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///2018 Abstract Details
2018 Abstract Details2019-08-02T15:57:01-05:00

Managing a Parturient with Acute Psychosis: A Multidisciplinary Approach

Abstract Number: F1D-2
Abstract Type: Case Report/Case Series

Kristen Fardelmann M.D.1 ; David Mayer M.D.2

Intro: Parturients are vulnerable to psychiatric illness, increasing risk to mother and fetus. Schizoaffective disorder (SAD) is associated with inadequate prenatal care, substance abuse, premature birth, low birth weight, placental abnormalities, congenital anomalies (with and without medication use), and postnatal death. Parturients with SAD present unique peripartum challenges.

Case: The patient is a 30 y.o. G1P0 at 23 weeks gestation transferred in four point restraints for inpatient treatment of SAD with severe psychosis and homicidal ideation triggered by medication noncompliance. Her history includes BMI=62 kg/m^2, chronic hypertension, asthma, type II diabetes mellitus, obstructive sleep apnea, marijuana abuse, and intolerance to haloperidol. At 26 weeks gestation, obstetric anesthesia was consulted for discussion of ECT, prolonged deep sedation, and to strategize a safe plan in the setting of an obstetric emergency. The patient had persistent psychosis and intermittent aggression requiring lithium, carbamazepine, trazodone, valproic acid, clozapine and clonazepam. On exam, she was unable to communicate due to excessive salivation, but followed commands. Airway exam was reassuring except for a mallampati score of IV. After a multidisciplinary meeting, the psychiatry service did not believe ECT would be beneficial and concluded deep sedation was not beneficient and likely maleficient. At psychiatric stabilization (31 weeks), the patient was discharged to home. At term, the patient was admitted for induction of labor in the setting of non-reactive antenatal testing. Due to failure to progress, the patient underwent a cesarean section with neuraxial anesthesia. Delivery of a liveborn female infant with APGARS 6 and 9 was completed uneventfully. The infant had no apparent anomalies and was without evidence of medication withdrawal. She was discharged on day of life 3.

Discussion: SAD is associated with medication noncompliance in pregnancy. In the setting of aggressive behavior, redirection is recommended. If unsuccessful, anti-psychotics are the first line therapy. Use of four point restraints should be avoided if possible due to concerns for IVC compression and inadequate placental perfusion. Although teratogenic and toxic, the benefits of psychiatric stability outweighed the risks of: lithium (ebstein’s anomaly, premature labor, polyhydramnios, cardiomegaly, hepatomegaly, neonatal nephrogenic DI, goiter, hypothyroidism, floppy infant syndrome, and lithium toxicity), carbamazepine (neural tube defects (NTD), cardiovascular malformations, craniofacial and urinary tract defects), valproic acid (NTD and decreased IQ), and benzodiazepines (neonatal abstinence syndrome). Colliding ethical principals of beneficence and nonmaleficence played a key role in deciding an appropriate treatment course.

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SOAP 2018