A 35-year-old, gravida 2, para 1 woman with chronic paranoid schizophrenia and substance abuse presented to a community free clinic for a regular appointment after having been lost to follow-up. At the appointment she was noted to have a pronounced gravid abdomen and to be acutely psychotic, prompting transfer to the local emergency department. On presentation she exhibited severe disorganization of thought, paranoia, auditory hallucinations, and delusional denial of her pregnancy. She was admitted to the inpatient psychiatry service with consultation to maternal-fetal medicine.
Treatment and Management
Baseline obstetric laboratory studies were performed, and an obstetric ultrasound estimated the gestational age to be consistent with 34 weeks. The patient refused to talk with the obstetrics team or answer any questions pertaining to the pregnancy. She also refused appropriate obstetric or psychiatric treatment. Due to the patient's refusal of treatments, and consequent risks for both her health and that of her fetus, a petition was made to the County Probate Court for inpatient treatment. The Probate Court approved both involuntary commitment to inpatient psychiatric services and mandatory medication therapy.
Treatment with a long-acting haloperidol depot was considered but the patient expressed a fear of injections. In an effort to maintain therapeutic alliance, oral haloperidol was prescribed and titrated until the patient exhibited improvements in thought process, paranoia, acceptance of her schizophrenia, and compliance with pharmacological treatment. However, her delusional denial of pregnancy persisted and she continued to decline physical examination or fetal surveillance. The obstetrics and psychiatric teams agreed that the patient should stay on the psychiatric unit until her baby was born to ensure her safety given her poor insight into her condition. Care was coordinated such that the psychiatric treatment team provided the obstetrics team with regular updates on the patient's status multiple times per day.
Once the decision for involuntary inpatient hospitalization was made, the hospital's legal department was consulted to file an emergency guardianship application for the patient because no family or social support could be reached. An initial petition for guardianship was declined as the court stated there was no direct proof that the patient displayed signs of irreparable harm to herself or to her pregnancy. The legal team presented further evidence of patient's noncompliance, lack of insight, and the impact of both on her pregnancy. Temporary guardianship was ultimately granted for the duration of the patient's hospitalization and delivery. Social work established a case with the county Child Protective Services requesting that the infant be placed in the custody of the state on delivery as no family could be identified.
Once a guardian ad litem was appointed, a multidisciplinary team consisting of psychiatry, obstetrics, nursing, anesthesia, social work, legal services, hospital ethics committee, and the guardian ad litem was formed to further address timing and route of delivery. The team agreed that induction of labor at 39 weeks gestation was the safest and most appropriate plan of care. Contingency plans were created to prepare for all possible labor and delivery scenarios in the event that the patient went into spontaneous labor prior to the planned induction. The obstetrics team prepared an emergency delivery kit to keep on the psychiatric unit and provided education to the nurses on signs of labor. An inpatient obstetrical team of physicians and nurses was also available at all times. Plans for postpartum care and contraception were also discussed, and the decision was made that the patient would have immediate postpartum placement of a long-acting reversible contraception device.
The patient had not gone into spontaneous labor by 39 weeks gestation so induction with intravenous oxytocin proceeded as planned. By this time, the patient had built some rapport with the psychiatric staff, despite her limited insight. Although she continued to deny that she was pregnant, she consented to transfer to the labor and delivery unit with the support of the psychiatric nurses with whom she was most familiar. Her induction progressed in an uncomplicated fashion and resulted in the vaginal delivery of a live-born male infant with a birth weight of 3,281 g and Apgar score of 8 and 9 at 1 and 5 minutes, respectively. After delivery the patient was transferred back to the inpatient psychiatric unit for continued treatment of her psychosis, and the child was transferred to the newborn unit until discharged to the custody of Child Protective Services. The mother demonstrated some mild improvement in symptoms before being discharged with follow-up to her previous community mental health service, with additional assertive community treatment and regular follow-up with the judge due to the civil commitment order established during her admission.
