Critical Care Obstetrics part 71 ppsx

Acute Psychiatric Conditions in Pregnancy 689 were correlated with psychiatric illness, substance abuse, younger age, being single, less education, poor prenatal care, being mul- tiparous, and being African - American. The consequences of attempted suicide on the neonate included preterm labor, low birth weight, respiratory distress syndrome, and cesarean deliv- ery. The women who delivered during the hospitalization for attempted suicide had an increased risk of neonatal and infant death. The authors stress the importance of prenatal treatment of an underlying psychiatric and/or substance abuse disorder, and the need to counsel women about potential adverse neonatal outcomes if suicide is attempted [101] . Agitation and p sychosis Acute agitation or violence is a symptom present in a wide range of psychiatric illnesses such as bipolar disorder, schizophrenia, substance abuse or personality disorders with impulsivity (such as borderline or antisocial) [102,103] . Agitation in psychosis can be from confusion, akathisia, fearfulness, paranoia, delusions or command hallucinations. Alcohol and substance abuse increase agitation and violence in patients with depression, bipolar disor- der and schizophrenia [104] . Agitation can also occur in medical conditions such as brain trauma, meningitis, encephalitis, demen- tia, thyrotoxicosis, infection or fever in the elderly and delirium [102] . Agitation has been defi ned as excessive motor activity asso- ciated with a feeling of inner tension [5] and motor restlessness, heightened responsivity to external or internal stimuli, irritabil- ity, inappropriate and/or purposeless verbal or motor activity, decreased sleep, and fl uctuation of symptoms over time [105] . The neuroanatomy and neurochemical basis of agitation are not well understood [104,106] . In patients with psychosis, the proposed pathophysiologic mechanisms include reduction of inhibitory γ - aminobutyric acid (GABA) action, hyperdopami- nergia in the basal ganglia, altered serotonin function and increased norepinephrine tone. Frontal lobe dysfunction has been implicated by neuroimaging and other studies [107] and a mutation in the catechol O - methyltransferase (COMT) gene has been identifi ed [104] . Even though men exhibit a higher rate of aggression than women, the gender gap disappears among psychiatric inpatients and patients evaluated in an ED [108] . Violence is common in the medical ED, and surveys indicate frequent occurrence of assaults of staff members and use of restraints [109] . The inci- dence of agitation and violence is higher in psychiatric EDs [104] . Determinants of violence in the ED include patient factors, such as psychiatric disorder, medical disorder, drug intoxication or withdrawal, transport to the hospital involuntarily, negative perception of hospital staff, and possession of a weapon at pre- sentation; staff factors, such as impoliteness, insensitivity, and inadequate training; environmental factors, such as high noise levels, overcrowding and uncomfortable waiting rooms; and system factors such as high patient volumes, prolonged waiting and evaluation times, inadequate security staff, and absent or assistance. In addition, besides inpatient psychiatric hospitaliza- tion, other treatment options may offer psychiatric stabilization such as partial hospital programs, intensive outpatient programs, substance abuse treatment, individual or family therapy and psy- chotropic medications. A multimodality treatment plan is best achieved through collaboration between psychiatry, social work, obstetrics and gynecology, and medicine services. Although there is not defi nite evidence that antidepressant medication specifi cally reduces suicidality in MDD, antidepres- sants are the mainstay treatment for reducing depressive symp- toms. There is also not compelling evidence that mood stabilizers, antipsychotics or benzodiazepines acutely reduce suicidality in psychiatric disorders, whereas lithium has been demonstrated to reduce suicide and suicide attempts in bipolar disorder [87] . Suicidality d uring p regnancy and p ostpartum Completed suicides are less prevalent in pregnancy [95,96] and the postpartum period [38,96] compared to non - puerperal times in a woman ’ s life. Adolescents may not have lower suicide rates than older postpartum women [38] . Results from a Danish cohort reported that suicide risk increased 70 - fold in the fi rst year after giving birth in the presence of a psychiatric dis- order [97] . An examination of perinatal maternal deaths in the