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Guiding Denial: Discussion of Mental Health in Pregnancy
Abstract Number: F1D-1
Abstract Type: Case Report/Case Series
Mental health is pervasive, affecting approximately 1 in 5 adults in the U.S. Co-occuring psychiatric illness (PI) and substance abuse (PSA) disorders occur in approximately 39.1% of the population. Medical therapy disruption can occur at any time, especially during pregnancy, and is a well-recognized trigger for relapse in as high as 79% of pts. Here we describe a PPROM pt with schizophrenia and bipolar and the ethical challenges in managing her care.
A 34 yo G5P1031 with bipolar, schizophrenia, and PSA presents to OSH at 33w2d GA acutely psychotic from a methamphetamine withdrawal. She had a positive amnisure, confirmed PPROM and was transferred to our institution in denial of PPROM, refusing medical treatment.
The pt has a history of prior psychiatric hospitalizations and history of self-harm in the setting her mental illness. Her diagnoses include bipolar, schizophrenia, and ADHD. PSA history includes methamphetamines, marijuana, and cigarettes. She self-discontinued the use of her mood stabilizing medications, aripiprazole, sertraline, and lithium, in her first trimester.
At our institution, she refused medical treatment despite counseling. Several questions were posed at this juncture: 1) does the patient have medical-decision-making capacity, 2) what is the best course of medical management for the pt and fetus, and 3) what is the best contraception option, as sterilization was requested by the medical proxy, her mother? Psychiatry, ethics committee, legal and risk management guided our care.
Psychiatry confirmed psychosis and denial and reported that the patient lacked medical-decision-making capacity. The ethics committee encouraged voluntary cooperation (respect), participation when able (autonomy), utilization of medical proxy for medical decisions except for permanent sterilization (nonmaleficence), and delivery of fetus at 34w GA (beneficence).
At 34w GA, the patient received haldol IM for IV placement, SVE, and monitoring. She was transferred to the ICU where she was started on a dexmedetomidine infusion for sedation while an epidural was placed in the lateral position. Her labor progressed with pitocin, and a full-assist FAVD was performed. A LARC was placed until the patient had the ability to request permanent sterilization voluntarily.
Perinatal psychiatric illness is common and carries significant morbidity and mortality for the mother and fetus. Up to 0.4% of pregnant women meet criteria for a psychotic disorders. Maternal schizophrenia and psychosis during pregnancy are associated with high risk of adverse pregnancy and birth outcomes and can lead to sensitive, complex legal and ethical issues. A multidisciplinary team approach was used, and open communication channels were maintained. This led to successful delivery of the baby and eventual transfer of patient from our hospital.