychological reactions to abortion and relinquishment of custody were assessed and contrasted among 119 hospitalized women of M age 40 yr. and psychiatric patients. An original questionnaire was developed to assess emotional symptoms, psychiatric signs, attitudes, and satisfaction with the decision regarding the loss of a fetus or child. As hypothesized, reported sequelae of relinquishments of custody were rated as significantly more severe than sequelae of abortion. Dissatisfaction with choice, negative attitudes, religious affiliation, and involuntary removal of a child from custody were predictive of distress following abortion or relinquishment. The findings show that increased efforts are needed to help women with psychiatric difficulties cope with reproductive planning and losses.

The effects of dual diagnosis on pregnancy and parenting

The desire to give birth and nurture can be significant for women with mental illness and substance-abuse disorders, despite the many internal and external barriers to the effective achievement of these desires. This article provides information on the effect of coexisting mental illness and alcohol or other drug dependency on pregnancy from a medical, obstetric, psychiatric, and psychologic perspective. The article also explores the effect on parenting and highlights the need to assess for parental competency in this population. Treatment planning, including the use of psychotropic medication and the need for collaboration between providers is discussed.

Obstetric complications in children born to parents with schizophrenia: a meta-analysis of case-control studies

On the basis of previous findings, we used meta-analyses to consider whether births to parents with schizophrenia have an increased risk of obstetric complications. Meta-analyses were based on published studies satisfying the following selection criteria. The schizophrenic diagnosis could apply to either parent: parents with non-schizophrenic psychoses were not included: only normal controls were accepted. In all, 14 studies provided effect sizes or data from which these could be derived. Studies were identified by data searches through MEDLINE, PSYCLIT and through references of papers relating to the subject. Births to individuals with schizophrenia incur an increased risk of pregnancy and birth complications, low birthweight and poor neonatal condition. However, in each case the effect size is small (mean r = 0.155; 95% CI = 0.057). The risk is greater for mothers with schizophrenia and is not confined to mothers with onset pre-delivery or to the births of the children who become schizophrenic themselves.

Denial of pregnancy: a review and case reports

This paper describes the characteristics of women who deny awareness of their pregnancies, the underlying causes and conflicts, and specific interventions required to address these issues. Case reports illustrate this complication of pregnancy. The absence of many physical symptoms of pregnancy, inexperience, general inattentiveness to bodily cues, intense psychological conflicts about the pregnancy, and external stresses can contribute to the denial in otherwise well-adjusted women. Assessment should include the possible contribution of painful reactivation of memories concerning childhood or adult trauma and the effect of dissociative states on the development of denial of pregnancy. Psychotherapy is recommended to resolve these conflicts, and to prevent future pregnancy denials and child abuse or neglect. Denial of pregnancy is easier to understand in women with psychosis or serious cognitive impairment than in those without such disorders. The underlying illness requires treatment by a psychiatrist. Psychological conflicts also exist in psychotic women, such as the intense wish to have a baby while fearing loss of the infant to child-protection services. Acknowledging the conflict and supporting the mother despite her puzzling behavior is an important task for health caregivers.

Antecedents of schizophrenia and affective illness. Obstetric complications

BACKGROUND

This exploratory study seeks to generate new hypotheses about the relationship between obstetric complications and schizophrenia.

METHOD

The British Perinatal Mortality Survey represents 98% of all births during one week in March 1958 in Great Britain. Present State Examination (PSE), Catego diagnoses of narrowly defined schizophrenia (n = 49), broadly defined schizophrenia (n = 79), affective psychosis (n = 44) and neurosis (n = 93) were derived from case notes for all cohort members. The remainder of the cohort, surviving the perinatal period, acted as controls (n = 16 812). Variables in the British Perinatal Mortality Survey were grouped into five categories: the physique/lifestyle of the mother (including demographic characteristics), her obstetric history, the current pregnancy, the delivery and the condition of the baby.

RESULTS

There were 7/17 significant differences in maternal physique/lifestyle and obstetric history between the births of schizophrenics and controls, compared to 4/40 comparisons of somatic variables relating to pregnancy, birth and the condition of the baby. This compares with 4/17 and 7/40 for affective psychotics and a total of 4/57 differences for all categories of variables when neurotics were contrasted with controls.

CONCLUSIONS

The purported increased risk of obstetric complications in schizophrenics may result from the physique/lifestyle of their mothers.