Although obstetricians commonly care for pregnant patients with psychiatric disorders, little has been written about the implications of managing a pregnancy during a prolonged psychiatric hospitalization for severe mental illness. Multidisciplinary care may optimize obstetric and psychiatric outcomes. We describe a severely mentally ill patient at 27 weeks’ gestation (G1P0) who was admitted after a suicide attempt. She exhibited intermittently worsening depression and anxiety throughout a 2-month inpatient psychiatric hospitalization, during which her psychiatric and obstetric providers collaborated regarding her care. We review recommendations for antepartum and intrapartum treatment of the acutely suicidal and severely mentally ill patient and, in particular, the evidence that a multidisciplinary coordinated approach to planning can maximize patient physical and mental health and facilitate preparedness for delivery.
Obstetricians regularly care for pregnant women with mental illness; such care largely unfolds without complications. Although major depression affects 3.1-4.9% of women during pregnancy, they rarely require prolonged psychiatric hospitalization. Care for pregnant patients with severe mental illness can be complicated by concerns regarding the appropriate treatment of symptoms relative to risks of exposure during pregnancy. For providers who are not familiar with the treatment of severe mental illness during the perinatal period, this can lead to diversions from obstetric and psychiatric standards of care. To illustrate the issues that arise in such cases, we describe a pregnant woman with longstanding severe mental illness who presented after intentional overdose. We review potential challenges to caring for severely mentally ill women during pregnancy and offer an example of a patient-centered multidisciplinary approach. We will not review psychotropic medication use during pregnancy, which has been addressed in detail elsewhere.
A third-trimester suicide attempt
This married 37-year-old Hispanic woman (G1P0) had a complicated psychiatric history that was significant for recurrent major depressive disorder and obsessive compulsive disorder (OCD) that resulted in multiple suicide attempts and psychiatric hospitalizations. Before her unplanned pregnancy, she had 4 years of stability on a regimen of paroxetine and lamotrigine. Her medical comorbidities included obesity and likely chronic hypertension. After consultation with her psychiatrist, the patient elected to discontinue her psychotropic medications once pregnancy was diagnosed. She consulted with maternal-fetal medicine (MFM) providers at 12 weeks’ gestation to discuss medication use, potential implications of pregnancy on her mental illness, and options for pregnancy management. She was counseled that the continuation of psychotropic medications during pregnancy is recommended in cases of severe, recurrent depression. Medication use for pregnant women with such severe mental illness is recommended because of the high risk of relapse with medication discontinuation, with corresponding maternal and fetal risks. Nevertheless, the patient elected to forego reinitiation of psychiatric medications until 24 weeks of gestation, when she agreed to resume them for worsening symptoms of OCD and depression. In the interim, she had had 2 psychiatric hospitalizations that were triggered, in part, by typical symptoms of pregnancy such as weight gain and fetal movement.
At 27 weeks 2 days’ gestation, the patient was transferred from a local hospital to our intensive care unit after an intentional overdose. She had been found unconscious by her husband after she had ingested a combination of quetiapine, paroxetine, fluoxetine and clonazepam. Once stabilized, she was transferred to the labor and delivery (L&D) unit for obstetric monitoring. She reported feeling “tired of the pregnancy,” was acutely anxious, worried she was a burden to family, and wondered whether she could care for a baby. On L&D, bedside ultrasound showed an appropriately grown fetus. Initial biophysical profile was 2 of 10, which was suspected to be a transient response to her overdose. Fetal status became reassuring during the period of observation. Because the psychiatry service had determined that the patient lacked the capacity to provide informed consent after the overdose, her husband consented for potential emergency cesarean delivery in the event fetal status had not improved. At this time, she did not have an advanced directive but designated her husband as her medical proxy.
