Does your OB patient have a psychiatric complaint? And can you manage it?
Here’s how to handle 5 challenges, including postpartum depression, an attempt to leave the hospital against advice, and denial of pregnancy
IN THIS ARTICLE
Dementia may also be on the differential diagnosis, but this chronic condition is unlikely in such a young patient (unless she were in the late stages of HIV/AIDS, for example). Dementia has a gradual onset and is irreversible.
TABLE 3
Some causes of agitation
Delirium
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Psychosis
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Dementia
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Personality dysfunction
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Workup for the agitated patient
Assess vital signs and basic laboratory studies, particularly a complete blood count, thyroid testing, metabolic screens, glucose, serum chemistry panel, and urine toxicology, to rule out causes of delirium and detect any substances the patient may have used. Also consider that the patient may have initiated a new medication recently.
Imaging of the brain or chest or electroencephalography may be necessary, such as in the setting of infection or concerns regarding seizure activity.
Gather collateral information about the patient from her relatives, friends, and the support staff. Search her chart for recent contacts. Did she have a visitor or phone call that may have upset her? Explore whether she is having problems with her partner or family and friends. Also confirm that her agitated behavior is an acute change.
Investigate the patient’s paranoia. Why does she believe that the staff is against her? Does she believe they are trying to harm, kill, or poison her? Assess her reasoning to determine whether her behavior is psychotic or a personality problem.
Ask her about hallucinations, keeping in mind that hallucinations are different from illusions, in which a patient misinterprets what she sees. What are the voices saying to her?
Also ask about any suicidal or homicidal commands. If she acknowledges that she is hearing them, get a sitter for her immediately and make her environment safe so that she is unable to harm herself. Then contact the psychiatry department again.
How to intervene
Talk gently and quietly in an attempt to calm the situation. Try to make yourself “small”: Stand back and stay at the patient’s eye level, not in her personal space or towering over her.
Also, protect yourself. Don’t challenge her complaints immediately or you will alienate her. Medically evaluate and treat the cause of her agitation, and, if medications are necessary for psychosis or sedation, contact psychiatry for assistance.
CASE 3 RESOLVED
The patient does not respond to your attempts to reason and refuses to allow the nurses to check her vital signs. Security is called to stand by while her vital signs are reassessed. The nurses inform you that the patient’s family is in the waiting room. Though you find no documented history of substance use or abnormal labs, the family reports that the patient had a history of alcohol abuse but quit drinking about 3 days earlier. They also report that, before she quit, she drank approximately 25 oz of vodka and a sixpack of beer nightly. They deny knowledge of any other illicit drug use. Because her vital signs suggest alcohol withdrawal, you offer oral lorazepam and treat her according to the hospital’s alcohol withdrawal protocol. She recovers without any further complications and is referred to the chemical dependency service for evaluation.
Drug abuse during pregnancy
CASE 4: Patient skips prenatal care
It is 2 AM, and you are about to get some rest when you are paged by the emergency room about a 26-year-old G5P4, who is in active labor with no dates. You check the database and discover that her previous pregnancies were complicated by chronic substance abuse.
How do you respond?
You might feel frustrated and angry with this patient. Considering that you have not met her, these feelings would be based on previous contacts with patients who had a similar history. This is countertransference. We all experience it. It can be helpful or harmful, but you cannot control it unless you are aware of it. Pay attention to the anger, happiness, or pride that a patient triggers in you, and acknowledge that it is your issue.
Your frustration may also stem from personal feelings about mothers who repeatedly expose their fetuses to drugs and neglect prenatal care, as well as anxiety about what you are legally and ethically bound to do.
In Ferguson v City of Charleston, the Supreme Court found that drug testing of a pregnant woman for the purpose of criminal prosecution is a violation of Fourth Amendment rights.14 However, there have been cases in which a state prosecuted a woman for using an illegal substance during pregnancy.
