Pregnancy is a period of social, physiologic, hormonal, and psychological change that affects all aspects of a woman’s life. These changes, especially when accompanied by overlying preexisting risk factors for psychiatric illness, are all triggers for a first episode, recurrence, or worsening of a behavioral or mental health problem. The data on the management and treatment of psychiatric disorders in pregnancy is both highly variable and highly controversial. A large population–based study of pregnant women in Sweden reported that the point-prevalence of any psychiatric diagnosis was 14.1%, and in the United States, it is likely higher and, data suggests, continuing to rise.1
Gaps in the healthcare system regarding adequate prevention and intervention for women with mood/anxiety disturbances in the perinatal period have shown to have devastating emotional and medical consequences. Perinatal psychiatric disorders are a leading cause of maternal morbidity and mortality, with suicide in particular being the leading cause of maternal death. Lack of adequate guidelines, research, knowledge, proper counseling, medication management, and social prejudice related to the topic are a few of the problems that contribute to this rising and disabling group of illnesses. This chapter outlines the most acute and highest-yield preventative measures that can present to and be taken by the hospitalist during the perinatal period.
KEY QUESTIONS
How is capacity assessed in the labor and delivery (L&D) setting?
How should one take proper consent of a pregnant altered patient?
How should one assess and document capacity?
The matters of capacity and informed consent are among the most common reasons for psychiatric consultation in the perinatal inpatient setting. This is sometimes because the matter of decisional capacity was not addressed in the outpatient setting, but more often because women afflicted with illness that leads to impaired capacity often present emergently to the inpatient unit without having a history of healthcare taken. It is also easy for clinicians to assume that a patient is demonstrating the capacity for decision-making when she is consenting to management; only when she does not comply is her capacity called into question. There are many medical causes of altered mental status that can lead to the question of capacity, but this chapter will address only the most common cause in healthy, reproductive-age women: underlying chronic psychiatric pathology, acute intoxication, or both. It will also focus on determining capacity when a physician is confronted with a patient with signs of impaired capacity or a surrogate decision-maker, and a decision needs to be made either urgently or emergently.
Any physician can perform and document a capacity assessment; it does not have to be a psychiatrist. In fact, the physician responsible for performing any particular medical intervention is the best equipped to determine if the patient is able to demonstrate capacity to consent to that particular intervention. Documentation should include a review of the patient’s personal risk-to-benefit ratio for the particular intervention and any efforts to find a surrogate decision-maker.
Diagnosis of a psychotic-spectrum illness does not prohibit individuals from making informed decisions about their medical treatment, even for pregnancy termination and permanent sterilization. It is important to remember two crucial principles when assessing capacity. First, decision-making capacity, medical or otherwise, is always specific to the task requiring the decision. Second, a patient’s decision-making capacity may change depending on the underlying cause and situation.
The current standard for determining capacity requires that the patient have the following four components regarding a specific medical decision: (1) the ability to communicate a choice, (2) the ability to understand relevant information (i.e. factual understanding), (3) the ability to appreciate the nature of the situation and its likely consequences, and (4) the ability to handle information rationally.2 A capacity evaluation usually takes only a few minutes and can be part of the usual course of informed consent, so it should not interfere with any critical time line to patient care with a patient who is able to communicate. A common mistake is stating that a patient has no medical decision-making capacity when in fact she is deemed not to have the capacity to make a particular medical decision. This distinction is critical, in that competency is a legal term and is only determined by a court of law, while capacity to make a specific decision may be determined by a physician, and that may fluctuate. A patient may have the capacity to understand that she would like to take acetaminophen for headache, but not have the capacity to consent to a complicated surgical procedure. Thus it is important to reassess capacity accordingly.
CASE 47-1
Ms. P is a 32-y.o. G unknown P unknown with schizophrenia, paranoid type, who is brought to the clinic by the staff of a healthcare facility for a positive urine pregnancy test, with gestation unknown. The staff states that Ms. P was placed in the facility approximately 1 week ago, after being hospitalized for 32 days in a psychiatric hospital. She is only taking haloperidol IM once a month, recently optimized, and has persistent paranoid delusions themed around government agencies, despite medications.
Ms. P has a history of medication noncompliance, aggression, abuse of multiple substances, and 24 psychiatric hospitalizations for grave disability and psychosis. She has no known outside contact information or surrogate decision-maker. She has a court-appointed (nonfamily member), designated payee who handles her finances. When questioning the patient’s decision-making ability, the staff mentioned that she is in the process of having a temporary conservatorship.
Ms. P is sitting quietly, is somewhat guarded, and has a delayed response time, but answers all questions. She has no concerns or complaints and is asymptomatic from a pregnancy perspective. She does not know the date of her last menstrual period but understands that she might be pregnant. During the evaluation, she is mostly engaged, but at one point expresses distrust of an unclear government faction. She has a tangential and incoherent thought process, but coherent speech. She actively has paranoid delusions and is unable to provide a good medical history, but she is able to be redirected and talk about the pregnancy.
