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PSYCHIATRIC DISORDERS IN PREGNANCY
Timothy J. G. Pavy
Introduction The aim of this chapter is to consider the anesthetic implica-
tions of conditions that arise de novo, as well as existing illnesses
The peak incidence of affective disorders in women occurs at 23 to
that may or may not be affected by the pregnant state.
44 years of age, which coincides with the prime child bearing
years. Pregnancy and childbirth represent major life stresses, as
well as a time of fundamental psychological and social change.
The experience of childbirth constitutes a major mental health
hazard for women, with an estimated fivefold increase in the The characteristic features of schizophrenia are delusions, hallu-
appearance of mental illness in the year following childbirth.1 cinations (auditory), disorganized speech (frequent derailment or
Women who are pregnant, or have recently given birth, may incoherence), grossly disorganized or catatonic behavior, and
experience relapses of earlier mental disease or develop a new negative symptoms (flat affect, alogia, or avolition). Two or
disorder. Women with psychiatric disorders become pregnant more of these features are required to make a diagnosis of schizo-
and their psychiatric condition can present management pro- phrenia and each must be present for a significant time during a
one-month period (or less if successfully treated).4
blems at different stages of pregnancy. Less commonly, previously
Schizophrenia affects 1% of the general population,5 and
well women may develop a major psychiatric disturbance during
or after pregnancy, which may or may not herald a chronic con- although it is often more florid in the reproductive years there is
dition. Many of these individuals take medications that have the a paucity of data concerning its incidence in pregnancy. The
potential to interact with anesthetic agents and other drugs. These condition was formerly further subdivided into the principal sub-
women require considerable tact and skill on the part of their types of paranoid, disorganized, and catatonic, although the clin-
attendants. ical relevance of that classification is now minimal.
The first three years of a consultation-liaison psychiatry service A significant disturbance of one or more â€˜â€˜major areas of func-
to an obstetric inpatient unit in an Australian hospital had a tioningâ€™â€™ occurs, such that self-care and interpersonal relation-
referral rate of 1.2% of obstetric admissions, totalling 90 consulta- ships are impaired. The disturbance has particular implications
tions over three years.2 The commonest DSM-III-R psychiatric for the newborn child, whose safety is of concern if the schizo-
diagnoses were personality disorders (19%), mood disorders phrenia is not properly managed.
(17%), schizophrenic disorders (15%), and adjustment disorders. Maintenance therapy consists of major tranquillizers, in either
Reasons for referral included coping problems, depression, anxi- oral or injectable form. Haloperidol and the phenothiazines have
ety or fear, and a history of major psychiatric illness. been the most studied drugs of this class during pregnancy. The
Obstetric anesthesiologists may have their management skills oral formulations include haloperidol, chlorpromazine, and
tested with women who have personality disorders. These thioridazine, whereas depot-injectable preparations include flu-
patients may be rude or complain excessively. The category of phenazine and flupenthixol.
dramatic personality disorders includes histrionic, borderline, All major tranquillizers have the potential to produce extra-
narcissistic, and antisocial. Affected women may also display pyramidal side effects, hence the common practice of coadminis-
poor impulse control, requiring a degree of firm professionalism. tration of atropine-like antiparkinsonian agents such as benztropine
However, these women are not commonly on medication for and benzhexol. If these agents are discontinued during the first
trimester, the balance of risks and benefits needs to be considered.1
their dysfunctional personality and interactions with anesthetic
agents per se are less likely. Case reports of limb reduction in babies born to women taking
haloperidol have been published,6 but the few large prospective
Women with a history of major psychiatric illness need coun-
seling before becoming pregnant as they are at greater risk for studies conducted have not found any teratogenic action related
postpartum psychoses, increasing the risk of harm to mother and to major tranquillizers. Chlorpromazine may be an exception,
child. It is important that the question of medication be dis- although the evidence implicating phenothiazines is based on
their use in treating hyperemesis gravidarum7 and not psychoses.
cussed. This is a contentious area that many clinicians find diffi-
cult to approach. The various risks are to the fetus, the pregnant Although there is little hard evidence to associate psychotropic
woman (due to altered physiology), the future behavioural tera- drugs with teratogenesis, there is an almost universal reluctance
togenesis in the newborn (effects on brain morphogenesis may to continue necessary medication during pregnancy. This reluct-
not appear for years), and to the mother and fetus from inade- ance is despite the fact that clinical deterioration may occur as a
quately managed disease.3 result. As pointed out by Kuller and coworkers,8 continuation of
Obstetric Anesthesia and Uncommon Disorders, eds. David R. Gambling, M. Joanne Douglas and Robert S. F. McKay. Published by Cambridge University Press.
