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 outco
Trang 1were 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 activirritabil-ity, 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
Trang 2immediate 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,
Trang 3pneumonia, 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 quesevalua-tions: “ 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 5mg PO/IM
2nd choice: haloperidol 5mg IM + lorazepam 2 mg IM
3rd choice: olanzapine 10mg IM
4th choice: ziprasidone 20mg IM
Lorazepam 2mg PO/IM
Persistent aggressive behavior: Atypical antipsychotics ± mood stabilizers
Remains agitated and a danger to self or others alcohol or sedatives?Withdrawal from
No
Yes
Simultaneous
Figure 48.1 Management of the agitated
pregnant patient Adapted from [103]
Trang 4bathroom 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, disdis-organized 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 medicdiscontinu-ations 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 prespres-ents 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
Trang 5tion, 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,
Trang 6depersonaliza-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
psychiatric visits to US emergency departments Acad Emerg Med
2004 ; 11 : 193 – 195
of depression among adult patients in an urban emergency
depart-ment Prim Care Companion J Clin Psychiatry 2006 ; 8 : 66 – 70
dis-orders in the emergency department in the context of substance use
Psychiatr Serv 2006 ; 57 : 1468 – 1473
medications for patients discharged from a psychiatric emergency
service J Clin Psychiatry 2006 ; 67 : 720 – 726
of Mental Disorders , 4th edn , rev Washington, DC : American
Psychiatric Press , 2000
disease and risk factors, 2001: systematic analysis of population
health data Lancet 2006 ; 367 : 1747 – 1757
J Psychosom Res 2002 ; 53 : 849 – 857
1284 – 1292
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
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
Trang 733 Chaudron L , Szilagyi P , Campbell A , et al Legal and ethical consid-erations: risks and benefi ts of postpartum depression screening at
well - child visits Pediatrics 2007 ; 119 : 123 – 128
34 Bradshaw Z , Slade P The effects of induced abortion on emotional
experiences and relationships: a critical review of the literature Clin
Psychol Rev 2003 ; 23 : 929 – 958
35 Sit D , Rothschild A , Creinin M , et al Psychiatric outcomes
following medical and surgical abortion Hum Reprod 2007 ; 22 :
878 – 884
36 Fergusson D , Horwood L , Ridder E Abortion in young women
and subsequent mental health J Child Psychol Psychiatry 2006 ; 47 :
16 – 24
37 Shadigian E , Bauer S Pregnancy - associated death: a qualitative
sys-tematic review of homicide and suicide Obstet Gynecol Surv 2005 ;
60: 183 – 190
38 Gissler M , Hemminki E , Lonnqvist J Suicides after pregnancy
1431 – 1434
39 Klier C , Geller P , Ritsher J Affective disorders in the aftermath of
miscarriage: a comprehensive review Arch Womens Ment Health
2002 ; 5 : 129 – 149
40 Neugebauer R , Kline J , Shrout P , et al Major depressive disorder in
the 6 months after miscarriage JAMA 1997 ; 277 : 383 – 388
41 Geller P , Kerns D , Klier C Anxiety following miscarriage and the subsequent pregnancy: a review of the literature and future
direc-tions J Psychosom Res 2004 ; 56 : 35 – 45
42 Brier N Anxiety after miscarriage: a review of the empirical
litera-ture and implications for clinical practice Birth 2004 ; 31 : 138 – 142
43 Turton P , Hughes P , Evans C , et al Incidence, correlates and predic-tors of post - traumatic stress disorder in the pregnancy after
still-birth Br J Psychiatry 2001 ; 178 : 556 – 560
44 Hughes P , Turton P , Evans C Stillbirth as risk factor for depression