Ms. P shows understanding and agrees to a bedside ultrasound after hearing what the process entails. The ultrasound shows a viable 15-week intrauterine gestation. Ms. P is told that she is pregnant, and she understands what that means, recalling that she has been pregnant before. She immediately asks if it is “too late” to have an abortion. The procedure for a termination at her current gestation is reviewed with her. She sits quietly and listened. She asks only one question, about whether she would be able to have birth control after her procedure. Given her residual symptoms, paranoid delusions, and unclear capacity for decision-making, a capacity exam was completed during this visit, as stated and documented in the medical chart:
All components of capacity to specifically make the decision for (Example: Pregnancy Termination) were evaluated Figure 47-1:
Patient demonstrates ability to communicate a choice and stick with that choice: (in patient’s own words) “I know there is a baby growing in me, I know I do not want to be pregnant, I know that an abortion can end this pregnancy.”
Patient understands and is able to convey back the relevant information about the procedure/treatment recommended: (in patient’s own words) “I know I will have to take medicine and that you or one of the doctors here will go in through my vaginal and take out the baby, and I will be sleepy while it happens and then I will not be pregnant and will not have a baby.”
Patient understands the risks/benefits of the procedure/treatment and also of not having it done: (in patient’s own words) “I know I will have bleeding like a period and cramping and I could maybe get an infection, and I will not be pregnant. I can’t even take a baby where I live and I don’t want a baby. I know it isn’t just easy to get an abortion but it’s easier than having a whole baby, I had a baby before.”
Patient is able to communicate the rationale behind their choice: (in patient’s own words) “I know about options. Adoption options. I don’t want to go through adoption and I don’t want to be pregnant all this time and it was horrible before and people asking questions it’s too hard and too much for me I don’t want to do any of it.”
Ms. P is deemed to have decision-making capacity for a termination of pregnancy.
A patient with schizophrenia and residual symptoms should be able to undergo a pregnancy termination procedure, even though she has active episodes of delusions, if she has passed a capacity evaluation for decision-making about such a procedure. Her psychiatrist should be contacted to perform a second capacity evaluation in the interval time period between the initial consult and the date of the procedure. The day of the procedure, the physician obtaining informed consent should perform and document a third capacity evaluation to show that the patient continues to have the capacity to make this decision. Having three serial, consistent evaluations further bolsters the patient’s consent capacity; however, serial examinations are ideal, but not mandatory.
A new and separate capacity evaluation must be completed to address the question of contraception (remembering the second principle of conducting capacity evaluations—decision-making capacity should be specific to the medical intervention at hand). Ms. P was found to have the capacity to provide informed consent for pills and for permanent sterilization. However, she did not have capacity to consent for any implant or IUD contraception due to her fixed paranoid delusions regarding government monitoring. This case illustrates the importance of evaluating a patient’s capacity for each individual specific decision.
Capacity assessments in the pregnancy setting are often a result of the patient refusing treatment that is intended to promote fetal well-being. Specific questions of capacity vary with the stage of pregnancy, with the second trimester tending to be related to management of pregnancy complications, and third-trimester assessments often centered on consent for an emergent or a recommended mode of delivery. In all cases in the obstetric setting, maternal patient care is the first responsibility of the obstetrician (nonmaleficence, respect for autonomy, beneficence, and justice), but consideration must be given to the presence of a fetus who can suffer adverse outcomes due to maternal decisions.
The latter has given rise to an ethical statement presented in 2014 by the American College of Obstetricians and Gynecologists (ACOG), saying that in addition to the ethical obligations of the physician, the pregnant patient has certain obligations to the fetus as well (i.e. beneficence and nonmaleficence).3 When confronted with the issue of capacity in the postviable perinatal period, the physician should consider two time lines: first, the amount of time available before a medical decision or intervention must be made; and second, whether anything can be done within said time constraints to optimize the patient’s capacity for decision-making.
The best approach to management is to attempt to optimize the patient’s decision-making capacity before an emergent decision has to be made. Many studies have shown that women with severe mental illness (those who bear the consequence of affective psychosis in such ailments as schizophrenia and bipolar disorder) have a much higher incidence of antenatal complications.4 Much of this research is international, performed in countries with healthcare systems with substantial variations from the United States; however, literature reviews and studies of highly inclusive populations seem to indicate that the data is likely universal.5,6
One substantially noteworthy and high-powered study conducted in Sweden used prospective cohort data from a registry of more than 1.5 million women to compare birth outcomes for mothers with affective psychosis with birth outcomes for unaffected mothers. The data concluded that mothers with affective psychosis were more than twice as likely to have a preterm delivery, low-birth-weight infants, or stillbirths, even after controlling for maternal factors such as tobacco use.7 In the study, patients admitted to the antepartum service who may have risk factors for impaired capacity or evidence of impaired capacity at time of admission should have appropriate consultations as early in the admissions process as possible to potentially optimize their capacity for decision-making.