# Cambridge University Press 2008.
5 Other disorders
a difficult area for obstetric anesthesiologists, becomes even more
Table 20.1 Guidelines for antipsychotics in pregnancy complicated in this clinical setting.
Consideration may be required for abandonment of regional
1. Avoidance during weeks four to ten postconception
techniques if operative delivery is necessary, on the grounds that
2. Discontinue two weeks predelivery
a violent awake patient presents a threat to the safe conduct of
3. Use potent agents
cesarean section (C/S) anesthesia. The principal tenet for inter-
4. Discontinue if neuroleptic malignant syndrome develops
action with these patients is that the attending clinician should be
5. Resume immediately postpartum
â€˜â€˜the ambassador of reality,â€™â€™ and the anesthesiologist needs to be
6. Avoid antiparkinsonian drugs
particularly sensitive to the dynamics of the situation. Emotional
support and a quiet environment are important, and the need for
medication throughout pregnancy is probably the wisest choice
urgent psychiatric consultation is self-evident.
in someone with a history of instability without medication, even
though exposure to the lowest dose is the preferred approach in
Neuroleptic malignant syndrome
the first trimester. Furthermore, patients with severe schizophre-
nia who are difficult to manage should be actively discouraged
This rare but sometimes fatal condition is similar to malignant
from conceiving until their illness is better controlled.
hyperthermia (MH), and may involve common pathways. It
When it is feasible to withdraw therapy, Miller9 has provided
occurs typically early in treatment and is characterized by fever,
specific guidelines, which are outlined in Table 20.1. Anti-
muscular rigidity, autonomic dysfunction, leukocytosis, and
psychotics should be avoided, if possible, during the period of
impaired level of consciousness. Therapy includes resuscitation
highest risk (four to ten weeks post conception) and discontinued,
with intravenous (i.v.) fluids, aggressive cooling, and administra-
if possible, two weeks before delivery to minimize withdrawal
tion of dantrolene following guidelines for management of MH.
effects in the neonate. Resumption of antipsychotic medication
An initial dose of 2.5 mg/kg can be repeated every 15 minutes
should begin immediately postpartum. Potent agents should be
until improvement or a total of 10 mg/kg has been administered.
given to minimize sedation, orthostasis, gastrointestinal slowing,
Bromocriptine has also been described in its management.9
and tachycardia. Therapy is discontinued if the neuroleptic malig-
nant syndrome develops (see later). Routine antiparkinsonian
agents are avoided.
Although this highly effective therapy is used most commonly in
the management of major depressive illness,11 it is sometimes
indicated in the acutely psychotic schizophrenic pregnant patient
when urgent control is required. Varan and coworkers12 reported
The archetypal phenothiazine is chlorpromazine, which was
its use in the emergency management of a pregnant woman at 18
given the trade name Largactil because of its â€˜â€˜large actions.â€™â€™
to 20 weeksâ€™ gestation who had homicidal impulses and tried to
The ability to exert an effect at many different receptors is a
strangle a nurse. The patient responded well to modified electro-
feature of most of the major tranquillizers. They are lipophilic
convulsive therapy (ECT) and low-dose chlorpromazine. She
amines whose action is on neuronal membranes. Binding sites
received a total of 12 courses of ECT with a conventional general
include presynaptic and postsynaptic receptors, as well as reup-
anesthetic of 0.6 mg atropine, 80 mg methohexital, 40 mg succi-
take sites for a host of neurotransmitters, including norepineph-
nylcholine, and assisted ventilation with 100% oxygen. Fetal heart
rine, dopamine, histamine, and acetylcholine.