Antepartum planning
After obstetric stabilization, the patient was transferred to the inpatient psychiatric unit where she stayed for the next 2 months. Her obstetric care was transferred from her private obstetrician to the MFM service. Once care was assumed by the MFM service, she had a consistent care team throughout her antepartum admission. Initially, she was treated with a combination of fluoxetine, quetiapine, lorazepam, and haloperidol for acute symptoms of depression and OCD. During the hospitalization, she experienced 2 acute setbacks with suicidal behaviors that necessitated one-to-one supervision for safety. Treatment with electroconvulsive therapy was proposed, but the patient declined. She was then restarted on her prepregnancy regimen of paroxetine and lamotrigine in conjunction with quetiapine. After the change in medications, she improved and transitioned from ambivalence to increased bonding with her fetus and motivation to participate in treatment. During this period of improvement, she reconfirmed her medical proxy. She signed a power of attorney for health care form that formally designated her husband as her primary surrogate decision-maker in the event of her incapacity. She included advanced directives regarding her wishes in the event of need for life-sustaining care.
At 31 weeks’ gestation, she was diagnosed with gestational diabetes mellitus (GDM) and started on medical nutritional therapy. The GDM diagnosis was made late because of both the patient’s receipt of betamethasone on initial presentation and the initial focus on her psychiatric needs. A hemoglobin A1c test that was performed at the time of her diagnostic oral glucose tolerance test was 5.8%. She had persistent hyperglycemia, despite dietary therapy. Although insulin was the preferred agent, she was started on the oral hypoglycemic medication glyburide because of OCD-related needle intolerance. On this regimen, she achieved adequate glycemic control. The patient was counseled about options for delivery mode and postpartum contraception. At our institution, cesarean delivery on maternal request is not presented typically to women as a preferable choice, but it is considered on an individual basis. This patient expressed her desire for a vaginal delivery and a long-acting reversible contraception method.
Antepartum planning
After obstetric stabilization, the patient was transferred to the inpatient psychiatric unit where she stayed for the next 2 months. Her obstetric care was transferred from her private obstetrician to the MFM service. Once care was assumed by the MFM service, she had a consistent care team throughout her antepartum admission. Initially, she was treated with a combination of fluoxetine, quetiapine, lorazepam, and haloperidol for acute symptoms of depression and OCD. During the hospitalization, she experienced 2 acute setbacks with suicidal behaviors that necessitated one-to-one supervision for safety. Treatment with electroconvulsive therapy was proposed, but the patient declined. She was then restarted on her prepregnancy regimen of paroxetine and lamotrigine in conjunction with quetiapine. After the change in medications, she improved and transitioned from ambivalence to increased bonding with her fetus and motivation to participate in treatment. During this period of improvement, she reconfirmed her medical proxy. She signed a power of attorney for health care form that formally designated her husband as her primary surrogate decision-maker in the event of her incapacity. She included advanced directives regarding her wishes in the event of need for life-sustaining care.
At 31 weeks’ gestation, she was diagnosed with gestational diabetes mellitus (GDM) and started on medical nutritional therapy. The GDM diagnosis was made late because of both the patient’s receipt of betamethasone on initial presentation and the initial focus on her psychiatric needs. A hemoglobin A1c test that was performed at the time of her diagnostic oral glucose tolerance test was 5.8%. She had persistent hyperglycemia, despite dietary therapy. Although insulin was the preferred agent, she was started on the oral hypoglycemic medication glyburide because of OCD-related needle intolerance. On this regimen, she achieved adequate glycemic control. The patient was counseled about options for delivery mode and postpartum contraception. At our institution, cesarean delivery on maternal request is not presented typically to women as a preferable choice, but it is considered on an individual basis. This patient expressed her desire for a vaginal delivery and a long-acting reversible contraception method.
