Critical Care Obstetrics part 70 ppsx

Ethics in the Obstetric Critical Care Setting 679 [11] ). Not many successful lawsuits of this nature have been reported. This may be due to pretrial settlements or to feelings on the part of the Witness that the injuries infl icted cannot be compensated by monetary awards [74] . Guidelines for a pproaching Jehovah ’ s Witness p atients One of the more important aspects in dealing with adult or eman- cipated Witness patients is for the physician to be honest regard- ing whether he or she can respect their wishes regarding transfusion of blood products. If it would be impossible for the physician to allow the patient to die without a transfusion then he or she needs to be honest at the fi rst patient encounter and if possible fi nd an alternative physician to assume care. It is impor- tant to determine the exact wishes of the Witness patient regard- ing which blood products are acceptable. There are local and individual variations in Witness ’ interpretation of the prohibi- tion, and it is important to ascertain what products would be acceptable in individual cases. Maximizing acceptable alternatives to blood product therapy, such as erthypoietin treatments and hemodilution of blood prior to major surgeries, should be emphasized. Remember that Jehovah ’ s Witnesses are in general very active and compliant in seeking alternatives to replacement therapy. This conversation should occur as early as possible in the care of the patient. In the critical care setting, this may not always be possible to do in early gestation. The conversation should occur in private because the presence of family or church members may unduly infl uence the patient in a potential life or death situation where the decision should belong to the patient. There are also Jehovah Witness patients who will allow transfu- sion if they do not sign a consent form putting their wishes in writing. This obviously would put the physician in a very awkward position later if the patient were transfused and then stated that a previous conversation with the physician never occurred. Whether to transfuse in this situation would be up to the indi- vidual physician. Other Witness patients may accept transfusions and consent in writing but not wish any family or church members to know they have done so. All conversations of this nature should be clearly documented in the patient chart so that anyone who assumes care of the patient is aware of the patient ’ s wishes. The physician should acquire support of other members of the healthcare team. The anesthesiology team needs to be aware of the patient ’ s wishes and be willing to honor them. Some hospitals have detailed written protocols regarding care of pregnant Jehovah ’ s Witnesses [83] . Other issues can develop after this initial conversation. It is important to affi rm that the patient ’ s wishes remain the same when faced with imminent loss of life during a critical bleeding episode. If the patient ’ s wishes have previously been clearly docu- mented, efforts to confi rm these wishes should not come across as attempts to change the patient ’ s mind, but rather as offers to reassess the beliefs when facing a life - threatening hemorrhage. It is important to keep in mind that most of the Witness population are dealing with much more than a life or death situation. They “ entitled to the law ’ s protection ” and that blood could be given “ if necessary to save her life or the life of her child, as the physi- cian in charge at the time may determine ” ( [78] , Raleigh Fitkin - Paul Morgan Hospital vs Anderson [77] as described in [75] ). This case determined that the First Amendment embodied two freedoms: the freedom to believe and the freedom to act on those beliefs. The court held that only the fi rst of these two con- cepts is absolute. The second concept in this case is limited by the child ’ s right to live [75] . This case has been criticized for the shortness of the opinion and the fact that the judgment was not enacted because the patient left the hospital [78] . In re: Jamaica Hospital in 1985, the New York Supreme Court addressed the issue of a Jehovah ’ s Witness who was 18 weeks pregnant and bleeding extensively from esophageal varices [79] . The mother refused blood. She was noted to be the single mother of 10 children with her only relative being a sister who was unavailable at the time. The court allowed the transfusion to protect the fetus [37] . It decided that a person does have the right to refuse medical treatment but that the state is permitted (under Roe vs Wade) to interfere with reproductive choices when it has a compelling interest. The court acknowledged that, in the case of a non - viable fetus, the interest is not compelling but rather “ signifi cant. ” This interest was felt to outweigh the patient ’ s right to refuse a blood transfusion and she was ordered to receive blood (re: Jamaica Hospital, 1985 [79] as presented in Mohaupt & Sharma, 1998 [40] ). In the Georgetown Hospital case, the court also ordered a transfusion for a non - pregnant woman who was the sole provider for a 7 - month - old child. This decision aimed to prevent child abuse and abandonment (Application of the President and Directors of Georgetown College Hospital [80] , as presented in Elkins, 1994 [75] ). There have been inconsistent decisions involv- ing patients without dependents or those who are not the sole providers for their children [75] . There have been frequent rulings in favor of intervention for transfusions for the children of Jehovah ’ s Witness against their parents ’ wishes [75] . The courts have ruled that parents cannot make martyrs of their chil- dren [81] . It is now commonplace for court orders for transfusion to be given in the case of children. There have also been cases of successful lawsuits against physi- cians who have knowingly transfused Witness patients in emer- gency settings. In a Canadian case, a 57 - year - old woman was brought unconscious to the emergency room with multiple inju- ries from a motor vehicle accident. In searching her belongings, a nurse located a note in her wallet that stated she was a Jehovah ’ s Witness and never wished to receive blood products. It was signed but not dated or witnessed. The treating physician decided to proceed with the blood transfusion despite this note. The patient recovered and sued, alleging battery. The court noted that the transfusion was necessary to save the patient ’ s life but the physi- cian knowingly did so against her wishes. The court could not absolve the physician from respecting the patient ’ s wishes on the basis that the wishes were unreasonable. The patient was awarded $20 000 (Malette vs Shulman [82] as presented in Sanbar, 2001 Chapter 47 680 sibility: to assist the family members who are left behind. The idea of writing a letter of condolence was recently presented by Bedell, Cadenhead, and Graboys in the New England Journal of Medicine [84] . This responsibility was an accepted part of a physician ’ s practice in 19th century America. Bedell et al. illustrate with this letter from Dr James Jackson to Mrs. Louisa Higgonson in 1892 [84] : My Dear Friend, I need not tell you how much I have sympathized with you. I think I realize in some measure how much you will miss Dear Aunt Nancy for a long time – for the rest of your life. I know that she has been a part of you … mind as well as body was duly exercised, and she always had stock from which she poured out stores for the delight of her friends, – stores of wit and wisdom, affording plea- sure with profi t to all around her. How constantly will the events of life recall her to our minds – realizing what she said or did under interesting and important circumstances – or perhaps suggesting imperfectly what she would have said under new and unexpected occurrences. For you my dear friend I implore God ’ s blessing. Your old friend, J. Jackson A letter of condolence can be a great help to the family during their grieving process. This is particularly true when the death is unexpected or comes after complications that occurred during hospitalization [84] . The loss of a fetus, and even more so of a mother, could fall into this category. This letter can be of great assistance to the family in dealing with the anger that naturally accompanies such a loss [84] . This letter can be much more comforting than expressions of sympathy given in person or via telephone in that it can be referenced over and over. The absence of a visible sign of sympathy can be quite distressing to the family. Bedell mentions a family member who felt strongly about this: “ After my mom died, the doctor never even wrote me. He ran and hid ” [84] . Bedell, Cadenhead, and Graboys encourage all physicians, house staff, and fellows who have had personal contact with their deceased patients to write condolence letters. Suggestions for w riting c ondolence l etters Phrases to a void Expressions that de - emphasize the loss or suffering: “ it was meant to be ” ; “ I know how you must feel ” ; “ it is better that she died ” . Avoid revisiting the medical details of the death (also helps to avoid legal liability issues). Suggestions for i nclusion Begin with a direct expression of sorrow for the loss, such as “ I would like to send you our condolences on the death of your wife. ” feel the use of blood products can prevent them from reaching eternal salvation. There is also the very real concern regarding being isolated from their community. A more diffi cult situation occurs when there is no time for conversation during a life - threatening hemorrhage (i.e. the patient is unconscious). This is especially diffi cult when dealing with a Witness who is unknown to the medical team and is only identifi ed by a card in the wallet. In these cases, patient autonomy should probably prevail and the patient ’ s wishes against transfu- sion be honored. As noted above, doctors have been successfully sued in these cases, but the amounts awarded have been relatively small, probably indicative of the court ’ s recognition that the phy- sicians were trying to save the lives of the involved patients. Prior documentation regarding alternatives such as autotransfusion devices may be helpful in these situations. Considerations such as leaving the patient intubated signifi cantly longer after surgery can also be effective in minimizing the workload on the patient ’ s metabolism (personal communication, Gary Dildy III, November 2001). Jehovah ’ s Witness patients who are minors represent another special category. In general, the courts have been quick to allow transfusions of minors against parental wishes. However, most states consider pregnancy to place minors in an emancipated category, which would give them the same decision - making capacities as adults. Even in non - emancipated minor cases, there has been a trend to allow more autonomy as the patient approaches the age of emancipation and is clearly able to articu- late her beliefs [81] . Some physicians and courts have placed the pregnant Jehovah ’ s Witness in a special category, especially when the fetus is viable. The presence of the fetus is used to justify transfusions in these settings, with the feeling that the transfusion is not as much an assault as a cesarean delivery on the patient ’ s autonomy. By com- parison, a transfusion is a more minor procedure. This author fi nds such reasoning troubling. To the Witness, the blood trans- fusion is much more of an assault than is cesarean delivery. In the case of a viable fetus with a hemorrhaging mother, delivery of the baby would seem to be a more ethical alternative than a blood transfusion. Thus, care of the Jehovah ’ s Witness in the critical care setting entails many ethical issues. It is important to respect the patient ’ s autonomy and to exercise benefi cence by understanding the alternative treatments the patient may allow consideration. If one has trouble caring for the patient within these limitations, it is imperative to inform the patient and assist in obtaining alterna- tive care. Letter of c ondolence It is fi tting to conclude a chapter on ethics in high - risk obstetrics with a reminder that a physician ’ s duty to his patient does not end with the death of the patient. There remains one fi nal respon- Ethics in the Obstetric Critical Care Setting 681 References 1 Brown D , Elkins T . Ethical issues in obstetrics cases involving prema- turity . Clin Perinatol 1992 ; 19 : 469 – 481 . 2 Chervenak F , McCullough L . Ethical and LEGAL ISSUES . In: Danforth ’ s Obstetrics and Gynecology , 8th edn. Philadelphia : Lippincott, Williams and Wilkins , 1999 : 939 – 953 . 3 Beauchamp T , Childress J . Principles of Biomedical Ethics , 5th edn. New York : Oxford University Press , 2001 : 57 – 164 . 4 American College of Obstetricians and Gynecologists . Ethical deci- sion making in obstetrics and gynecology . In: Ethics in OB/GYN , 2nd edn. Washington, DC : American College of Obstetricians and Gynecologists , 2004 : 3 – 8 . 5 Schloendorff v. Society of New York Hospitals . 211 N.Y. 125, at 129, 105 N.E. 92, at 93 ( 1914 ). 6 L o B . Resolving Ethical Dilemmas: A Guide for Clinicians , 2nd edn. Philadelphia: Lippincott , Williams and Wilkins , 2000 : 19 – 29, 181 – 188 . 7 American College of Obstetricians and Gynecologists . Informed consent . In: Ethics in OB/GYN , 2nd edn. Washington, DC : American College of Obstetricians and Gynecologists , 2004 : 9 – 17 . 8 American College of Obstetricians and Gynecologists, Committee on Ethihcs Opinion 108 . Ethicak Dimensions of Informed Consent. Washington, DC: ACOG, 1992 : No.108. 9 Lane v. Candura 6 Mass. App. Ct 377, 376 N.E. 2d 1232 ( 1978 ). 10 Annas GJ , Densberger JE . Competence to refuse medical treatment: autonomy vs paternalism . Toledo Law Rev 1984 ; 15 : 561 – 592 . 11 Sanbar S , Firestone M , Gibofsky A . Legal Medicine , 5th edn. St Louis : Mosby , 2001 ; 292 , 341 . 