rate (FHR) monitoring revealed a short-duration bradycardia
It is the action of antipsychotics on the a-1 adrenergic receptor
coinciding with the tonic phase of the seizure. External uterine
that has the greatest significance for anesthesiologists, because the
monitoring indicated no abnormal activity.
reduction in peripheral vascular resistance can lead to orthostatic
DeBattista and coworkers13 have reported a short but marked
hypotension. In the anesthetized patient, hypotension, heat loss,
FHR deceleration to 60 beats per minute (bpm) for three to five
and inadequate compensation for blood loss are complicating fac-
seconds some ten seconds after ECT was administered to a
tors. The quinidine-like effects of these drugs can produce changes
depressed 41-year-old primigravid woman. These authors specu-
on the electrocardiogram, including increases in PR, QRS, and QT
intervals. Preexisting heart block may be exacerbated.10 late that activation of the sympathetic nervous system by the
seizure may have played a role by reducing uterine blood flow.
Schizophrenic women are at increased risk of peripartum psy-
Unlike grand mal seizures, when hypoxia is common, anesthe-
choses, with considerable potential for self-harm, as well as harm
tized patients receiving ECT are well oxygenated. The clinical
to the neonates, if the mothers are delusional. Women with poorly
significance of decelerations is uncertain but probably of no
controlled disease may be uncooperative and hostile when
great moment, in view of their very short duration.
attempts are made to provide analgesia for labor pain. Paranoid
patients, in particular, may suspect that the anesthesiologist means
to harm them. It is useful to obtain a brief psychiatric history and
Manic depressive illness
ascertain whether medication has been taken as prescribed. Non-
This general term embraces a number of disturbances of affect
compliance, perhaps as part of perinatal deterioration, may pre-
(mood), including unipolar depression, unipolar mania, bipolar
sage a difficult interaction. Informed consent, which is traditionally
vomiting, prolonged sick leave during pregnancy, and increased
Table 20.2 Features of depression numbers of visits to the obstetrician.17 There is also a significant
increase in planned C/S and epidural analgesia in labor.
1. Depressed mood most of the day, nearly every day
Untreated depression in pregnancy carries substantial perina-
2. Markedly diminished interest or pleasure in all, or almost all,
tal risks.18 These include direct risks to the fetus and infant, as
activities most of the day
well as risks secondary to the unhealthy maternal behaviors seen
3. Significant weight loss
in depressed women. Untreated maternal depression can result
4. Insomnia or hypersomnia
in a catastrophic outcome. Too many studies focus on the poten-
5. Psychomotor agitation or retardation
tial but unproven risks of psychotropic medication (see later).18
6. Fatigue or loss of energy
Women suffering from gestational depression, with its attendant
7. Feelings of worthlessness or excessive or inappropriate guilt
biological dysregulation, may refuse treatment because of
(which may be delusional)
unfounded fears about teratogenesis. This is regrettable and has
8. Diminished ability to think or concentrate
important implications for the mental health of the woman and
the care of her child. One study showed that 75% of women who
disorder, and hypomania. An estimated 10% of pregnant women stopped taking antidepressants soon after conception had
develop a serious depression,14 for which therapy may be insti- relapses, often in the first trimester, with symptoms severe
enough to require retreatment.19 However, although continuing
tuted. Depression includes some or all of the symptoms listed in
Table 20.2. antidepressants throughout pregnancy reduces relapses, it does
Maternal depression has been associated with a number of not eliminate them. Pregnant women are twice as likely to have a
relapse if they do not take their medication.20
factors that predict poor neonatal outcome. Depressed women
often have poor appetite and so may have low weight gain in
pregnancy and are more likely to use tobacco, alcohol, or illicit
drugs. All of these factors increase the risk of preterm birth, small
head circumference, and low Apgar scores. Mood modulation in women with a bipolar disorder is achieved
A systematic review15 aimed at estimating the prevalence of commonly with lithium, but great concern has been expressed
depression in pregnancy by trimester, as detected by validated about the use of this drug in pregnancy. Avoidance of lithium in