The complexity of this case highlights the importance of interdisciplinary collaboration and communication. Multiple medical, ethical, and legal questions arose requiring input from each discipline involved to ensure optimal outcomes for the patient and her unborn child. The psychiatry team was primarily responsible for ensuring the patient's safety on the unit while stabilizing her mental illness through use of both pharmacologic treatment and psychoeducation. Among antipsychotic medications, haloperidol has been the most studied and has been associated with safe fetal outcomes, regardless of timing of exposure.1,2 The largest wealth of reproductive data for antipsychotics exists for haloperidol (which has been used in the treatment of hyperemesis gravidum). The data have shown no significant teratogenic risk or adverse fetal outcome, making it the treatment of choice for this patient.2,3 Both the American College of Obstetricians and Gynecologists (ACOG) and the American Psychiatric Association recognize the high-potency, first-generation antipsychotics as being the treatments of choice for schizophrenia in pregnancy.4,5
Although this therapy improved her paranoid delusions, it did not improve her pregnancy denial. The incidence of pregnancy denial typically decreases throughout the duration of the pregnancy with only 1 in 2,500 women exhibiting continued denial at term.6 The majority of the literature describes cases of nonpsychotic, stress-related denial of pregnancy in women without prior known mental illnesses, in contrast to only a few case reports of documented delusional denial of pregnancy.7–9 It is unlikely that, even if the patient had presented for care earlier in her pregnancy, she would have achieved greater insight into her gravid state without aggressive antipsychotic therapy, intensive psychoeducation, and (most importantly) treatment compliance.
From an obstetrics perspective, assigning an estimated due date, determining timing and route of delivery, and postpartum contraception were of primary concern. The due date was estimated based on a third-trimester ultrasound, which has a large margin of error (± 21–30 days). Based on this error range, a fetus estimated to be 39 weeks could actually be preterm at 36 weeks or post-term at 42 weeks, both of which pose fetal risks. After weighing the risks and benefits of the timing of delivery, the team recommended 39 weeks gestation. After establishing the timing of delivery, addressing the safest route of delivery was needed. The patient's denial and poor insight made it impossible to predict how the patient would respond to labor induction or to surgery. A cesarean delivery could be done in a controlled setting, yet the team was reluctant to expose the patient to the associated risks. The obstetrics team determined expectant management with induction of labor at 39 weeks gestation had the potential for the best outcome with a vaginal delivery.
Finally, there needed to be a strategy to prevent unplanned future pregnancies. With her history of poor medication compliance, time-sensitive contraception options (eg, oral contraceptive pills and depot medroxyprogesterone acetate) were deemed inappropriate. Long-acting reversible contraception in the form of an intrauterine device (IUD) was selected. A great deal of misconception continues to exist about the safety and ease of postpartum administration of IUDs.10 The Centers for Disease Control and Prevention classified immediate postpartum IUD insertion as “level 1 = A condition for which there is no restriction for the use of the contraceptive method” in the 2016 US Medical Eligibility Criteria for Contraceptive Use.11 The ACOG recommends that IUDs should be offered routinely because of their safety profile and the fact that IUDs (and implants) are the most effective forms of reversible contraception.12 The state of legislature of Ohio also recognized the importance of offering this type of contraception to women in the immediate postpartum period. A law was passed in 2016 that requires maternity centers in Ohio to offer long-acting reversible contraception to all women at the time of admission for delivery.13 The risk of a subsequent unintended pregnancy and its sequelae for this patient was weighed against the risks and benefits of the IUD. An IUD was recommended given the ease of immediate postpartum insertion, length of approved contraceptive efficacy, and safety profile. Both the guardian ad litem and the judge overseeing the patient's case agreed with this recommendation and provided consent for the IUD placement.
This case presented significant legal challenges. Due to the severity of the patient's mental illness, she required inpatient psychiatric treatment, assignment of guardianship, and obstetric observation throughout the remainder of her pregnancy. The patient had already established a pattern of noncompliance with outpatient management for her schizophrenia and overt denial of her pregnancy. Despite the significant functional impairment observed by health care professionals involved in this case, the court initially denied guardianship. The appeal for guardianship was eventually approved but only after the multidisciplinary team more clearly demonstrated the patient's inability to comprehend medical topics, to appreciate potential adverse maternal and fetal consequences, or to compare options and engage in comparative reasoning. Without court-approved treatment and management, appropriate care for this patient would not have occurred.