United Kingdom in 1997 – 99 suggested that suicide was the leading cause of maternal death, was increased in women with psychiatric and substance abuse disorders, and was more likely to be a violent death compared to the suicides of men and non - childbearing women [98] . Other studies confi rm that although suicide rates may be lower during pregnancy and the postpartum period, perinatal women complete suicide by more violent and lethal means than when not perinatal [94] . Lindahl and col- leagues have suggested that when assessing suicidality in the preg- nant or postpartum woman, specifi c inquiry should be made about reasons for dying, reasons for living, prior suicide attempts, prior psychiatric illness, previous trauma, and current marital violence [94] . Pregnant and postpartum women also have lower rates of self - injury and suicide attempts than non - puerperal women, ranging from one - half to two - thirds the expected rates [94] . Suicidal ide- ation occurs in up to 14% of perinatal women [94] . Suicide attempts (mostly poisoning) have been associated with unwanted pregnancy [99] . A recent study of a United States population sample reported that fetal demise and infant death in the fi rst year after delivery increased the risk of a suicide attempt threefold (mostly poisonings) and increased inpatient psychiatric admis- sions [100] . In this study, labor and delivery complications, cesar- ean section, preterm delivery, low birth weight and congenital malformations were not associated with increased risk of suicide attempts. Another recent study examined the characteristics of 2132 women who delivered and had attempted suicide during their pregnancy compared to women who did not attempt suicide [101] . Again, the majority of the women (86%) attempted suicide by ingestion of a drug overdose or poisoning. Suicide attempts Chapter 48 690 immediate reversibility, and no change to the mental state of the patient that might hinder further assessment. Leather restraints are preferred because they are more reliable and cause less injury than other types of physical restraints. One of the disadvantages of physical restraints is that they require signifi cant training: how to take the patient down, how to apply them and how to monitor their use. Poor training or incorrect use can result in injury to the patient or others. Chemical restraints require that the patient agrees to take medications or medications may be administered to a patient involuntarily, which involves holding a patient down until the medication starts exerting its calming effect. An advan- tage of chemical restraints is that the administered medication may also constitute initiation of treatment for the underlying cause of the agitation. Restraints should be used for the least amount of time as clinically indicated, in the least restrictive manner possible, and staff must adhere to hospital policies about training, monitoring and documentation [112,113] . The Expert Consensus Panel for Behavioral Emergencies 2005 recommends specifi c chemical restraints (see Figure 48.1 ) [114] . Benzodiazepines are the recommended choice when the cause of agitation is not known, when there is no specifi c treatment (e.g. personality disorders), or when there might be specifi c benefi ts (e.g. intoxication with certain substances). The fi rst - line recom- mended benzodiazepine is lorazepam due to its complete and rapid intramuscular absorption, an elimination half life of 12 – 15 hours, and a duration of action of 8 – 10 hours [102] . The goal is to calm the patient without excessive sedation. Lorazapam 2 mg IM may be suffi cient to calm the patient and allow the clinician to further assess the patient. Benzodiazepines have the potential to cause respiratory depression, ataxia, excessive sedation and paradoxical disinhibition [102] . Combination treatment with both an antipsychotic and a ben- zodiazepine is often necessary to control agitation. Several studies have reported benefi t with haloperidol (5 mg IM) combined with lorazepam (2 mg IM), and this regimen is preferred in pregnant agitated women due to the existence of a fair amount of safety data with exposure to haloperidol in pregnancy [114] . Haloperidol 5 mg IM or IV will have an onset of action of 30 – 60 minutes, an elimination half - life of 12 – 36 hours, and a duration of effect of up to 24 hours [102] . Droperidol is also effective but is now used infrequently due to concerns about a risk of fatal cardiac arrhyth- mias caused by possible prolongation of the QTc interval [115] . Possible adverse effects