For instance, a severely mentally ill patient may not be compliant with her medication regime and should have a psychiatric consultation to optimize treatment or assess her risk of imminent decompensation. A patient who is under the influence of a substance or in the throes of withdrawal from such a substance should participate in an appropriate consultation for detoxification. Such patients should have the management plan reviewed multiple times, with the four components of capacity briefly addressed each time. Patients with risk factors for impaired capacity or decompensation should be asked as a preventative measure whom they consider to be a surrogate decision-maker. If the patient is able to designate a surrogate decision-maker, risk management should be contacted as well as the appointed individual to determine the proper protocol. When decisional capacity cannot be optimized, concurrent efforts should be made to find a capacitated decision-maker, both to protect the autonomy of the pregnant woman and to ascertain the relative moral and legal claims of the fetus.8
The most difficult issue that can arise with impaired capacity is when an emergent intervention must be done immediately for the well-being of the fetus and the patient is refusing. In the best-case scenario, the patient may have previously appointed an agent (a surrogate decision-maker or conservatorship). In the worst-case scenario, the court may need to become involved. It is not common that reproductive-age women have documents often used in medical care, such as advanced directives in place. In emergent cases of patients without decision-making capacity to consent to an emergent intervention, the standard of care should be carried out by the physician, even if the patient must be managed with chemical sedation. Risk management should be contacted immediately, and under their discretion, a court may be contacted just prior to imminent intervention as the final resort.
Finally, for patients who have had ongoing capacity concerns during L&D, in addition to the usual social work evaluation, a Maternal Competency Evaluation (conducted by the Child Psychiatry department as part of the neonate’s chart) must be completed prior to discharging an infant with a mother with even transiently impaired capacity. As previously discussed, competency is a legal term, and if a woman is deemed by a court not to have “maternal competency,” legal intervention ensues on behalf of the neonate for placement with a competent caretaker.
KEY QUESTIONS
How can a psychotic patient be managed in L&D?
How can one manage agitation in pregnant patients with underlying mental illness?
There are many reasons why patients may become agitated or combative in the hospital setting; acute intoxication and psychosis are among the most common. The treatments of the various types of intoxication are far too broad to review fully here; however, the consensus algorithm that follows addresses options for urgent treatment of agitation related to substance withdrawal.
Most women with schizophrenia report a worsening of their illness during pregnancy.9 Many mental health facilities are ill equipped and even a dangerous environment in which to manage a pregnant patient. In addition to worsening illness and lack of adequate treatment facilities, pregnancy in women with schizophrenia is accompanied by factors such as loss of housing, lack of prenatal care, being a victim of violence, and poor social support.10 Many women develop specific delusions about the pregnancy being related to something other than pregnancy. These delusions often result in self-injurious behavior, lack of recognition of labor as the delivery of an infant, and overt paranoia about the medical staff, as they often become incorporated into the patient’s delusions when they insist that there is indeed a pregnancy or confront the patient about her delusions.11 Another reason that women with schizophrenia or serious mental illness become agitated in the hospital is due to fear of losing custody of their babies, and perhaps exacerbations of past grief-related reactions as well.12
Regardless of the underlying thought process, paranoia, already a prominent symptom of schizophrenia, is often the drive behind a patient’s agitation. There are algorithms that provide guidance to clinicians regarding the pharmacological management of aggression. However, there are no efficacy or safety studies recommending strategies for the management of the agitated, pregnant patient.
Standard safety precautions should be taken and all staff should be notified, and chemical sedation should be given to the patient as quickly as possible in an effort to avoid the need for physical restraints. It is also advised not to confront the patient’s delusion, as this may escalate her level of agitation. If absolutely necessary, law enforcement or security may need to be called to place physical restraints on the patient, or for the nurse to administer chemical sedation, and it is also advisable that mitts be added to the restraint order so the patient does not harm herself. Physical restraints should be removed as soon as possible, as these may pose significant risks to the pregnant patient. Women in the second and third trimesters may develop obstruction of venous return to the heart and supine hypertension syndrome if placed in the supine position for prolonged periods of time.13 Based on a literature review and expert consensus, Currier and Medori (2006) proposed a treatment algorithm for the management of acute agitation or aggression in nonpregnant patients. It is commonly used with pregnant patients due to lack of other options supported by data,14 as shown in Table 47-1.
All are administered as needed every 30–60 minutes | |
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Given the long history of safety of haloperidol in pregnancy, the drug is often used in place of olanzapine, given the latter’s atypical antipsychotic metabolic disturbances and its association with gestational diabetes. Haloperidol 5 mg in combination with lorazepam 2 mg and an antihistamine such as cogentin 1 mg (to counteract the side effects of haloperidol), every 30 to 60 minutes as needed for agitation, can all be mixed in the same syringe or offered orally, and these drugs are commonly more available in practice and less expensive than the atypical antipsychotics, not to mention lacking the metabolic side effects.
Admittedly, in an acute scenario, it is unlikely that gestational diabetes or metabolic disturbances would be a consequence of an emergent dose of medication, and using any regimen is preferable to the patient placing herself or others in danger (and, of course, also preferable to physical restraints). In the absence of safety data, clinicians should attempt to use the minimum amount of medication necessary to reduce agitation and the risk of aggression. A Psychiatrist should be consulted to recommend standing doses of medication, in addition to as-needed medications to treat agitation in patients with psychotic disorders, in order to decrease the need for repeated urgent administrations of chemical restraints.