Multidisciplinary coordination of care
A multidisciplinary meeting for collaborative management was organized at 32 weeks’ gestation and included members of the MFM, L&D nursing, psychiatry, social work, pediatrics, anesthesiology, hospital administration, and medical ethics teams. Some of these teams initially suggested a planned cesarean delivery might be better for the patient because of her difficulty coping in unpredictable circumstances and her obsessive fear of contamination. Weighing the maternal and fetal benefits of vaginal delivery against the patient’s mental illness, the group arrived at the consensus that a trial of labor was preferable in the absence of obstetric indications for cesarean delivery. Because the patient achieved sufficient psychiatric stability to be involved in decisions about her care, her preference for vaginal delivery and subsequent intrauterine contraception carried significant weight. Contingency plans were developed for the management of emergent obstetric events on the psychiatric unit. Induction of labor was planned for 39 weeks’ gestation because of her GDM. Although Department of Child and Family Services involvement is not mandatory for all mentally ill patients, this patient’s severe mental illness and high risk for self-harm warranted consultation with the Department of Child and Family Services to ensure newborn infant safety. A care plan was developed and distributed.
One aspect of the plan involved repeated exposures to typical aspects of L&D. Nonstress tests, which were performed for fetal surveillance because of GDM, increased her comfort with the obstetrics unit and fetal monitoring. She met with anesthesiologists to address her fear of needle contamination; they demonstrated the materials and sterile technique that would be used to provide labor analgesia. The obstetrics team educated her about the evolving pregnancy and labor symptoms.
At 33 weeks 2 days’ gestation, her blood pressure became mildly elevated, and a 24-hour urine collection revealed 336 mg of protein. Mild preeclampsia was suspected. Because she was psychiatrically stable, she was transferred to the obstetrics antepartum unit with constant psychiatric supervision for safety. At 34 weeks 5 days’ gestation, she experienced worsening transaminitis and severe hypertension; repeat urine collection contained 525 mg of protein. A decision was made to proceed with delivery for severe preeclampsia.
Key points of the labor plan included (1) a psychiatric nurse to be present in the labor room, (2) an early combined spinal-epidural to minimize pain and avoid pain-induced anxiety, (3) intrapartum telemetry because of Q-T interval prolongation that had recently normalized, (4) premedication with lorazepam before epidural placement to prevent worsening anxiety, (5) parenteral haloperidol (5 mg), lorazepam (2 mg), and benztropine (1 mg) available for acute psychiatric symptoms, and (6) efforts to avoid mechanical restraints (if needed, a left-sided restraint was planned because patients are supine in a 4-point restraint, which could result in inferior vena cava compression by the gravid uterus).
Delivery and recovery
At the time of decision for delivery, the fetus was found to be in a transverse presentation. She consented to an external cephalic version, which was unsuccessful. She subsequently underwent an uncomplicated low transverse cesarean delivery under spinal anesthesia that resulted in delivery of a 2645 g male neonate with Apgar scores of 7 and 9 at 1 and 5 minutes, respectively. A ParaGard intrauterine device (IUD; Teva Women’s Health Inc, Sellersville, PA) was placed after delivery of the placenta. She tolerated delivery without worsening of psychiatric symptoms and recovered without postoperative complications.
During the postpartum period, the patient was seen daily by the psychiatric consult team. She denied any thoughts of harm to herself or her baby and exhibited appropriate behaviors with her son. After a stay in the neonatal intensive care unit for prematurity, her son was discharged to the care of family with a supervision plan that allowed her increasing visitation pending further mental health improvement. Although anxious when informed of the supervision plan, she did not show signs of psychiatric deterioration. This patient had significant familial support; her husband and extended family remained active in her care and were critical in the support of her wellness and autonomy. Close collaboration between psychiatry, MFM, social work, and the patient’s family led to a decision on postoperative day 4 to discharge the patient in good condition home with her family with a trial of intensive outpatient psychiatric care. On postoperative day 7, having missed an outpatient follow-up visit, she came to the Emergency Department with worsening depression and suicidal ideation and was hospitalized briefly. After discharge, she complied with her outpatient psychiatric follow-up schedule. When seen for her 6-week postpartum visit, she was gaining confidence in caring for her newborn infant with supervision by the family. At 4 months after delivery, with regular psychiatric treatment, the patient demonstrated improved mental health and had assumed full care of her infant.