with typical antipsychotics include extra- pyramidal symptoms (EPS), cardiac arrhythmias, and neurolep- tic malignant syndrome (NMS). EPS include dystonia, akathisia and parkinsonian - like effects and are unwelcome due to their potential to increase patient distress and medication refusal. Dystonic reactions can be managed with diphenhydramine, which is not contraindicated during pregnancy. It should be noted that diphenhydramine may be eliminated before a dose of haloperidol is completely eliminated, creating the potential for a return of EPS. Akathisia from neuroleptics is diffi cult to assess in a patient who is already agitated. Akathisia may partially respond to lorazepam. NMS is a rare complication of typical antipsychotic inadequate formal training in the management of hostile and aggressive patients [109] . Cultural issues can infl uence patient, staff and system factors involved in a clinical emergency [110] . Specifi c psychiatric symp- toms and behaviors can present from a culturally determined response to a specifi c event rather than from a clinical disorder. An acute psychotic episode may be related to a religious trance or misleading somatic symptoms may be part of a depressive crisis in certain ethnic groups. Reactions to a trauma may look very different in Hispanic compared to Asian patients [110] . Clinicians evaluating patients need to achieve cultural compe- tence which requires the understanding of cultural beliefs, assumptions and expectations, the acceptance of alternative per- spectives and the expression of compassion and empathy. Management of a gitation and p sychosis The immediate goal is the rapid reduction of agitation or psycho- sis while maintaining the safety of the patient and staff. The long - term goal is the treatment of the underlying condition and reduction of future agitation. One of the fi rst tasks is to try to discern the etiology of the agitation. A quick medical evaluation should be done to determine if there are any life - threatening medical conditions. Much of the time, staff must start with pre- sumptive diagnoses. Precautions must be taken to modify or manipulate the environment to maximize the safety of all indi- viduals present [111] . These may include assuring that the patient is physically comfortable, minimizing wait time, removing poten- tially dangerous objects, decreasing external stimuli through use of a quiet and private examination room, and communicating a respectful, safe and caring attitude [112] . Personnel should be educated to maintain calmness, keep a safe distance, identify cues for violence, respect the patient ’ s per- sonal space, avoid direct confrontation, refrain from prolonged or intense eye contact, and avoid any body language that might be interpreted as threatening or confrontational [111] . The fi rst treatment approach generally involves verbal de - escalation or “ defusing ” or “ talking down ” . The staff should be seen as calm and in control while at the same time conveying empathy, profes- sional concern for the patient ’ s well - being, and continuous reas- surance that the patient is safe. At least one staff member should form a therapeutic alliance that could be used later if the patient ’ s agitation escalates. This staff member should not be involved with the use of physical or chemical restraints since he or she may be helpful later for the patient to re - establish normal interpersonal relationships. If, despite initial interventions, the patient ’ s agita- tion is so severe that the threat of harm to self or others is a para- mount concern, the immediate goal of treatment is safety. Restraints may need to be employed when other methods of de - escalation and attempts to calm the patient have failed [113] . There are two types of restraints used in emergency situations: physical and chemical restraints. Physical restraints, e.g. four - point leather restraints (both arms, both legs), are important adjuncts to the emergency treatment of agitated patients. Advantages include minimal side effects when used correctly, Acute Psychiatric Conditions in Pregnancy 691 pneumonia, myocardial infarction, alcohol intoxication, alcohol withdrawal, other substance withdrawal, acute liver disease and chronic obstructive pulmonary disease [105] . Less common medical illnesses that can present with psychiatric symptoms include pulmonary embolism, subarachnoid hemorrhage, epidural hemorrhage, encephalitis, malignant hypertension, hypokalemia, hypocalcemia, splenic rupture, subacute bacterial endocarditis, cocaine intoxication, amphetamine