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
These cases involved:
- child neglect15
- delivery of a stillborn fetus whose autopsy revealed traces of cocaine by-products16
- reckless endangerment after a newborn tested positive for cocaine.17
What is drug abuse?
According to the 4th edition of the Diagnostic and Statistical Manual of Mental Health Disorders, it is a “maladaptive pattern of substance use manifested by recurrent and significant adverse consequences related to the repeated use of substances” within a 12-month period, or persistently.7 To meet criteria for substance dependence, in addition to the criteria just mentioned, the individual must be tolerant to the drug, experience withdrawal when the drug is cut back or stopped, continue to use the drug despite knowledge of its dangers, or all of the above. Mothers who match this description often lose custody of their child—sometimes to foster care, sometimes to other family members.20,21
Some states use positive serum and urine toxicology as evidence to remove a child from the mother’s custody.19
It is important to attempt to build a doctor–patient relationship. You cannot solve the patient’s substance dependence problem in one night, but you can refer her to drug treatment. A urine toxicology screen can help you and the pediatricians know what the patient has been exposed to (TABLE 4).
TABLE 4
Commonly abused drugs and their potential effects
| Drug | Withdrawal effects on mother | Drug effects on fetus or infant |
|---|---|---|
| Alcohol | Sweating, increased heart rate, hand tremor, nausea/vomiting, physical agitation, hallucination (tactile, visual, auditory), illusions, grand mal seizures25 | Fetal alcohol syndrome. Withdrawal symptoms similar to those of the mother |
| Cocaine | Agitation, anxiety, anger, nausea/vomiting, muscle pain, disturbed sleep, depression, intense cravings for the drug, irritability25 | Risk of abruptio placenta, small-for-gestational-age infant, microcephaly, congenital anomaly (cardiac and genitourinary abnormality, necrotizing enterocolitis), central nervous system stroke or hemorrhage. Withdrawal effects include hypertonia, jitteriness, and seizures.26 |
| Crystal methamphetamine | Anxiety, psychotic reaction, intense hunger, irritability, restlessness, fatigue, depression, sleep disturbance, cravings25 | Premature birth, abruptio placenta, small-for-gestational age, hypertonia, tremors, poor feeding, abnormal sleep patterns26 |
| Marijuana | Irritability, anxiety, physical tension, decreased appetite and mood25 | Irritability, increase in bodily motility, tremors, startles, poor habituation to visual stimuli, abnormal reflexes, symptoms similar to mild withdrawal27 |
| Opioids (Heroin, methadone) | Dilated pupils, watery eyes, runny nose, diarrhea, nausea/vomiting, muscle cramps, piloerection, chills or profuse sweating, yawning, loss of appetite, tremor, jitteriness, panic, insomnia, stomach ache, irritability26 | Risk of prematurity, small-for-gestational age, adult withdrawal symptoms, irritability, hypertonia, wakefulness, jitteriness, diarrhea, increased hiccups, yawning and sneezing, excessive sucking and seizures. Withdrawal effects occur earlier in heroin-exposed babies than in methadone-exposed infants.26 |
CASE 4 RESOLVED
After delivery, a test indicates that the newborn has been exposed to cocaine. The mother admits to cocaine use during pregnancy. She says she did not seek prenatal care because she was afraid of being prosecuted and sent to jail. A social work consult is requested, and the mother is referred to a substance abuse treatment program. State law requires the case to be reported to child protective services. Upon hospital discharge, the newborn is initially placed with the paternal grandmother.
Denial of pregnancy
CASE 5: Patient’s labor takes her by surprise
The night is nearing its end, but it isn’t over yet. At 5:30 AM, you are called to a precipitous delivery involving a 17-year-old who has had no prenatal care. She denies knowing that she was pregnant, and says she thought her labor pains were a bowel movement. Her parents were similarly unaware that their daughter was pregnant, and are threatening to disown her.
How do you defuse the situation?
In a study of women who denied or concealed pregnancy, patients presented to the hospital for various reasons.22 For example, one woman went to the ER because she was seizing and her workup revealed that she had eclampsia. A number of women did not even recognize when they were in labor. The infants born to these women are at risk for a poor neonatal outcome.21,22
How can psychiatry help in such a case? By determining whether the patient denied her pregnancy—even to herself—or actively concealed it from others. Obviously, these circumstances have differing implications.
Denial is not a simple entity. It may involve a psychotic schizophrenic woman who is out of touch with the reality of her pregnancy; a woman who “affectively” denies her pregnancy, keeping the significance of her condition from herself and behaving as though she is not gravid (perhaps because she plans to give the baby up for adoption); or a woman who has pervasive denial and does not know that she is pregnant.22,23 In contrast, a woman who conceals her pregnancy is quite aware that she is gravid but consciously hides the gestation from others, begging the question of what she had planned for the future.22