12 In the Matter of Karen Quinlan 70 N.J. 10, 335A, 2d 647, cert. Denied U.S. 922 ( 1976 ). 13 Cruzan v. Missouri Department of Health , 497 U.S. 261 110 S. Ct. 2842 ( 1990 ). 14 Brophy v. New England Sinai Hospital, Inc. 497 N.E. 2d 626 (Mass. 1986 ). 15 Bouvia v. Superior Court , 179 Cal. App. 3d 1127, 225 Cal Rpt. 297 (Ct. App. 1986 ). 16 Leiberman J , Mazor M , Chaim W , Cohen A . The fetal right to live . Obstet Gynecol 1979 ; 53 : 515 – 517 . 17 Fost N , Chudwin D , Wikler D . The limited moral signifi cance of “ fetal viability ” . Hastings Cent Rep 1980 ; 10 – 13 . 18 Fletcher J . The fetus as patient: ethical issues . JAMA 1981 ; 24 : 772 – 773 . 19 Chervenak F , Farley A , Walters L , Hobbins JC , Mahoney MJ . When is termination of pregnancy during the third trimester morally justifi - able? N Engl J Med 1984 ; 310 : 501 – 504 . 20 Gillon R . Pregnancy, obstetrics and the moral status of the fetus . J Med Ethics 1988 ; 14 : 3 – 4 . 21 Abrams F . Polarity within benefi cence: additional thoughts on nonag- gressive obstetric management . JAMA 1989 ; 261 : 3454 – 3455 . 22 Chervenak F , McCullough L . Nonaggressive obstetric management: an option for some fetal anomalies during the third trimester . JAMA 1989 ; 261 : 3439 – 3440 . 23 Chervenak F , McCullough L . The limits of viability . J Prenat Med 1997 ; 25 : 418 – 420 . 24 Mahoney M . The fetus as patient . West J Med 1989 ; 150 : 459 – 460 . Include a personal memory of the patient and/or a reference to her family or work. References to the patient ’ s achievements, devotion to family, character, or strength during the hospitaliza- tion are also helpful. Mention the strength the patient received from the family ’ s love. Tell the family that it was a privilege to participate in the care of their loved one. Let the family know your thoughts are with them in their hour of need [84] . The above suggestions are meant simply as guidelines for helping start a letter of condolence. The letter may be a few short sentences or a more detailed description of the physician – patient relationship. The physician should write the type of letter with which he or she is most comfortable. As Bedell, Cadenhead, and Graboys point out, “ the letter of condolence is a professional responsibility of the past that is worth reviving ” [84] . Such a letter provides a sense of comfort to the patient ’ s family and affects positively the family ’ s interactions with physicians in the future. On the other hand, a failure to communicate our sadness at the loss can be seen as a lack of interest or concern. Conclusion This book has detailed how to technologically deal with many of the high - risk situations that confront us in the care of our criti- cally ill obstetric patients. This chapter helps the physician take a step back from the technology and look at the patient and her family as individuals who need to be dealt with at more levels than just the technological ones. Doing so is not always an easy process, especially when balancing the physician ’ s ethical respon- sibility of benefi cence with the patient ’ s right to autonomy. Identifying possible ethical confl icts early in the decision process and clarifying these issues through communication can often help resolve them. Ethics committees can be helpful when com- munication between the physician, the patient, and her family is at an impasse. Rarely, if ever, should the courts be called upon to help in this decision process. The old French proverb to “ cure sometimes, help often and comfort always ” is especially appli- cable to the ethical dilemmas that face the high - risk obstetrician. When the best medical technologies do not result in the best outcome, it is also important to remember that a thoughtful letter of condolence can further the healing process. Acknowledgments The author wishes to thank Doug Brown PhD, Thomas Nolan MD, Cliona Robb Esq., Ginger Vehaskari PhD, and Ms Betty Rowe for their invaluable assistance in preparation of the manuscript. Chapter 47 682 54 Berdowitz RL . Should refusal to undergo a cesarean delivery be a criminal offense? Obstet Gynecol 2004 ; 104 ( 6 ): 1220 – 1221 . 55 Minkoff H , Paltrow LM . Melissa Rowland and the rights of pregnant women . Obstet Gynecol 2004 ; 104 ( 6 ): 1234 – 1236 . 56 Haack S . Letter to the Editor . Obstet Gynecol 2005 : 105 ( 5 ): 1147 . 57 Habiba M . Letter to the Editor . Obstet Gynecol 2005 ; 105 ( 5 ): 1147 – 1148 . 58 Kolder V , Gallagher J , Parson M . Court ordered obstetrical interven- tions . N Engl J Med 1987 ; 316 : 1192 – 1196 . 59 Berg RN . Georgia Supreme Court orders caesarean section – mother nature reverses on appeal . J Med Assoc Ga 1981 ; 70 : 451 – 543 . 60 Elkins T , Andersen H , Barclay M , et al. Court - ordered cesarean section: an analysis of ethical concerns in compelling cases . Am J Obstet Gynecol 1989 ; 161 : 150 – 154 . 61 American Academy of Pediatrics, Committee on Bioethics . Fetal therapy – ethical considerations . Pediatrics 1999 ; 103 : 1061 – 1063 . 62 American College of Obstetricians and Gynecologists . Patient choice in the maternal - fetal relationship . In: Ethics in OB/GYN , 2nd edn. Washington, DC : American College of Obstetricians and Gynecologists , 2004 : 34 – 36 . 63 McCullough LA , Chervenak F . Ethics IN Obstetrics and Gynecology . New York, NY . Oxford University Press , 1994 : 196 – 237 . 64 Gill AW , Saul P , McPhee J , Kerridge I . Acute clinical ethics consulta- tion: the practicalities . Med J Aust 2004 ; 181 ( 4 ): 204 – 206 . 65 Dillon W , Lee R , Tronolone MJ , et al. Life support and maternal brain death during pregnancy . JAMA 1982 ; 248 : 1089 – 1091 . 66 Loewy E . The pregnant brain dead and the fetus: must we always try to wrest life from death? Am J Obstet Gynecol 1987 ; 157 : 1097 – 1101 . 67 Bush MC , Nagy S , Berkowitz R , Gaddipati S . Pregnancy in a persistent vegetative state: case report, comparision to brain death, and review of the literature . Obstet Gynecol Surv 2003 ; 58 ( 11 ): 738 – 748 . 68 Webb G , Huddleston J . Management of the pregnant woman who sustains severe brain damage . Clin Perinatol 1996 ; 23 : 453 – 464 . 69 President ’ s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavorial Research . Guidelines for the determi- nation of death. Report of the Medical Consultants on the Diagnosis of Death to the President ’ s Commission . JAMA 1981 ; 246 ( 19 ): 2184 – 2186 . 70 Halevy A , Brody B . Brain death: reconciling defi nitions, criteria and test . Ann Intern Med 1993 ; 119 : 519 – 525 . 71 Burch TJ . Incubator or individual: the legal and policy defi ciencies of pregnancy clauses in living wills and advance healthcare directive statutes . Maryland Law Rev 1995 ; 54 : 528 – 570 . 72 Mallampalli A , Powner DJ , Gardner MO . Cardiopulmonary resusci- tation and somatic support of the pregnant patient . Crit Care Clin 2004 ; 20 : 747 – 761 . 