intoxication, steroid - induced psychosis and phencyclidine psychosis [105] . After potentially life - threatening medical conditions have been ruled out, a full psychiatric assessment should be conducted to determine if there is a new - onset psychiatric disorder or an ongoing psychiatric disorder. An emergency psychiatric evalua- tion in an agitated patient should focus on specifi c questions: “ What is the problem? ” “ Why now? ” “ What are the patient ’ s expectations? ” Determining what is wrong may be diffi cult to ascertain. The patient may feel that nothing is wrong; and the collection of collateral information from signifi cant others may be crucial. Are chronic symptoms suddenly exacerbated? Clarifying the precipitating factor is crucial for determining further treatment. Is there a psychosocial stressor? Is the patient trying to communicate something to a signifi cant other or pro- vider? Has there been a change in the pattern or amount of substance use? The patient ’ s expectations are also important. Patients that come in willingly to a medical service are expecting use, but the risk increases in highly agitated patients who are poorly hydrated, restrained, and kept in poorly ventilated holding areas. It is imperative that periodic monitoring of vital signs and muscular rigidity are performed in the patient receiving typical antipsychotics [112] . The newer second - generation atypical antipsychotics (SGAs) include clozapine, olanzapine, risperidone, quetiapine, aripipra- zole and ziprasidone. SGAs are alternatives to haloperidol that offer some advantages, e.g. absence of risk of EPS and a smoother transition to long - term oral pharmacotherapy. However, fewer safety data are available about risks with fetal exposure. Ziprasidone and olanzapine are available PO and IM, and olan- zapine and risperidone are available as dissolvable oral tablets. Ziprasidone 10 mg and 20 mg IM and olanzapine 5 mg and 10 mg IM have been reported to effectively decrease agitation in several studies [112,114,116] . However, olanzapine has been associated with hypotension and some fatalities, and concern exists with the potential prolongation of the QTc interval with ziprasidone [114 – 116] . Once the patient is stable enough to undergo a medical evalu- ation, a physical examination should be performed and labora- tory tests and toxicology screens should be obtained. Medical illnesses that can present as psychiatric emergencies should be ruled out. These include hypothyroidism, hyperthyroidism, diabetic ketoacidosis, hypoglycemia, urinary tract infection, Agitated Pregnant Patient Environmental and behavioral interventions: • Decreased stimulation • Ventilation • “Talkingdown” Focused medical assessment of mother and fetus Electrolytes? Toxicology? Seclusion and/or physical restraint 1 st choice: haloperidol 5 mg PO/IM 2 nd choice: haloperidol 5 mg IM + lorazepam 2 mg IM 3 rd choice: olanzapine 10 mg IM 4 th choice: ziprasidone 20 mg IM Lorazepam 2 mg PO/IM Persistent aggressive behavior: Atypical antipsychotics ± mood stabilizers Remains agitated and a danger to self or others Withdrawal from alcohol or sedatives? No No YesYes Simultaneous Figure 48.1 Management of the agitated pregnant patient. Adapted from [103] . Chapter 48 692 bathroom parts when utilizing a toilet or shower unit that can be used to infl ict injury to self or others. It is usually easier to work with an agitated patient who presents voluntarily. In this case, the woman is likely to want help for herself and her fetus, and it may be possible to de - escalate her agitation by reminding her of her initial purposes in seeking help. Sometimes patients are very close to their “ breaking point ” when they fi nally decide to come to an ED, and a noisy environment or perceived disrespect can quickly escalate a situation that otherwise could have been managed. The labor and delivery units present similar issues as the obstetric ED, i.e. noise and equipment that can be dangerous. The antepartum units have visitors and children that need to be protected from a risk of injury from an agitated and violent patient. A private and quiet room on the antepartum or postpartum fl oor can be helpful in secluding an agitated pregnant or postpartum woman. Obstetrics and gynecology attendings , residents and nurses often feel uncomfortable managing acutely agitated pregnant and postpartum patients. Unfortunately, the patient may perceive rising levels of anxiety in the staff. If the staff – patient relation is fragile this can lead to escalation in an agitated patient. Staff should honestly