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

Metz conducted a study, in Colorado from 2004 to 2012, of all women with pregnancy-associated deaths (death during pregnancy or within 1 year postpartum from any cause). It was found that in the 211 maternal deaths, 63 (30%) were classified as maternal death by self-harm (accidental overdose or suicide). The overall pregnancy-associated mortality ratio was 34.4 (95% confidence interval [CI] 29.9–39.3) per 100,000 live births. Self-harm was the leading cause of maternal death with a mortality ratio of 9.6/100,000 live births. The mortality ratio from accidental overdose was 5.0 (95% CI 3.4–7.2) per 100,000 live births and from suicide at 4.6 (95% CI 3.0–6.6) per 100,000 live births.⁸ Almost 90% of the deaths from self-harm occurred in the postpartum period and in the majority of these women substance use and psychiatric disorders were present. In this study, among the women with suicide documented as the manner of death, the most common means were further subclassified as asphyxia by hanging (n = 10), penetrating trauma (gunshot wound or stab wound, n = 8), and intentional overdose (n = 5). Prior psychiatric diagnoses were documented in the clinical records of 54.2% (n = 32) and prior suicide attempts in 10.2% (n = 6). Depression was the most common documented psychiatric diagnosis. Social stressors were commonly documented in the medical records of women who died of self-harm, including unemployment (n = 38 [64.4%]); being single, divorced, or separated (n = 24 [40.7%]); history of domestic violence (n = 11 [18.6%]); unstable living situations such as homelessness (n = 3 [5.1%]); and current domestic violence (n = 3 [5.1%]). Less than 50% of women with maternal death from self-harm attended a postpartum visit; thus, targeting postpartum visits alone for depression screening and management will be inadequate to reach women at risk. Rather, each point of contact throughout the pregnancy should be considered an opportunity for screening and intervention including preconception visits, antenatal care, hospitalization for delivery, and postpartum visits for both the mother and the neonate.

A common misconception about suicide screening is that one may actually increase the risk of the patient attempting suicide (or implanting the suicidal notion into a patient’s mind) simply by inquiring about these thoughts. There is evidence to support exactly the opposite; empathic questioning of a patient about her possible thoughts of self-harm may actually alleviate some of the related emotional distress and may even serve to reduce the risk for a suicide attempt. An honest, open, and gentle probing of a patient’s thoughts and feelings about harming herself (or others) will often yield a wealth in useful information (Table 21-2). Not all women who express thoughts of suicide will go on to attempt or commit suicide but given the potential cost is so great that each and every expression of suicidal thinking deserves appropriate consideration.

Arrange for a safe environment! There are no limitations to when and where we may encounter a suicidal patient but there is no reason to limit the most basic of interventions—assure her safety. Examples of techniques that can be used to assure safety are listed in Table 21-3.

The Council on Patient Safety in Women’s Health Care interdisciplinary workgroup developed a maternal mental health safety bundle. The full bundle which includes the provision to activate an Emergency Referral Protocol for Women With Suicidal or Homicidal Ideation or Psychosis can be found on the Council on Patient Safety in Women’s Health Care website.⁹ Such a protocol, structured as a response to the patient expressing suicidal or homicidal ideation, includes an emergency management plan that should provide direction for the following:

1. 
   

   Determine the working diagnosis: severe depression, psychotic features (such as auditory, visual, olfactory, or tactile hallucinations), delirium, or mania.

   
   
2. 
   

   Trigger emergency psychiatric consultation, treatment, transport (by ambulance), or admission.

   
   
3. 
   

   Facilitate open communication between the perinatal care team and the psychiatric team and defining all members’ respective roles during the initial evaluation and initiation of treatment, as well as for additional care and follow-up.

   
   
4. 
   

   Identify medication, resources, support staff and family, and other tools needed by personnel at each stage.

Identification of an emergency process for getting the patient safely to care should include the following:

1. 
   

   Identify mental health screening tools to be made available in every clinical setting (outpatient obstetric clinics and inpatient facilities).

   
   
2. 
   

   Establish a response protocol and identify screening tools for use based on local resources.

   
   
3. 
   

   Educate clinicians and office staff on use of the identified screening tools and response protocol.

The expression of anger often follows a recognized pattern. Being aware of this pattern can guide the healthcare provider to diffuse a potentially explosive situation. Anger is a ubiquitous human emotion and may be reflective of unexpressed fear, a feeling often expressed as anger. A triggering event (such as a comment, action/inaction, or event) can release a cascade of emotions that come out as anger. The true source of the anger is often difficult to clarify, as we tend to focus more on the behavior demonstrated during the acting out phase of the anger process (Table 21-4).