and anxiety in the subsequent pregnancy: cohort study BMJ 1999 ;
318 : 1721 – 1724
45 Badenhorst W , Hughes P Psychological aspects of perinatal loss
Best Pract Res Clin Obstet Gynaecol 2007 ; 21 : 249 – 259
46 Hughes P , Turton P , Hopper E , et al Assessment of guidelines for good practice in psychosocial care of mothers after stillbirth: a
cohort study Lancet 2002 ; 360 : 114 – 118
47 O ’ Leary J Grief and its impact on prenatal attachment in the
sub-sequent pregnancy Arch Womens Ment Health 2004 ; 7 : 7 – 18
48 Chaudron L Critical issues in perinatal psychiatric emergency care
Psychiatr Issues Emerg Care Sett 2005 ; 4 : 11 – 18
49 Martin S , Li Y , Casanueva C , et al Intimate partner violence and
women ’ s depression before and during pregnancy Violence Against
Women 2006 ; 12 : 221 – 239
50 Gazmararian J , Lazorick S , Spitz A , et al Prevalence of violence
against pregnant women JAMA 1996 ; 275 : 1915 – 1920
51 Silverman J , Decker M , Reed E , et al Intimate partner violence victimization prior to and during pregnancy among women residing
in 26 U.S states: associations with maternal and neonatal health Am
J Obstet Gynecol 2006 ; 195 : 140 – 148
52 Boy A , Salihu H Intimate partner violence and birth outcomes: a
systematic review Int J Fertil Womens Med 2004 ; 49 : 159 – 164
53 Renker P , Tonkin P Women ’ s views of prenatal violence screening:
acceptability and confi dentiality issues Obstet Gynecol 2006 ; 107 :
348 – 354
54 American College of Obstetricians and Gynecologists , Committee
on Healthcare for Underserved Women ACOG Committee Opinion
14 Gavin N , Gaynes B , Lohr K , et al Perinatal depression: a systematic
1071 – 1083
15 Cox J , Holden J , Sagovsky R Detection of postnatal depression
Development of the 10 - item Edinburgh Postnatal Depression Scale
Br J Psychiatry 1987 ; 150 : 782 – 786
16 Matthey S , Henshaw C , Elliott S , et al Variability in use of cut - off
scores and formats on the Edinburgh Postnatal Depression Scale –
implications for clinical and research practice Arch Womens Ment
Health 2006 ; 9 : 309 – 315
17 Halbreich U Prevalence of mood symptoms and depressions during
Spectr 2004 ; 9 : 177 – 184
18 Munk - Olsen T , Laursen T , Pedersen C , et al New parents and
mental disorders: a population - based register study JAMA 2006 ;
296 : 2582 – 2589
19 Cohen L , Altshuler L , Harlow B , et al Relapse of major depression
during pregnancy in women who maintain or discontinue
antide-pressant treatment JAMA 2006 ; 295 : 499 – 507
20 Viguera A , Nonacs R , Cohen L , et al Risk of recurrence of
bipolar disorder in pregnant and nonpregnant women after
179 – 184
21 Dell D , O ’ Brien BW Suicide in pregnancy Obstet Gynecol 2003 ; 102 :
1306 – 1309
22 Halbreich U The association between pregnancy processes, preterm
deliv ery, low birth weight, and postpartum depressions – the need
for interdisciplinary integration Am J Obstet Gynecol 2005 ; 193 :
1312 – 1322
23 Van den Bergh B , Mulder E , Mennes M , et al Antenatal maternal
anxiety and stress and the neurobehavioural development of the
fetus and child: links and possible mechanisms A review Neurosci
Biobehav Rev 2005 ; 29 : 237 – 258
24 Wadhwa PD Psychoneuroendocrine processes in human pregnancy
infl uence fetal development and health Psychoneuroendocrinology
2005 ; 30 : 724 – 743
25 Henshaw C Mood disturbance in the early puerperium: a review
Arch Womens Ment Health 2003 ; 6 : S33 - S42
26 Henshaw C , Foreman D , Cox J Postnatal blues: a risk factor for
267 – 272
27 Robertson E , Grace S , Wallington T , et al Antenatal risk factors for
postpartum depression: a synthesis of recent literature Gen Hosp
Psychiatry 2004 ; 26 : 289 – 295
28 Bernstein I , Rush A , Yonkers K , et al Symptom features of
20 – 26