assess their feelings and reactions and use those reactions to help manage their interactions. If they feel fear, staff should maintain a safe distance. If they feel anger, it is important to remember that the patient and fetus need help and the patient may not know how to ask for help. If they feel hostility, forming an alliance with another staff member that feels sympathy for the patient can be helpful. In an emergency situation it may be tempt- ing to allow a belligerent and agitated patient to leave (or hope that they will leave) without an evaluation. However, a belligerent patient that is demanding to leave may have a life - threatening condition and deserves a full medical and psychiatric evaluation. Having the involvement of a psychiatry consultation service familiar with the management of psychiatric illness in the context of pregnancy can make the management of acute agitation easier for obstetrics and gynecology clinicians. Psychosis and m ania d uring p regnancy and p ostpartum Schizophrenia is characterized by delusions, hallucinations, dis- organized speech, disorganized behavior, and fl attened emotions [5] . Women with schizophrenia have a high risk of unplanned and unwanted pregnancies and they tend to have poorer prenatal care, poorer nutrition, more alcohol, drug and tobacco use, and a higher risk of suicide and injury to others than women without schizophrenia [117] . Psychosis itself is associated with low birth weight, small for gestational age babies, stillbirth, prematurity and infant death [118 – 120] . Women with schizophrenia and schizoaffective disorder have an increased risk of relapse in the fi rst 3 months after delivery, possibly due to the decrease in anti- dopaminergic activity with the fall of estrogen following delivery [121] . Mothers with active psychosis have severely impaired func- tioning and adverse effects on child development. Because of the negative effects of active psychosis on fetal and infant develop- ment, women with psychotic disorders should strongly consider continuation of their psychotropic medication through preg- something such as a cure, alleviation of a particular symptom, avoidance of incarceration, hospitalization to avoid a situation at home or on the streets, a prescription, or a note to be out of work for a few days. Sometimes the expectation is overtly displayed. For example, a pregnant patient may become acutely agitated and complain of contractions to be hospitalized in order to avoid arrest or incarceration. Sometimes the expectations are covert and the patient expects the clinician to infer what the patient ’ s desires are. Every emergency evaluation of agitation requires identifi cation of any underlying conditions and the circumstances that led to the agitation. A new - onset psychiatric disorder involves educa- tion of the patient and family about the disorder and treatment options. For chronic psychiatric disorders, adjustment of medica- tion may be necessary. It is necessary to ascertain whether or not treatment can be administered in an outpatient setting, or if admission to a medical or psychiatric hospital is necessary. Contact with existing outpatient clinicians is important for con- tinuity of care. If alcohol or substance abuse is present, the patient should be referred to a detoxifi cation or rehabilitation program. Management of a gitation in the p regnant and p ostpartum p atient The management of agitation in the pregnant patient represents additional challenges. Specifi c precipitants that can arise with a pregnant woman include an unwanted pregnancy or discontinu- ation of psychotropic medications due to fears of harming the fetus. Since the well - being of the fetus is important, the physical assessment becomes a primary concern. The risks to the fetus with medication or physical restraints need to be considered. One of the concerns in the use of physical restraints is harm to the fetus during takedown, particularly during the second or third trimester when the gravid abdomen is prominent. However, if leather restraints are necessary the fetus is already likely to be at physical risk due to the mother ’ s level of agitation. An agitated pregnant patient elicits concern in family members, ED staff and police. A psychiatric ED is more equipped to deal with agitation, violence and psychosis than a medical ED, but is less experienced in the physical assessment treatment of a pregnant woman and her fetus. If an agitated pregnant woman is being evaluated in a medical or obstetrics and gynecology facility, the setting in which the assessment