Critical Care Obstetrics part 70 ppsx

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

[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 regardregard-ing 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

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

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 Lo 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:

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23 Chervenak F , McCullough L The limits of viability J Prenat Med

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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

54 Berdowitz RL Should refusal to undergo a cesarean delivery be a

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55 Minkoff H , Paltrow LM Melissa Rowland and the rights of pregnant

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56 Haack S Letter to the Editor Obstet Gynecol 2005 : 105 ( 5 ): 1147

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59 Berg RN Georgia Supreme Court orders caesarean section – mother

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60 Elkins T , Andersen H , Barclay M , et al Court - ordered cesarean

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63 McCullough LA , Chervenak F Ethics IN Obstetrics and Gynecology New York, NY Oxford University Press , 1994 : 196 – 237

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66 Loewy E The pregnant brain dead and the fetus: must we always try

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70 Halevy A , Brody B Brain death: reconciling defi nitions, criteria and

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76 Macklin R The inner workings of an ethics committee: latest battle

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77 Raleigh Fitkin - Paul Morgan Hospital v Anderson 42 NJ421, 201 A2d, 537 cert Denied 377 U.S 985 ( 1964 )

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79 Re: Jamaica Hospital, 491 NYS 2d 898 ( 1985 )

80 Application of the President and Directors of Georgetown College

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Critical Care Obstetrics, 5th edition Edited by M Belfort, G Saade,

M Foley, J Phelan and G Dildy © 2010 Blackwell Publishing Ltd.

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

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, nutriatten-tion, 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 sympsymp-toms 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

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 jittrimes-teriness, 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

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 intervendepriva-tion, 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

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