Comment
Mental illness can reduce a patient’s ability to regulate emotions and adapt to change. This limited ability to adapt to change is of particular concern during the dynamic period of pregnancy; in this example, symptoms worsened when she experienced the onset of fetal movement, an enlarging abdomen, and signs of impending birth. This patient’s course may have been substantially different had she continued on her psychotropic medications throughout pregnancy, rather than opting to discontinue them in the first trimester. A crucial component of care for the severely ill pregnant woman includes a discussion of the risk of adverse psychiatric outcomes when medications are discontinued. For patients with such severe mental illness, in addition to medication optimization through collaborative perinatal psychiatric care, a number of steps can be taken to enhance care. Offering anticipatory guidance, safety, and one-on-one teaching via multiple disciplines (psychiatry, nursing, obstetric anesthesia, MFM, and social work) can help patients treat symptoms and participate in their care. Given the importance of entering labor in the healthiest possible mental, physical, and emotional state, we provide several recommendations for achieving this goal.
Delivery planning
Decision-making regarding the route of delivery is at the crux of delivery planning for severely mentally ill patients. A fundamental goal of obstetric care is to afford patients the least morbid route of delivery for mother and fetus. For women with severe mental illness and possibility of self-harm, an added goal is to maintain patient autonomy and to minimize restrictive measures to the extent their mental health allows. It has been suggested that cesarean delivery is one means by which fear of childbirth can be minimized. Some caregivers have suggested that a mentally ill woman’s need for control over timing and route of delivery may justify cesarean delivery. On the other hand, some obstetric providers might argue that vaginal delivery potentially offers increased patient autonomy over a cesarean delivery because of physical restrictions placed on the mother during surgery. Others have reasoned that allowing a choice between cesarean and vaginal delivery is autonomy-enhancing for any woman. Cesarean delivery on maternal request may be considered in individual circumstances after adequate counseling, although it is not considered a preferable choice at our institution. This is consistent with the general approach to delivery decisions for all women, but it should not imply that no recommendation is given, because providers have an obligation to offer medical recommendations and women may feel abandoned by providers.
Literature suggests that mode of delivery is not associated with mental health changes and that worsening mental health is not precipitated by vaginal delivery. There are no data to suggest that worsening mental health is precipitated by cesarean delivery. Additionally, as for women without mental illness, cesarean delivery incurs risks that are greater than with vaginal delivery. Thus, concerns for intra- and postpartum mental health should not influence mode of delivery decisions. In our case, despite initial concerns that labor might exacerbate psychiatric symptoms acutely, the team ultimately agreed that cesarean delivery for nonobstetric indications would be a divergence from standard obstetrics practice, particularly in the absence of patient request.
Similar to women with schizophrenia, women with other severe mental illnesses may require unique provider efforts to overcome the barriers that are posed by their limited coping ability. Guidelines have been proposed for laboring women with schizophrenia to aid in optimizing their intrapartum course. In developing plans for intrapartum care of depressed and anxious women with high potential for recurrent self-harm, we suggest adapting those guidelines as follows:
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Provide consistent messaging about the pregnancy, delivery, and postpartum period.
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Obstetric and psychiatric providers should work collaboratively to optimize medication regimens. Fetal risks should be weighed against the risk of untreated illness and anticipated maternal psychiatric and obstetric benefits. Psychiatrists with expertise in the use of psychotropic medications during pregnancy (sometimes known as perinatal psychiatrists) should be involved when possible.
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Early and adequate pain relief can provide comfort and prevent unnecessary anxiety in a patient whose psychiatric symptoms are triggered by pregnancy-related bodily sensations and pain.
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Clarify expectations with the patient, familiarize her with the labor environment, introduce her to the team members and procedures, and explain the feeling of anesthesia to minimize exposures possibly perceived as “new” or “unfamiliar” and prepare her for unfamiliar bodily sensations.