and management of the agitation is taking place pres- ents challenges. In the ED, how the patient presents is important. Was she brought in unwillingly or did the patient request an evaluation? A patient that is brought involuntarily may be bel- ligerent and agitated from the start. The noise in an ED may lead to further escalation. Effort should be made to locate a room away from the most active areas of the ED and away from patients in active labor or requiring much care. Equipment commonly found in an obstetrics ED triage area or on a unit can quickly become a weapon in the hands of an agitated and hostile patient. Potentially dangerous articles should be removed from the prox- imity of an agitated patient. An agitated patient can break off Acute Psychiatric Conditions in Pregnancy 693 tion, and intermittent amnesia of delivery [128,130] . Infanticidal thoughts can occur in mothers with PPD and who have babies with colic, but most women do not act on infanticidal thoughts. More study is needed of specifi c risk factors for neonaticide and infanticide [128] . Treatment of m ania and p sychosis d uring p regnancy and p ostpartum The treatment of mania, psychosis and agitated behavior in the pregnant woman is likely to involve mood stabilizers, antipsy- chotics and, on occasion, benzodiazepines. It is assumed that the response rates to these medications approximate the response rates with non - puerperal use, but this assumption has not been studied. As with antidepressant medications, exposure of the fetus to mood stabilizers and antipsychotic medications is associ- ated with potential risks that need to be discussed with the mother. The goal of treatment of the pregnant or breastfeeding woman with mania or psychosis is to maintain emotional and physical stability for the mother, fetus and infant. Psychosocial support and psychotherapy can be useful adjuncts to pharmacotherapy. Women with a postpartum manic episode or PPP should be stabilized with a mood stabilizer [126] . Antipsychotic medication and electroconvulsive therapy (ECT) should also be considered, as well as an antidepressant if a woman with PPP has had previous psychotic depression [124] . Postpartum administration of estro- gen has demonstrated mixed effi cacy for PPP and is currently considered investigational [131] . In one study, 12 days of trans- dermal estradiol did not reduce PPP in 29 women with previous mania or psychosis [132] . Divalproex was reported not to be superior to no drug in preventing PPP in women with bipolar disorder [133] . Olanzapine was recently reported to be superior to no drug in preventing PPP and mood episodes in women with bipolar disorder [134] . PPP may preferentially respond to ECT compared to non - puerperal psychosis [135] . Studies of congenital malformations with fi rst - trimester ben- zodiazepine exposure have suggested both no teratogenic risk [136] and a small increased risk of oral cleft [137] . Neonatal concerns with third - trimester benzodiazepine use include fl oppy infant syndrome and benzodiazepine withdrawal [138] . Benzodiazepines have been safely administered during lactation, but excessive sedation is a risk [138] . First - trimester exposure to lithium confers an increased risk of Ebstein ’ s cardiac anomaly from 1 in 2000 to 1 in 1000 [139] . The appearance of this anomaly can be evaluated by ultrasound at 16 – 18 weeks gestation. Neonatal concerns with third - trimester lithium use include fl oppy infant syndrome, hypotonicity, cya- nosis, hypothyroidism, and neonatal diabetes insipidus [140,141] . It has been suggested to discontinue lithium prior to delivery to avoid toxicity with the sudden decrease in vascular volume at delivery and immediately restarting lithium after delivery, with serum monitoring, to prevent postpartum relapse [142] . Lithium is generally not recommended during breastfeeding due to its elevated levels in breast milk [124,141] . nancy and the postpartum period. If they do wish to discontinue their medication, a slow taper over 2 months reduces the risk of relapse, compared to a taper in less than 2 weeks [122] . The woman ’ s competence to make decisions and her treatment pref- erences must be taken into account [123] . Bipolar disorder is a chronic psychiatric disorder characterized by recurrent mania, hypomania, depression, mixed states and euthymic mood. Mania involves elevated, expansive or irritable mood and may be accompanied by infl ated self - esteem or gran- diosity, pressured speech, racing thoughts, decreased need for sleep, increased goal - directed activity, psychomotor