73 Jonsen A . Blood transfusions and Jehovah ’ s Witnesses: the impact of the patient ’ s unusual beliefs in critical care . Crit Care Clin 1986 ; 2 ( 1 ): 91 – 99 . 74 Sacks DH , Koppes RH . Caring for the female Jehovah ’ s Witness: balancing medicine, ethics, and the First Amendment . Am J Obstet Gynecol 1994 ; 170 ( 2 ): 452 – 455 . 75 Elkins T . Exploring Medical - Legal Issues in Obstetrics and Gynecology . Washington, DC : Association of Professors of OB/GYN , 1994 : 35 – 38 . 76 Macklin R . The inner workings of an ethics committee: latest battle over Jehovah ’ s Witnesses . Hastings Cent Rep 1988 ; 15 – 20 . 77 Raleigh Fitkin - Paul Morgan Hospital v. Anderson 42. NJ421, 201 A2d, 537 cert. Denied 377 U.S. 985 ( 1964 ). 25 Newton E . The fetus as a patient . Med Clin North Am 1989 ; 73 : 517 – 540 . 26 Strong C , Garland A . The moral status of the near - term fetus . J Med Ethics 1989 ; 15 : 25 – 27 . 27 Beller F , Zlatnik G . The beginning of human life: medical observa- tions and ethical refl ections . Clin Obstet Gynecol 1992 ; 35 : 720 – 727 . 28 Mattingly S . The maternal fetal dyad: exploring the two - patient obstetric model . Hastings Cent Rep 1992 ; 13 – 18 . 29 Botkin J . Fetal privacy and confi dentiality . Hastings Cent Rep 1995 ; 32 – 39 . 30 Annas G . Forced cesareans: the most unkindest cut of all . Hastings Cent Rep 1982 ; 16 – 17 , 45 . 31 Annas G . Protecting the Liberty of Pregnant Patients . N Engl J Med 1987 ; 316 : 1213 – 1214 . 32 McCullough L , Chervenak F . Ethics in Obstetrics and Gynecology . New York : Oxford University Press , 1994 : 96 – 129 , 241 – 265 . 33 Mahowald M . Beyond abortion: refusal of caesarean section . Bioethics 1989 ; 3 : 106 – 121 . 34 Rhoden N . Cesareans and Samaritans . Law Med Healthcare 1987 ; 15 : 118 – 125 . 35 Harris L . Rethinking maternal – fetal confl ict: gender and equality in perinatal ethics . Obstet Gynecol 2000 ; 96 : 786 – 791 . 36 Strong C . Ethical confl icts between mothers and fetus in obstetrics . Clin Perinatol 1987 ; 14 : 313 – 328 . 37 Strong C . Court ordered treatment in obstetrics: the ethical views and legal framework . Obstet Gynecol 1991 ; 78 : 861 – 868 . 38 Roe v. Wade: United States Supreme Court : 35 LED 2d 147 ( 1973 ). 39 Re: AC, District of Columbia, 573 A. 2d 1235 (D.C. App. 1990 ). 40 Mohaupt S , Sharma K . Forensic implications and medical - legal dilemmas of maternal versus fetal rights . J Forensic Sci 1998 ; 43 ( 5 ): 985 – 992 . 41 Brown D . Maternal Fetal Topic II . Presented at AC Clinical Ethics for Practitioners Symposium, Hard Choices at the Beginning of Life, November 16 2001 , Nashville, TN. 42 Adams F , Mahowald MB , Gallagher J . Refusal of treatment during pregnancy . Clin Perinatol 2003 ; 30 : 127 – 140 . 43 Baby Doe v. Mother Doe , 632 NF2d 326 (III App 1 Dist 1994 ). 44 Pinkerton J , Finnerty J . Resolving the clinical and ethical dilemma involved in fetal - maternal confl icts . Am J Obstet Gynecol 1996 ; 175 : 289 – 295 . 45 Colautti v. Franklin 439 U.S. 379 ( 1979 ). 46 Jefferson v. Griffen Spalding Hospital Authority , Ga., 274 S.F. 2d 457 ( 1981 ). 47 Smith v. Brennan 157 A 2d 497 (NJ 1960 ). 48 Nelson L , Milliken N . Compelled medical treatment of pregnant women: life, liberty and law in confl ict . JAMA 1988 ; 259 : 1060 – 1068 . 49 Re: Maydun, 114 Daily Wash L. Rptr 2233 (DC Super Ct 1986 ). 50 Webster v. Reproductive Health Services , Daily Appellate Report, July 6 , 1989 ;8724. 51 Planned Parenthood of Southeastern Pennsylvania v. Casey 112 U.S. 674 ( 1992 ). 52 American College of Obstetricians and Gynecologists, Committee on Ethics . Opinion 321. Maternal Decision Making, Ethics and the Law . Washington, DC : American College of Obstetricians and Gynecologists , 2005 . 53 Dalton K . Refusal of interventions to protect the life of the viable fetus – a case - based transatlantic overview . Medico - Legal J 2006 ; 74 ( 1 ): 16 – 24 . Ethics in the Obstetric Critical Care Setting 683 84 Bedell SE , Cadenhead K , Graboys TB . The doctor ’ s letter of condo- lence . N Engl J Med 2001 ; 344 ( 15 ): 1162 – 1164 . 85 American College of Obstetricians and Gynecologists, Committee on Ethics . Opinion 214. Patient Choice and the Maternal - Fetal Relationship . Washington, DC : American College of Obstetricians and Gynecologists , 1999 . 86 Chervenak FA , McCullough FB . Perinatal ethics: a practical method of analysis of obligations to mother and fetus . Obstet Gynecol 1985 ; 66 : 442 – 446 . 87 Mohr v. Williams, Minn , 261,265;104 N.W. 12, 15 ( 1905 ). 88 Superintendent of Belchertown v. Bouvia ( 1983 ). 78 Elias S , Annas G . Reproductive Genetics and the Law . Chicago : Yearbook Medical Publishers , 1987 : 83 – 120 , 143 – 271 . 79 Re: Jamaica Hospital, 491 NYS 2d 898 ( 1985 ). 80 Application of the President and Directors of Georgetown College Hospital, F2d 1000 ( 1964 ). 81 Cain J . Refusal of blood transfusion . In: Elkins T . Exploring Medical - Legal Issues in Obstetrics and Gynecology . Washington, DC : Association of Professors of OB/GYN , 1994 : 62 – 64 . 82 Malette v. Shulman 630 R. 2d, 243, 720R. 2d, 417 (O.C.A.). 8 3 G y a m fi C , G y a m fi M , Berkowitz R . Ethical and medicolegal consid- erations in the obstetric care of a Jehovah ’ s Witness . Obstet Gynecol 2003 ; 102 ( 1 ): 173 – 180 . 684 Critical Care Obstetrics, 5th edition. Edited by M. Belfort, G. Saade, M. Foley, J. Phelan and G. Dildy. © 2010 Blackwell Publishing Ltd. 48 Acute Psychiatric Conditions in Pregnancy Ellen Flynn , Carmen Monzon & Teri Pearlstein Alpert Medical School of Brown University, Women and Infants Hospital, Providence, RI, USA Introduction Visits to emergency departments (EDs) that involve psychiatric issues have substantially increased in the past 15 years, particu- larly among persons covered by Medicaid and the uninsured [1] . The decreased rates of inpatient hospitalization and decreased availability of psychiatric and substance abuse outpatient care have contributed to this increase in ED visits. Patients presenting to EDs have an increased prevalence of psychiatric diagnoses compared to community prevalence fi gures, and the psychiatric diagnoses are often missed or not included in the treatment plan [2] . Substance use disorders, which can present as depression or psychosis, are also suboptimally evaluated and treated [3] . A recent survey reported that ED clinicians were less likely to administer psychotropic medications to patients with active sui- cidal ideation or substance abuse, and there was no indication that receiving a prescription for a psychotropic medication at discharge from the ED improves the likelihood of follow - up with outpatient care [4] . This chapter will focus on some of the acute behavioral health problems that commonly present in an ED or other medical setting: depression, suicidality, and agitation/ psychosis. These topics will be discussed in terms of general adult populations followed by specifi c issues that arise in the perinatal woman. Assessment of d epression Major depressive disorder (MDD) is more common in women than in men, and the peak prevalence of MDD occurs in women during the reproductive years [5] . MDD is characterized by depressed mood, hopelessness, guilt, decreased motivation, low energy, poor concentration, change in sleep, change in appetite, decreased libido and decreased enjoyment of relationships and activities [5] . MDD can also include recurrent suicidal ideation, suicide attempt, and completed suicide. MDD is a serious disor- der associated with behavioral and functional impairments. MDD is currently one of the world ’ s leading causes of disability [6] . MDD is underdiagnosed and undertreated in medical set- tings and can negatively infl uence the course of comorbid medical illnesses [7] . Studies have suggested that two screening questions : “ Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things? ” or “ how often have you been feeling down, depressed or hopeless? ” can reliably screen for depression in medical settings [8] . Depression d uring p regnancy Perinatal depression is also under - recognized and undertreated [9 – 12] . Even with obstetrician encouragement and on - site avail- ability of mental health treatment, pregnant women are unlikely to pursue treatment for depression [13] . A recent systematic review reported that the point prevalence of MDD ranged from 1.0 to 5.6% through pregnancy, while the point prevalence of major and minor depression was 11.0% in the fi rst trimester and 8.5% in the second and third trimesters [14] . The Edinburgh Postnatal Depression Scale (EPDS) [15] is commonly used to screen for depression during pregnancy and the postpartum period. An EPDS score of 15 or higher has been suggested as a threshold that warrants further evaluation [16] . The evaluation of depression in pregnancy is complicated since the symptoms of sleep change, appetite change, fatigue and decreased libido are common in both normal pregnancy and MDD. Symptoms that are more specifi c to MDD include feelings of worthlessness, hopelessness, helplessness, guilt, and ruminations about death, dying and/or suicide. Risk factors for increased depressive symp- toms or MDD during pregnancy include being adolescent, unmarried, fi nancially disadvantaged, African American or Hispanic, having had a prior MDD, lack of social support and a recent negative life event [17] . Pregnancy has long been thought to be a time of enhanced well - being and quiescence of mental illness. A recent large cohort Acute Psychiatric Conditions in Pregnancy 685 stressful life event [27] . The EPDS is the most widely used and validated screening measure for PPD. A score of 13 or higher suggests probable PPD, and a full diagnostic evaluation should ensue [16] . Restlessness, agitation and decreased concentration may be more common in PPD compared to MDD occurring outside of the postpartum period [28] . The recent large cohort study conducted in Denmark reported that the fi rst 90 days postpartum represented a time of increased risk of new - onset psychiatric disorder, inpatient admission and outpatient treatment in new mothers, but not in new fathers [18] . Primiparity was a signifi cant risk factor, and PPD was the most common new - onset psychiatric disorder. In women with pre - existing MDD or bipolar disorder, the postpartum period is a time of increased risk of relapse [20,29] . There is a large body of literature describing the long - term negative consequences of untreated PPD on infant development. Children of mothers with untreated maternal depression are more likely to have slowed motor and cognitive development, behavioral diffi culties, poor affect tolerance, poor social development, and increased risk of psychiatric and medical disorders [30,31] . Thus, the need to effectively screen for and treat the psychiatric disorders that appear de novo or as a relapse during the early postpartum period is of paramount public health signifi cance [32,33] . Additional p erinatal r isk f actors for d epression When evaluating the pregnant woman for depression, it is impor- tant to note that other pregnancy - related circumstances may contribute to an increased risk of depression. A literature review of emotional symptoms associated with induced abortion for unwanted pregnancy reported that prior to abortion 40 – 45% of women have signifi cant levels of anxiety and 20% have signifi cant levels of depression [34] . One month following elective abortion, mood and anxiety symptoms decrease in most women. Women with previous or current depressive and anxiety disorders are at risk for post - abortion depression [35] and a proportion of women who undergo an induced abortion will be at risk for later develop- ment of MDD, anxiety disorder, suicidal ideation and alcohol dependence [36] . Some studies have suggested increased risk of suicide following induced abortion [37,38] . Miscarriage, defi ned as an involuntary pregnancy loss before 20 weeks gestation, is associated with depressive symptoms and an increased risk of MDD [39,40] . Miscarriage is also associated with anxiety symptoms for at least 4 months, and an increased risk for acute stress disorder, post - traumatic stress disorder and obsessive – compulsive disorder [41,42] . Stillbirth is likewise asso- ciated with subsequent depression, anxiety and post - traumatic stress disorder [43,44] . The benefi t of holding the stillborn or the promotion of a quick next conception is debated [44 – 46] . Women who have had a previous reproductive loss may experi- ence depression, anxiety and unresolved grief in a subsequent pregnancy [41,47,48] . Pregnant women experiencing intimate partner violence (IPV) during pregnancy are more likely to have depressive symptoms than non - abused women [49] . IPV has been estimated to occur study conducted in Denmark confi rmed that pregnancy was a time of decreased risk of new - onset psychiatric disorders in pri- migravid women [18] . However, recent studies have suggested that women with previous psychiatric diagnoses are not protected against relapse during pregnancy, particularly if they discontinue their maintenance psychotropic medication. One study reported that 68% of women with treated depression who discontinued their antidepressant medication had a recurrence of depression compared to 26% of women who maintained their antidepres- sant [19] . Abrupt discontinuation of medication during preg- nancy also signifi cantly increases the risk of relapse, psychiatric decompensation and suicide in pregnant women with bipolar disorder [20,21] . Since both untreated psychiatric disease and psychotropic medications have potential adverse risks on the developing fetus, how pre - existing psychiatric illness is managed during pregnancy poses signifi cant treatment dilemmas. Untreated depression in pregnancy has deleterious conse- quences for both the mother and the developing infant. Obstetric complications reported with untreated prenatal stress and depres- sion include pre - eclampsia, preterm delivery, low birth weight, miscarriage, growth restricted babies, low Apgar scores and neon- tatal complications [22] . Untreated prenatal anxiety and depres- sion have also been correlated with language and cognitive impairment, impulsivity, and psychopathology in children [23,24] . Depression in pregnancy is associated with poor atten- tion to maternal health, nutrition, and prenatal care, as well as an increased risk of impulsive and potentially dangerous activities, substance abuse, and tobacco use. In addition, undertreated depression in pregnancy places women at risk for completed suicide and for attempted suicide with its sequelae. Depression d uring the p ostpartum p eriod When women present with depression during the postpartum period, the differential diagnosis includes postpartum blues, postpartum depression (PPD), and postpartum psychosis (PPP). Postpartum blues occur in 15 – 85% of women, depressive symp- toms peak at postdelivery day 5, and symptoms are usually resolved by day 10 [25] . Postpartum blues may include mood swings, irritability, tearfulness, confusion, fatigue and mild elation. Postpartum blues are so common that they can be con- sidered normal. Postpartum blues are not accompanied by sig- nifi cant functional impairment and the symptoms rarely require treatment. However, postpartum blues are a risk factor for sub- sequent PPD [26] . The prevalence of PPD is similar to non - puerperal prevalence rates of MDD in women. The systematic review by Gavin and colleagues reported that the point prevalence of MDD ranged from 1.0 to 5.7% through the fi rst 6 postpartum months, peaking at 3 months post delivery, and most episodes were with postpar- tum onset of depressive symptoms [14] . The point prevalence of major and minor depression ranged from 6.5 to 12.9% through the fi rst 6 postpartum months. Depression in pregnancy is the leading risk factor in the development of PPD. Other risk factors include anxiety during pregnancy, lack of social support and a Chapter 48 686 her treatment. Factors that govern the selection of treatment options include her previous psychiatric history, response to treatment, plans for breastfeeding, the clinician ’ s presentation of treatment choices with their risks and benefi ts, the patient ’ s per- ception of the treatment choices with their risks and benefi ts, and cultural expectations [60] . Recent published studies regarding the safety of antidepressant medication during pregnancy have led to worrying and often contradictory conclusions, widespread public concern in lay and media venues, and the introduction of warnings by regulatory authorities. Meta - analytic reviews have reported a small increased risk of spontaneous miscarriages with fi rst - trimester selective serotonin reuptake inhibitor (SSRI) use [61,62] . Although several prospective studies have failed to identify increased congenital malformations with fi rst - trimester antidepressant exposure [61,63] , a recent study reported a 1.34 increased relative risk [64] . A retrospective unpublished study reported a 2.2 increased rela- tive risk of congenital malformations with paroxetine which led to an FDA and Health Canada Advisory in 2005 and the revision of paroxetine ’ s safety category from “ C ” to “ D ” [65] . A recent study reported that fi rst - trimester exposure to paroxetine doses in excess of 25 mg/day, but not lower daily paroxetine doses, was associated with increased risk of congenital cardiac and other malformations [66] . Recent studies have characterized symptoms that appear in about one - third of neonates exposed to SSRIs in the third trimes- ter that include jitteriness, poor muscle tone, respiratory distress, hypoglycemia and possible seizures [67] . These symptoms are usually mild and transient, and may be due to excess serotonin, SSRI discontinuation or cholinergic overdrive [67 – 69] . An FDA Alert about neonatal symptoms with third - trimester antide- pressant use was issued in 2004. A compelling study that con- trolled for the level of maternal depression, comparing depressed women treated with SSRIs, depressed mothers not treated with SSRIs, and non - exposed control mothers, reported that infants of depressed mothers exposed to SSRIs were more likely to have lower birth weight, prematurity, and increased respiratory dis- tress than control mothers [70] . An FDA Alert was issued in 2006 about an increased risk of persistent pulmonary hypertension of the newborn in women exposed to SSRIs after week 20 of gestation [71] . Untreated depression, anxiety and stress have known adverse effects on the fetus and infant as outlined above. Discontinuation of an antidepressant in a euthymic pregnant woman carries a risk of relapse with its attendant potential adverse effects. The risks to the fetus with SSRI exposure summarized above, and the paucity of studies of the effects of fetal SSRI exposure on long - term cogni- tive, behavioral and motor development, pose diffi cult treatment dilemmas for the pregnant woman with depression. A position paper by ACOG advised that paroxetine not be used during pregnancy and that the use of SSRIs should be individualized [72] . As with depression in pregnancy, there are no FDA - approved antidepressants for PPD. It is generally assumed that antidepres- in 1 – 20% of pregnant women [49,50] . Homocide, often the result of IPV, occurs in 12 – 63% of pregnancy - associated deaths [37] . A recent large population - based study reported that IPV during pregnancy was associated with preterm labor, vaginal bleeding, nausea and vomiting, urinary tract infections, increased ED visits and hospitalizations, preterm delivery and low birth weight [51] . A systematic review identifi ed similar adverse pregnancy out- comes as well as increased rates of maternal and fetal deaths with IPV during pregnancy [52] . Several national health organizations promote universal screening for domestic violence, and screening is acceptable to the majority of pregnant women although report- ing mandates may decrease disclosure [53,54] . Healthcare pro- viders ’ concern and recommendations for safe options often need to be repeated several times, and pregnant women may wait to act until after the infant is born [53] . The American College of Obstetricians and Gynecologists (ACOG) recommends screening perinatal women for psychoso- cial risk factors such as barriers to care, unstable housing, unintended or unwanted pregnancy, communication barriers, nutrition, tobacco use, substance use, psychiatric symptoms, safety, IPV and stress [54] . Psychosocial stressors can also include employment instability, economic burdens, and lack of social support. At the time of delivery, a premature infant and neonatal medical complications may be unexpected stressors. Pediatricians and other medical clinicians are also encouraged to screen for maternal depression and know of available resources [33] . Referral to appropriate