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Plan for medications for acute psychiatric symptoms, if necessary, in addition to labor analgesia.
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Antenatally, review possible outcomes of the intra- and postpartum periods with the patient and provide her with realistic expectations for recovery.
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Before labor, discuss patient preferences for potential intrapartum decisions. Obtain consent if possible. Discuss with the patient and/or her surrogate decision-maker the plans for consent for intrapartum decisions. When possible, the patient should be encouraged to designate formally a health care power of attorney and complete an advanced directive to document her wishes.
Further, comprehensive care of the severely mentally ill woman includes planning for the postpartum period, when she is at high risk for psychiatric decompensation. Our patient transitioned to outpatient care, but many patients with less drastic improvement during pregnancy may require ongoing hospitalization. Planning for postpartum well-being should include consideration of family, cultural, and community resources that may address the severely depressed patient’s psychosocial needs. In some communities, mother-infant programs for women with psychiatric disability may enhance the patient’s recovery, provide an ongoing source of mental health support, prevent separation of mother and child, and improve her parenting capacity during this fragile postpartum time period. We encourage providers to connect patients with such programs when possible.
Autonomy and preventive ethics
In women with recent acute psychiatric decompensation who have limited decision-making capacity, the obstetric and psychiatric teams must anticipate the possibility of similarly limited capacity during labor. It is important for clinicians to understand the issues of competence and capacity as related to care of the obstetrics patient. Capacity is the ability to participate rationally in medical decision-making; patients may lack the capacity for a variety of possible reasons, including temporary illness. Capacity may be determined by the physician and may change with an evolving clinical situation. However, competency is a legal term that refers to the ability to make prudent decisions in one’s best interest; a declaration of incompetence effectively denies individual autonomy and requires legal procedures. A full discussion of the requirements for competence and capacity, with their legal implications, is beyond the scope of this article and has been published previously.
Patients with chronic mental illness can exhibit chronic and variably impaired autonomy that can influence medical approaches to obstetric care. Nondirective counseling that incorporates patient preferences is advised. In this example, obstetric decision-making was guided primarily by patient preference, unless she were to experience a period of impaired decision-making because of psychiatric decompensation. However, we also used a model of preventive ethics that involves clinical strategizing to anticipate and prevent ethical conflict or controversies in the medical decision-making process. We planned for the possibility of impaired decision-making. Such a model additionally advises anticipating and minimizing dilemmas regarding intrapartum decision-making by developing plans for precipitous or emergent delivery. Contingency plansshould include both logistical planning (such as equipment readiness on inpatient units other than L&D) and notification systems for obstetric and psychiatric providers in the event of acute issues.
The model of preventive ethics additionally includes anticipating intrapartum ethical decision-making for women with severe mental illness by holding advance discussions of patient preferences and provider recommendations. This process enhances patients’ future autonomy by eliciting her values about clinical options, providing education, and negotiating an appropriate treatment plan that is centered around her preferences and clinical needs. For this patient, during the antepartum period of stability, we sought her opinions about potential emergency situations and her preferences for delivery mode and postpartum contraception. It is imperative to document in the medical record the patient preferences that are expressed during such a period of lucidity. Typically, patient consent for anesthesia or cesarean delivery would have been sought at the time of such a procedure. However, after consultation with the ethics committee, consensus was that, if the patient were judged to be unable to provide such consent or assent in a time of acute need, her previous statements consenting for such procedures would be deemed an appropriate indication of her wishes. Thus, her preferences that were expressed during a period of psychiatric stability would serve as substitute judgment to guide choices for anesthesia and delivery as warranted by the obstetric situation. This substitute judgment would only be used if the patient lacked the capacity during the moment of need for decision-making or consent. Should she be deemed capable of reasonable medical decision-making, her autonomy would be respected, even if her choices were inconsistent with provider recommendations. Furthermore, this concept of substitute judgment was not intended to supersede the involvement of the patient’s surrogate identified decision-maker but was intended to supplement the involvement of her power of attorney to ensure the team was carrying out decisions that were consistent with the patient’s expressed preferences.