agitation, and risky behaviors [5] . Pregnancy is neither protective nor a time of increased risk for bipolar episodes if medication is main- tained. However, decreasing a mood stabilizer during pregnancy (or at any time), especially a rapid decrease, leads to a high risk of relapse [20] . The postpartum risk of recurrence of bipolar disorder is 20 – 50% [117] . A woman with active mania is severely impaired in her functioning, as is an actively psychotic woman. There is an elevated risk of risk - taking behaviors, poor self - care and nutrition, substance abuse and risk of suicide. Again, due to the deleterious effects of active psychosis on fetal and infant development, women with bipolar disorder should strongly con- sider continuation of their psychotropic medication through pregnancy and the postpartum period. Postpartum psychosis (PPP) occurs in 1 in 500 mothers, with rapid onset in the fi rst 2 – 4 weeks after delivery. PPP includes delusions, paranoid thinking, confused thinking, mood swings, disorganized behavior, poor judgement and impaired function- ing [124] . It is considered a psychiatric emergency and usually results in inpatient psychiatric hospitalization. Risk factors include a previous episode of PPP, obstetric complications, pri- miparity, sleep deprivation, environmental stressors, family history, and recent discontinuation of mood stabilizers [124 – 126] . Having a family member with previous PPP was associated with an increased risk of PPP in women with bipolar disorder compared to not having a relative with previous PPP [127] . Longitudinal studies suggest that the majority of PPP cases are related to bipolar disorder, not schizophrenia [124] . Overall, the prognosis for recovery from PPP is good with adequate treatment [124] . One of the most serious risks of PPP is infanticide. The rate of homicide of infants up to 1 year of age is 8 per 100 000 in the United States [128] , but it is unknown how many women with PPP commit infanticide. Symptom exacerbation, command hal- lucinations and the stressor of being postpartum can increase the risk of infanticide in a postpartum mother with psychosis [129] . However, not all infanticide is committed by psychotic mothers. Infanticide also occurs in the context of severe depres- sion, due to neglect and abuse, due to the child being unwanted, or as revenge against the infant ’ s father [129] . Between 16 and 29% of mothers who kill their children also kill themselves [128] . Neonaticide is defi ned as killing of a newborn within 24 hours of birth. It is associated with denial of pregnancy, relative lack of prenatal care, dissociative hallucinations, depersonaliza- Chapter 48 694 postpartum period are similar to those for adults in general. Abortion may be a specifi c risk factor for suicide, and this should be taken into account. Although pregnancy and the postpartum period are associated with fewer suicide attempts and completed suicides, perinatal women should be asked about unwanted preg- nancy, hopelessness, IPV, social support, preparations for the infant, attention to self - care and prenatal care, and alcohol and substance abuse. Women may have discontinued psychotropic medication that had been working due to fears of harming the fetus. The treatment of depression, bipolar disorder, psychosis and agitation should involve medications with the best - known safety profi le in pregnancy and lactation. Women and their fami- lies need to make informed decisions about the risks and benefi ts of both treating and not treating psychiatric disorders. The goal is maternal – fetal and maternal – infant well - being. References 1 Hazlett S , McCarthy M , Londner M , et al. Epidemiology of adult psychiatric visits to US emergency departments . Acad Emerg Med 2004 ; 11 : 193 – 195 . 2 Boudreaux E , Cagande C , Kilgannon H , et al. A prospective study of depression among adult patients in an urban emergency depart- ment . Prim Care Companion J Clin Psychiatry 2006 ; 8 : 66 – 70 . 3 Schanzer B , First M , Dominguez B , et al. Diagnosing psychotic dis- orders in the emergency department in the context of substance use . Psychiatr Serv 2006 ; 57 : 1468 – 1473 . 4 Ernst C , Bird S , Goldberg J , et al. The prescription of psychotropic medications for patients discharged from a psychiatric emergency service . J Clin Psychiatry 2006 ; 67 : 720 – 726 . 5 American Psychiatric Association . Diagnostic and Statistical Manual of Mental Disorders , 4th edn , rev. Washington, DC : American Psychiatric Press , 2000 . 6 Lopez A , Mathers C , Ezzati M , et al. Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data . Lancet 2006 ; 367 : 1747 – 1757 . 7 Cassano P , Fava M . Depression and public health: an overview . J Psychosom Res 2002 ; 53 : 849 – 857 . 8 Kroenke K , Spitzer R , Williams J . The Patient Health Questionnaire - 2: validity of a two - item depression screener . Med Care 2003 ; 41 : 1284 – 1292 . 9 Flynn H , Blow F , Marcus S . Rates and predictors of depression treat- ment among pregnant women in hospital - affi liated obstetrics prac- tices . Gen Hosp Psychiatry 2006 ; 28 : 289 – 295 . 10 Smith M , Rosenheck R , Cavaleri M , et al. Screening for and detec- tion of depression, panic disorder, and PTSD in public - sector obstetric clinics . Psychiatr Serv 2004 ; 55 : 407 – 414 . 11 Sundstrom I , Bixo M , Bjorn I , et al. Prevalence of psychiatric dis- orders in gynecologic outpatients . Am J Obstet Gynecol 2001 ; 184 : 8 – 13 . 12 Miranda J , Azocar F , Komaromy M , et al. Unmet mental health needs of women in public - sector gynecologic clinics . Am J Obstet Gynecol 1998 ; 178 : 212 – 217 . 13 Flynn H , O ’ Mahen H , Massey L , et al. The impact of a brief obstet- rics clinic - based intervention on treatment use for perinatal depres- sion . J Womens Health 2006 ; 15 : 1195 – 1204 . First - trimester exposure to carbamazepine increases the risk of neural tube defects, craniofacial abnormalities, fi ngernail hypo- plasia and growth retardation [143] . The teratogenic risks with fi rst - trimester exposure with valproate are more profound, par- ticularly with doses above 800 – 1000 mg/day. Valproate has been associated with neural tube defects, craniofacial abnormalities, cardiac abnormalities and developmental delay. With third - trimester exposure, neonatal symptoms of jitteriness, diffi culty feeding, abnormal tone, bradycardia, hypoglycemia and liver tox- icity have been reported [141] . Supplemental folic acid (3 – 5 mg/ day) is recommended with carbamazepine and valproate, ideally started prior to conception. Vitamin K 20 mg/day is recom- mended in the last month of pregnancy to decrease the risk of a bleeding diathesis [144] . Less information is available about the teratogenicity of lamotrigine, topiramate, gabapentin and newer antiepileptic drugs. Monotherapy confers less teratogenic risk than the use of multiple antiepileptic mediations [145] . Carbamazepine and valproate are considered relatively safe with breastfeeding, and minimal safety data are available for the newer antiepileptic medications with breastfeeding [141,143,146] . As mentioned above, antipsychotic medications may be needed during pregnancy for the treatment of agitation, bipolar disorder or chronic schizophrenia. Reviews of studies of haloperidol use in pregnancy have suggested both no increased risk of congenital malformations [147] and a possible increase in limb defects [148] . First - trimester exposure to phenothiazines confers a small increase in risk of congenital malformations compared to the general population rate [149] . It is important to note that untreated psy- chosis itself is associated with adverse birth outcomes [117,119] . Third - trimester use of traditional antipsychotics has been associ- ated with neonatal dyskinesias, hypertonicity, tremor, motor rest- lessness, poor feeding and cholestatic jaundice [147] . The newer SGAs are currently used more frequently in psychosis and bipolar disorder than traditional antipsychotics due to their easier toler- ability and decreased risk of EPS. Studies have reported both an absence of congenital malformations [150,151] and a small increase in congenital malformations with olanzapine and clozap- ine [121,152] . Neonatal concerns with third - trimester exposure to SGAs have not been reported, except with clozapine (seizures and theoretical risk of agranulocytosis) [121,150] . Concerns with SGA use during pregnancy include the potential weight gain with hyperinsulinemia and hypertension and their adverse effects on birth outcomes [121] . Few data have been published on the safety of SGAs with breastfeeding but low infant serum levels and absence of adverse effects have been reported [124] . Clozapine is not rec- ommended with breastfeeding due to reports of high concentra- tions in breast milk and infant serum, agranulocytosis, excess sedation and seizures [121,153] . Conclusions The recommendations for the assessment and treatment of depression, suicidality and agitation during pregnancy and the Acute Psychiatric Conditions in Pregnancy 695 33 Chaudron L , Szilagyi P , Campbell A , et al. 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