intervention, social support, and counsel- ing should ideally improve maternal, fetal and infant outcomes. Treatment of d epression d uring p regnancy and p ostpartum Pregnant patients presenting with depression need to be informed of the potential risks to the fetus associated with not treating their symptoms as well as the risks with fetal exposure to antidepres- sant medications. If the depressive symptoms are not severe and are not jeopardizing the well - being of the woman, her fetus, and her family, non - pharmacologic treatments may be recommended initially. These would include supportive psychotherapy, inter- personal psychotherapy (IPT), and cognitive behavioral psycho- therapy (CBT). IPT is a short - term treatment that addresses role transitions and promotes the increase of social support which has been demonstrated to improve depression during pregnancy [55] . Preliminary controlled trials with light therapy [56] , massage [57] , and acupuncture [58] , and a preliminary open trial with fi sh oil [59] suggest alternative options for pregnant depressed women that deserve further study. Antidepressant medications during pregnancy should be con- sidered if the depressive symptoms are severe and disabling, the symptoms do not respond to non - pharmacologic treatments, or a woman is already on an antidepressant and her tapering the medication would pose a risk of recurrence. It is imperative that severely depressed women be referred to a clinician with expertise in psychotropic prescription during pregnancy and lactation so that she and her family can make the best informed decision for Acute Psychiatric Conditions in Pregnancy 687 rates are found with MDD (14.6%), bipolar disorder (15.5%) and mixed drug abuse (14.7%) [87] . Besides the presence of psychi- atric illness, prior suicide attempts represent a major risk factor for suicide, particularly in women (see Table 48.1 ) [90] . In a systematic review of risk factors for suicide in bipolar disorder, previous suicide attempt and hopelessness were the strongest risk factors [91] . Methods of suicide in women include in decreasing frequency fi rearms, overdose and hanging, followed by all other forms [88] . For every completed suicide, there have usually been 18 – 20 attempts [92] and women account for most of the attempts [88] . Suicide attempts substantially increase the risk of sub- sequent suicide, and need to be taken seriously [93,94] . The suicidal patient represents one of the most signifi cant chal- lenges to the healthcare professional. Failed suicide attempts account for 1 – 2% of ED visits, 5% of ICU admissions and 10% of admissions to general medical services [92] . The assessment of suicidality includes the evaluation of current suicidal thoughts sants would work for PPD as well as for non - puerperal MDD, although this has not been tested. Three published randomized controlled trials in PPD have reported equal effi cacy of sertraline and nortriptyline [73] , superiority of fl uoxetine to placebo [74] , and equal effi cacy of paroxetine and combined paroxetine/CBT in women with comorbid PPD and anxiety [75] . It should be noted that most open and controlled pharmacotherapy trials of PPD have excluded breastfeeding women. Although double - blind placebo - controlled studies of antide- pressant medication for PPD in breastfeeding mothers do not exist, there is a growing observational database. A pooled analysis of antidepressant levels in mother – infant dyads concluded that sertraline, paroxetine and nortriptyline usually yield undetectable infant serum levels and that elevated serum levels are more likely with fl uoxetine and citalopram [76] . There has also been an absence of adverse effects reported with sertraline, paroxetine and nortriptyline. Adverse reports in breastfeeding infants have been reported with fl uoxetine, citalopram, bupropion and doxepin [77 – 80] . Breast milk and infant serum antidepressant levels are not routinely monitored. Breastfeeding mothers should monitor the infant for new - onset somnolence, irritability, poor feeding, colic, or change in temperament. Adverse effects in the infant should be reported to the prescribing clinician and pediatrician, and a change of antidepressant or lowering of dose may be necessary. Breastfeeding mothers with PPD often prefer non - pharmaco- logic treatments rather than antidepressant medication. IPT has been demonstrated to be superior to a waitlist control [81] . Positive results have also been reported with CBT, lay peer support, health visitors in the home, and group therapy [82 – 84] . Initial positive reports with light therapy, maternal sleep depriva- tion, massage, exercise, infant sleep intervention, herbs and fi sh oil deserve further study [85] . The adverse effects on infant and child development of untreated maternal depression are substan- tial and well characterized. However, many barriers to seeking care exist including perceived negative stigmata, availability of highly trained IPT or CBT psychotherapists, childcare and time commitment issues, cost, and sensitivity of the therapist to cul- tural sociodemographic variables [77,86] . Discussions of treat- ment options for PPD need to include the risks of not treating, psychotherapy options, available data about the safety of medica- tions with breastfeeding, the woman ’ s previous psychiatric history and responses to treatment, and her individual treatment preferences and expectations [60] . Suicidality The annual suicide rate in the general population is 10.7 per 100 000 persons [87] and men commit suicide at a 4 times greater rate than women [88] . The general population suicide rate for women in the United States aged 20 – 45 was 3.2 – 6.4 per 100 000 in 2000 [88] and 3.5 – 7.7 per 100 000 in 2002 [89] . The single most signifi cant risk factor for suicide is psychiatric illness and elevated Table 48.1 Risk factors for suicide in women. Increased suicide risk Psychiatric illness Depression Anhedonia * Hopelessness * Insomnia * Anxiety * Persistent symptoms * Psychotic symptoms (delusions) * Cigarette smoking Substance use or abuse Psychiatric history Psychiatric hospitalization Postpartum psychiatric hospitalization History of suicide attempts Personality characteristics * Impulsive * Aggressive History of violence Family history of suicide * Abortion Child has died Child has psychiatric illness Demographic characteristics Single or unmarried Higher levels of education Middle - aged Firearm access Decreased suicide risk Pregnancy Postpartum Young children (under 18 years old) in the home Adapted from [88] and [90] . * Risk factors identifi ed in mixed gender groups, not specifi c to women. Chapter 48 688 medical and obstetric examination to address any acute medical or obstetric problems that may be life - threatening or contribut- ing to the patient ’ s presentation. Attention should be paid to maximizing the patient ’ s comfort, addressing such symptoms such as