This case demonstrates how psychiatric illness during pregnancy poses unique clinical complexities that require coordination and communication from multiple specialties including psychiatrists, obstetricians, social workers, and legal authorities to ensure optimal outcomes for both the patient and her unborn child. When caring for these patients, it is prudent to have ongoing meetings throughout their hospitalization to address various medical and legal questions that develop during the course of treatment. Without using an inpatient multidisciplinary approach, there was the potential for detrimental consequences for the patient and her pregnancy. In summary, a collaborative approach between various disciplines ultimately led to the safe delivery for the patient and the fetus.
- Gentile S. Antipsychotic therapy during early and late pregnancy. A systematic review. Schizophr Bull. 2010;36(3):518–544. https://doi.org/10.1093/schbul/sbn107 PMID: doi:10.1093/schbul/sbn107 [CrossRef]2879689
- Iqbal MM, Aneja A, Rahman A, et al. The potential risks of commonly prescribed antipsychotics during pregnancy and lactation. Psychiatry (Edgmont). 2005;2(8):36–44. PMID:21152171
- Committee on Obstetric Practice, the American Institute of Ultrasound in Medicine, and the Society for Maternal-Fetal Medicine. Committee Opinion No. 700: methods for estimating the due date. Obstet Gynecol. 2017;129(5):e150–e154. https://doi.org/10.1097/AOG.0000000000002046 PMID: doi:10.1097/AOG.0000000000002046 [CrossRef]
- ACOG Committee on Practice Bulletins–Obstetrics. ACOG practice bulletin: clinical management guidelines for obstetrician-gynecologists. Use of psychiatric medications during pregnancy and lactation. Obstet Gynecol. 2008;111(4):1001–1020. doi:10.1097/AOG.0b013e31816fd910 [CrossRef]18378767
- Lehman AF., Lieberman JA, Dixon LB, et al. Work Group on Schizophrenia. Practice guideline for the treatment of patients with schizophrenia. http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/schizophrenia.pdf. Accessed October 7, 2019.
- Jenkins A, Millar S, Robins J. Denial of pregnancy: a literature review and discussion of ethical and legal issues. J R Soc Med.2011;104(7):286–291. https://doi.org/10.1258/jrsm.2011.100376 PMID: doi:10.1258/jrsm.2011.100376 [CrossRef]217250943128877
- Friedman SH, Heneghan A, Rosenthal M. Characteristics of women who deny or conceal pregnancy. Psychosomatics. 2007;48(2):117–122. https://doi.org/10.1176/appi.psy.48.2.117 PMID: doi:10.1176/appi.psy.48.2.117 [CrossRef]17329604
- Kuppili PP, Gupta R, Pattanayak RD, Khandelwal SK. Delusional denial of pregnancy: unique presentation of Cotard's syndrome in a patient with schizophrenia. Asian J Psychiatry. 2017;30:26–27. https://doi.org/10.1016/j.ajp.2017.07.005 PMID: doi:10.1016/j.ajp.2017.07.005 [CrossRef]
- Walloch JE, Klauwer C, Lanczik M, Brockington IF, Kornhuber J. Delusional denial of pregnancy as a special form of Cotard's syndrome: case report and review of the literature. Psychopathology. 2007;40(1):61–64. https://doi.org/10.1159/000096685 PMID: doi:10.1159/000096685 [CrossRef]
- Yoost J. Understanding benefits and addressing misperceptions and barriers to intrauterine device access among populations in the United States. Patient Prefer Adherence. 2014;8:947–957. https://doi.org/10.2147/PPA.S45710 PMID: doi:10.2147/PPA.S45710 [CrossRef]250500624090129
- Curtis KM, Tepper NK, Jatlaoui TC, et al. U.S. medical eligibility criteria for contraceptive use, 2016. MMWR Recomm Rep.2016;65(3):1–103. https://doi.org/10.15585/mmwr.rr6503a1 PMID:27467319
- Committee on Practice Bulletins-Gynecology, Long-Acting Reversible Contraception Work Group. Practice Bulletin No. 186: long-acting reversible contraception: implants and intrauterine devices. Obstet Gynecol. 2017;130:e251–e269. doi:10.1097/AOG.0000000000002400 [CrossRef] PMID:29064972
- 7 Ohio Rev. Code. § 3727.20 (2016). http://codes.ohio.gov/orc/3727.20v1. Accessed October 7, 2019.