29 Kendell R , Wainwright S , Hailey A , et al The infl uence of
302
30 Grace S , Evindar A , Stewart DE The effect of postpartum depression
on child cognitive development and behavior: a review and critical
263 – 274
31 Weissman M , Wickramaratne P , Nomura Y , et al Offspring of
1001 – 1008
32 Wisner K , Chambers C , Sit D Postpartum depression: a major
public health problem JAMA 2006 ; 296 : 2616 – 2618
Trang 873 Wisner K , Hanusa B , Perel J , et al Postpartum depression: a
ran-domized trial of sertraline versus nortriptyline J Clin Psychopharmacol
2006 ; 26 : 353 – 360
74 Appleby L , Warner R , Whitton A , et al A controlled study of fl
postnatal depression BMJ 1997 ; 314 : 932 – 936
75 Misri S , Reebye P , Corral M , et al The use of paroxetine and cognitive - behavioral therapy in postpartum depression and anxiety:
a randomized controlled trial J Clin Psychiatry 2004 ; 65 : 1236 –
1241
76 Weissman A , Levy B , Hartz A , et al Pooled analysis of antidepressant
levels in lactating mothers, breast milk, and nursing infants Am J
Psychiatry 2004 ; 161 : 1066 – 1078
77 Abreu A , Stuart S Pharmacologic and hormonal treatments for
postpartum depression Psychiatr Ann 2005 ; 35 : 568 – 576
78 Eberhard - Gran M , Eskild A , Opjordsmoen S Use of psychotropic medications in treating mood disorders during lactation: practical
recommendations CNS Drugs 2006 ; 20 : 187 – 198
79 Gentile S The safety of newer antidepressants in pregnancy and
breastfeeding Drug Saf 2005 ; 28 : 137 – 152
80 Hallberg P , Sjoblom V The use of selective serotonin reuptake inhibitors during pregnancy and breast - feeding: a review and
clini-cal aspects J Clin Psychopharmacol 2005 ; 25 : 59 – 73
81 O ’ Hara M , Stuart S , Gorman L , et al Effi cacy of interpersonal
psy-chotherapy for postpartum depression Arch Gen Psychiatry 2000 ;
57 : 1039 – 1045
82 Dennis C Treatment of postpartum depression, part 2: a critical
review of nonbiological interventions J Clin Psychiatry 2004 ; 65 :
1252 – 1265
83 Kopelman R , Stuart S Psychological treatments for postpartum
depression Psychiatr Ann 2005 ; 35 : 556 – 566
84 Bledsoe S , Grote N Treating depression during pregnancy and the
postpartum: a preliminary meta - analysis Res Soc Work Pract 2006 ;
16 : 109 – 120
85 Pearlstein T Perinatal depression: treatment options and dilemmas
J Psychiatry Neurosci 2008 ; 33 : 302 – 318
86 Dennis C , Chung - Lee L Postpartum depression help - seeking barri-ers and maternal treatment preferences: a qualitative systematic
review Birth 2006 ; 33 : 323 – 331
87 Practice guideline for the assessment and treatment of patients with
suicidal behaviors Am J Psychiatry 2003 ; 160 : 1 – 60
88 Chaudron L , Caine E Suicide among women: a critical review
J Am Med Womens Assoc 2004 ; 59 : 125 – 134
89 Knox K , Caine E Establishing priorities for reducing suicide and its
1898 – 1903
90 Oquendo M , Bongiovi - Garcia M , Galfalvy H , et al Sex differences
in clinical predictors of suicidal acts after major depression: a
pro-spective study Am J Psychiatry 2007 ; 164 : 134 – 141
91 Hawton K , Sutton L , Haw C , et al Suicide and attempted suicide in
bipolar disorder: a systematic review of risk factors J Clin Psychiatry
2005 ; 66 : 693 – 704
92 Stern T , Perlis R , Lagomasino I Suicidal patients In: Stern T ,
Fricchione G , Cassem N , et al., eds Massachusetts General Hospital
Handbook of General Hospital Psychiatry , 5th edn Philadelphia :
Mosby , 2004 : 93 – 104
93 Nock M , Kessler R Prevalence of and risk factors for suicide attempts versus suicide gestures: analysis of the National Comorbidity Survey
J Abnorm Psychol 2006 ; 115 : 616 – 623
No 343: psychosocial risk factors: perinatal screening and
interven-tion Obstet Gynecol 2006 ; 108 : 469 – 477
55 Spinelli M , Endicott J Controlled clinical trial of interpersonal