nausea, hunger, cramping, pain, etc. Anxiety can be managed with a low - dose benzodiazepine. It is important, however, not to overly sedate the patient, as this can interfere with psychiatric and medical assessment. The essential feature of the management of suicidal patients is risk assessment with particular attention to modifi able risk factors. Risk factors that need to be inquired about include the lethality of previous suicide attempts, depression, panic disorder, unremitting anxiety, psychosis, borderline personality disorder, antisocial personality disorder, alcohol or substance abuse, medical illness including delirium, childhood sexual or physical abuse, family history of suicide, hopelessness, impulsiveness, aggression, and a recent psychosocial stressor such as IPV, loss of employment, or loss of a close relationship [87] . In evaluating the lethality of a previous suicide attempt, several features should be noted such as number of prior suicide attempts, the means, avail- ability of fi rearms, was medical admission or ICU level of care necessary, likelihood of discovery, communication with others, disappointment about survival and intention to die. If the patient has a specifi c current suicidal plan, the intent to die and lethality must be evaluated. It is important to ascertain whether there are contributing life stressors that are impacting the current situation. It is critical to assess how and why suicide appears to be a reasonable alternative to their current situation. Feelings of worthlessness, hopelessness and ruminations about death, dying and suicide are characteristic of severe depression. When these thoughts increase or are associated with changes in behavior, this may represent an increased likelihood or immi- nence of acting on suicidal ideation. The following could signify concerning behavioral alterations: becoming more isolative, giving objects away, writing a suicide note, disconnecting from family and community, poor self - care, increasing impulsive and risky behaviors, and obtaining fi rearms. Corollary information from family members can provide critical information that the patient might be unwilling to disclose or is minimizing. Collaboration with family is also important in the treatment planning process. The exception to this is involvement of the domestically violent partner or abusive family member. While it is helpful to obtain consent from the patient to contact family, because of the risk of death, patients do not need to provide consent for such contact to take place. Patients in imminent danger of suicide usually warrant psychi- atric admission. If the patient is deemed not to be at imminent danger of suicide, collaboration with outpatient healthcare pro- viders, as well as the mobilization of family and community resources with attention to current psychosocial stressors, is criti- cal. Social work can be extremely helpful in identifying commu- nity and support services that can assist the patient and family in addressing specifi c psychosocial concerns, such as shelter pro- grams for IPV victims, rent and housing assistance, and food and plans, inquiry about past suicidal behavior, and inquiry about risk factors. It is common lore that asking a patient about suicidal thoughts or plans for suicide will “ give them ideas ” . In fact, the exploration of suicidal thoughts and plans often allows the patient to feel less isolated and it may lead to further discus- sion of the patient ’ s thoughts and feelings because the topic has been normalized to some degree by the healthcare provider ’ s inquiry. There are multiple self - report and clinician - rated suicide assessment tools that can be helpful to the psychiatric evaluation [87] . Screening for suicidal ideation and plan is a critical part of the evaluation of a patient presenting with depression and other psychiatric disorders. Self - i njurious b ehavior Often in medical settings, when patients present with self - injurious behaviors such as cutting, scarring, or burning oneself, it is assumed that this represents a suicide attempt. The single most important question is the intent, i.e. does the patient intend to die? The self - injurious behaviors may be coping mechanisms that patients employ to modulate diffi cult emotional states. However, careful examination for suicidal intent and plan is always prudent and necessary. A recent study reported that self - injury or suicide gesture in women tended to represent a means to communicate with others while self - injury in men tended to represent an intent to die [93] . The authors caution that even though an intent to die is associated with medical lethality and completed suicide, self - injury and suicidal gestures without an intent to die are dangerous and warrant clinical attention [93] . Assessment and m anagement of the s uicidal p atient The most important goal with a suicidal patient is to assure the patient ’ s safety. The safest means of transfer from home or from an outpatient setting is by ambulance, or police if necessary, to the nearest ED for further evaluation and management. A suicidal patient should be immediately admitted to the ED due to the patient ’ s high risk status. It should be ascertained at admission if the patient possesses means for suicide, e.g. fi rearms, knives, or pills. A suicidal patient should not be isolated in the ED. The suicidal patient requires maximal supervision via nursing staff as well as constant observation with a one - to - one sitter, including trips to the bathroom. This is recommended even if a family member is present. As with an agitated patient, items in the room that could be used as self - infl icting weapons should be removed. Suicidal patients should not be permitted to leave the ED even to smoke, due to the risks of imminent self - harm and elopement. Hospital security should be involved, if needed, to hold the patient until a thorough risk and safety assessment can be accom- plished by psychiatric staff. Securing the suicidal patient ’ s safety may involve the use of physical and or chemical restraints. Once the patient is in a safe and secure environment, a thor- ough medical and psychiatric work - up should be initiated. Toxicology screens should be obtained. Psychiatry and social work should be contacted immediately upon arrival of a suicidal patient to the ED. The pregnant patient should receive a focused . the p ostpartum p eriod When women present with depression during the postpartum period, the differential diagnosis includes postpartum blues, postpartum depression (PPD), and postpartum psychosis. medicolegal consid- erations in the obstetric care of a Jehovah ’ s Witness . Obstet Gynecol 2003 ; 102 ( 1 ): 173 – 180 . 684 Critical Care Obstetrics, 5th edition. Edited by M. Belfort,. patient . Crit Care Clin 2004 ; 20 : 747 – 761 . 73 Jonsen A . Blood transfusions and Jehovah ’ s Witnesses: the impact of the patient ’ s unusual beliefs in critical care . Crit Care Clin 1986