Late-term Peripartum Psychosis as a Potential Indication for Induction: An Interdisciplinary Approach to the Ethical and Patient Safety Considerations of Severe Mental Illness in Late Term Pregnancy

Background: Acute psychosis during pregnancy is an obstetric emergency due to potential maternal and fetal risk. Women with severe mental illness have higher obstetric and neonatal complications with a dearth of literature to guide management. A 2014 case report notes the importance of comprehensive, coordinated care between psychiatric and obstetric teams. We describe an interdisciplinary approach to the labor and delivery of an acutely psychotic patient who underwent late-term induction of labor (IOL).

Case Report: Ms. L is a 33-year-old female G3P2 found to be at 38 weeks gestation on arrival and involuntarily admitted to our stand-alone psychiatric hospital for erratic behavior and suicidal gestures. She was diagnosed with unspecified psychotic disorder and initiated on haloperidol due to significant harm towards self and staff necessitating restraints. Given concerns around maternal and fetal safety, planned IOL at 39 weeks was considered to minimize potential harm related to ongoing pregnancy and spontaneous labor. Collaboration between Nursing Leadership, Social Work, Inpatient Psychiatry, Family Medicine, Consultation-Liaison (CL) Psychiatry, Maternal Fetal Medicine, OB Anesthesiology, Neonatology, and Security Leadership included discussions around patient safety, ethical considerations, and clear role assignments. This team coordinated transfer to the women’s hospital for elective IOL with surrogate decision-maker consent. The CL team was involved throughout admission including greeting the patient on arrival and managing acute agitation that posed a safety risk with as-needed benzodiazepines and mechanical restraints. Epidural was placed within 10 hours, IOL initiated within 12 hours, and she underwent uncomplicated vaginal delivery of a healthy baby (Apgars 8 and 9) after 20 hours of arrival. She transferred back to the psychiatric hospital within 16 hours of delivery, improved with antipsychotic treatment, and was discharged with a diagnosis of peripartum psychosis.

Discussion: The management of late-pregnancy psychosis raises numerous ethical and patient safety concerns and depends upon cross-disciplinary collaboration. In this instance, planned IOL permitted necessary preparation to optimize maternal and fetal outcomes while maintaining patient, baby, and staff safety. We will present systems considerations detailing handoff, transfer, consultation, agitation management, and postpartum care including kinship placement. We will also delineate role assignments by specialty and recommend best practices in the care of late-term acutely psychotic patients.