When faced with an escalating situation, the initial response should be to remain calm (both emotionally and physically) and maintain appropriate eye contact (remembering that in some cultures direct eye-contact may be viewed as aggression). The patient is attempting to communicate something to you (which may not be clear to anyone, including the patient, at this point). Your job is to ensure safety and to gather as much data as possible. Some helpful steps toward understanding the patient’s needs are outlined in Table 21-5.

The following examples of techniques that can be used in these situations, as a process of de-escalating a crisis situation, can be found in many counseling resources such as Behavioral Medicine: A Guide for Clinical Practice by Feldman (2007).¹⁰

Modeling

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  Slow, steady breathing

  
  
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  Monitor the pace and tone of your voice.

  
  
• 
  

  Open body language

  
  
• 
  

  Monitor your body language to avoid closed, aggressive postures. Sitting directly in front of someone can appear confrontational.

  
  
• 
  

  Consider sitting at a 45 degree angle, or if safe, facing the same direction.

Rapport Building

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  Listen with attention and intention.

  
  
• 
  

  Make empathic statements

  
  
  
  
  • 
    

    “I can appreciate how you feel.”

    
    
  • 
    

    “It concerns me that you feel so strongly about this.”

    
    
  • 
    

    “Tell me how I can make it easier for you.”

Confrontation (Difficult to do Until Rapport has Been Established)

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  “You seem very angry?”

  
  
• 
  

  “It’s unlike you to be like this.”

  
  
• 
  

  “I get the feeling that you are upset with…”

  
  
• 
  

  “What is it that’s upsetting you?”

  
  
• 
  

  “What really makes you feel this way?”

Reflection, Facilitation, Clarification

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  Do not parrot patient statements or phrases, but try to accurately reflect or rephrase what you think the patient is trying to communicate.

  
  
  
  
  • 
    

    “I find it puzzling that you are angry with me.” “So you feel that…..”

    
    
  • 
    

    “You seem to be telling me….”

    
    
  • 
    

    “If I understand you correctly…”

    
    
  • 
    

    “Tell me more about this….”

    
    
  • 
    

    “I would like you to enlarge on this point…it seems important.”

Searching

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  “Do you have any special concerns about you or your baby’s health?”

  
  
• 
  

  “Tell me more.”

  
  
• 
  

  “How are things at home, work?”

  
  
• 
  

  “How are you sleeping, eating?”

  
  
• 
  

  “Do you have any special dreams?”

  
  
• 
  

  “Can you identify anyone who has a problem like you have?”

• 
  

  A past history of violence is the greatest predictor of future violence.

  
  
• 
  

  Watch for premonitory signs (fist clenching, use of profanity, violence to inanimate objects, actual verbal threats).

  
  
• 
  

  Verbally engage the patient’s threat.

  
  
• 
  

  Assess for access to a weapon.

  
  
• 
  

  Actively respond to escalating threat behavior.

  
  
• 
  

  Do not hesitate to call for security support.

  
  
• 
  

  Always position yourself with an easy exit.

  
  
• 
  

  If escape is not possible, prepare for self-defense.

It is impossible to predict with 100% certainty when a patient will become violent. Patients with perceived injury, either physical or psychological, are at increased risk for committing violence against clinicians, especially if their complaints are dismissed.^11,12 A patient who remains upset, yet is responsive to your efforts, will be managed differently than a patient who continues to display escalating hostile behavior.

When the patient begins to display agitation or altered mental status, a process for evaluating other potential sources is necessary. Table 21-6 describes some potential causes of agitation, while a guideline for the evaluation for causes of altered mental status is shown in Table 21-7.

Part of the goal of controlling an erupting situation is to assure the safety of the patient, the staff, and others in the immediate area. Given that such scenarios are often highly emotionally charged, utilizing basic crisis management techniques must occur so as to have the greatest likelihood of a smooth resolution. Table 21-8 describes the management of such situations. Table 21-9 lists medications often used for treatment of the agitated patient. Rarely physical restraint becomes necessary. Guidelines for use of restraints in pregnancy are outlined in Table 21-10.

Anxiety disorders are among the most prevalent psychiatric conditions in the general population¹ and consist of a wide range of conditions as listed in Table 21-11.¹ Incidence rates have been reported as high as 18% to 28%. While there are no specific reports documenting these rates in pregnancy, it is suspected that rates of anxiety (posttraumatic stress disorder [PTSD], generalized anxiety disorder [GAD], panic disorder, specific phobia, agoraphobia) are 2 to 3 times greater for women.