Family planning for mentally ill women
As with women with any chronic disease, reproductive-aged women with severe mental illness benefit when the potential for pregnancy is addressed by their health care providers, particularly those with perinatal expertise. Additionally, contraception planning is an important component of prenatal and postpartum care. The relative lack of knowledge and low use of contraception among women with mental illness results in an increased risk of unintended pregnancy. Sexually active women with mental illness have more lifetime sexual partners, lower contraceptive usage, and higher rates of unwanted pregnancies and sexually transmitted infections. Women with mental illness should not be counseled definitively to avoid pregnancy nor coerced into accepting contraception. However, for a woman who does not desire to parent at the current time, suboptimal contraception and the attendant morbidity of unplanned pregnancy can impact her physical and mental health significantly.
Thus, family planning education is critical to the comprehensive care of the severely mentally ill woman for a number of reasons. First, handling the consequences of an unplanned pregnancy may be particularly challenging for the severely mentally ill woman, given her greater obstacles to insight and lesser ability to adapt to change. Second, family planning counseling provides an opportunity to optimize mental health care, including medication regimens, before conception. Sexual activity and birth control status are not discussed regularly in mental health settings; in one study, only 31% of providers reported knowing their severely mentally ill patients’ contraceptive plans. A lack of experience in treating this population can often lead to hasty decisions about treatment when a patient becomes pregnant. Abrupt discontinuation of psychotropic medication during pregnancy because of concerns about medication safety is known to put women at significant risk for relapse of a severe mood disorder. The opportunity for balanced and accurate preconception counseling about mental health in pregnancy is an important reason to discuss family building desires with mentally ill patients. Third, women with severe mental illness may have little contact with reproductive health providers; thus, interaction with psychiatric providers may present the only opportunity to address family planning needs and to provide appropriate referrals.
Research on contraception use among severely depressed women is scant. Although the range of contraceptive choices is not limited by mental illness, women with mental illness might be better equipped to avoid contraceptive failure if able to make educated choices about birth control methods that best suit their needs. Use of a long-acting reversible contraceptive (LARC) method such as IUD or an implant offers women the lowest contraceptive failure rate and highest likelihood of contraception continuation. For women with bipolar disorder, IUD use is associated with higher 1-year continuation rates than injectable methods, with no difference in complications or hospitalizations that are associated with mental illness. In multiple settings, neither the copper nor levonorgestrel-releasing IUD have been shown to increase symptoms of depression. LARC methods’ ease of use and minimal interaction with psychiatric medications can optimize reproductive choice for severely mentally ill women who might engage in unplanned or coerced sexual behavior, sexual trading, or sexual activity with multiple partners. Such women may find it difficult to adhere to contraception regimens that require user action or to negotiate barrier contraception at the time of intercourse. However, dual protection that includes barrier methods to prevent sexually transmitted infections remains the recommendation for all sexually active, reproductive-aged women. LARC use combined with consistent condom use can help women align their reproductive outcomes with their reproductive goals.
Finally, when any woman has an unplanned pregnancy, comprehensive options counseling should be a component of early obstetric care. Options counseling for women with severe mental illness should include consultation with an obstetrician and psychiatrist who are familiar with the treatment of mental illness during pregnancy to discuss thoroughly the risks of the mental illness and medications that are used for maternal benefit. When a perinatal psychiatric specialist is unavailable, we recommend collaborating care with the patient’s current mental health provider. Counseling should include all medically appropriate pregnancy options (parenting, pregnancy termination, and adoption) in a manner that incorporates the psychosocial context of the patient’s pregnancy and parenting intentions. When termination is desired, close collaboration with perinatal psychiatry may help facilitate the healthiest possible psychiatric transition, with close attention to the postpartum state.
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