psy-chotherapy versus parenting education program for depressed
preg-nant women Am J Psychiatry 2003 ; 160 : 555 – 562
56 Epperson C , Terman M , Terman J , et al Randomized clinical trial
of bright light therapy for antepartum depression: preliminary fi
nd-ings J Clin Psychiatry 2004 ; 65 : 421 – 425
57 Field T , Diego M , Hernandez - Reif M , et al Massage therapy effects
on depressed pregnant women J Psychosom Obstet Gynaecol 2004 ;
25 : 115 – 122
58 Manber R , Schnyer R , Allen J , et al Acupuncture: a promising
treat-ment for depression during pregnancy J Affect Disord 2004 ; 83 :
89 – 95
59 Freeman M , Hibbeln J , Wisner K , et al An open trial of omega - 3
fatty acids for depression in pregnancy Acta Neuropsychiatr 2006 ;
18 : 21 – 24
60 Sit D , Wisner K Decision making for postpartum depression
treat-ment Psychiatr Ann 2005 ; 35 : 577 – 585
61 Rahimi R , Nikfar S , Abdollahi M Pregnancy outcomes following
exposure to serotonin reuptake inhibitors: a meta - analysis of clinical
trials Reprod Toxicol 2006 ; 22 : 571 – 575
62 Hemels M , Einarson A , Koren G , et al Antidepressant use during
pregnancy and the rates of spontaneous abortions: a meta - analysis
Ann Pharmacother 2005 ; 39 : 803 – 809
63 Einarson T , Einarson A Newer antidepressants in pregnancy
and rates of major malformations: a meta - analysis of prospective
823 – 827
64 Wogelius P , Norgaard M , Gislum M , et al Maternal use of selective
serotonin reuptake inhibitors and risk of congenital malformations
Epidemiology 2006 ; 17 : 701 – 704
65 Williams M , Wooltorton E Paroxetine (Paxil) and congenital
mal-formations Can Med Assoc J 2005 ; 173 : 1320 – 1321
66 Berard A , Ramos E , Rey E , et al First trimester exposure to
parox-etine and risk of cardiac malformations in infants: the importance
18 – 27
67 Moses - Kolko E , Bogen D , Perel J , et al Neonatal signs after late in
utero exposure to serotonin reuptake inhibitors: literature review
2372 – 2383
68 Nordeng H , Spigset O Treatment with selective serotonin reuptake
inhibitors in the third trimester of pregnancy: effects on the infant
Drug Saf 2005 ; 28 : 565 – 581
69 Sanz E , De - las - Cuevas C , Kiuru A , et al Selective serotonin reuptake
inhibitors in pregnant women and neonatal withdrawal syndrome:
a database analysis Lancet 2005 ; 365 : 482 – 487
70 Oberlander T , Warburton W , Misri S , et al Neonatal outcomes after
prenatal exposure to selective serotonin reuptake inhibitor
antide-pressants and maternal depression using population - based linked
health data Arch Gen Psychiatry 2006 ; 63 , 898 – 906
71 Chambers C , Hernandez - Diaz S , van Marter L , et al Selective
sero-tonin - reuptake inhibitors and risk of persistent pulmonary
hyper-tension of the newborn N Engl J Med 2006 ; 354 : 579 – 587
72 American College of Obstetricians and Gynecologists , Committee
on Obstetric Practice Committee Opinion No 354: treatment with
Gynecol 2006 ; 108 : 1601 – 1603
Trang 9tion or violence in the emergency department J Emerg Med 2006 ;
31 : 317 – 324
117 Howard L Fertility and pregnancy in women with psychotic
dis-orders Eur J Obstet Gynecol Reprod Biol 2005 ; 119 : 3 – 10
118 Jablensky A , Morgan V , Zubrick S , et al Pregnancy, delivery, and neonatal complications in a population cohort of women with
schizophrenia and major affective disorders Am J Psychiatry 2005 ;
162 : 79 – 91
119 Nilsson E , Lichtenstein P , Cnattingius S , et al Women with schizo-phrenia: pregnancy outcome and infant death among their
off-spring Schizophr Res 2002 ; 58 : 221 – 229
120 Bennedsen B , Mortensen P , Olesen A , et al Congenital malformations, stillbirths, and infant deaths among children
674 – 679
121 Yaeger D , Smith H , Altshuler L Atypical antipsychotics in the
treat-ment of schizophrenia during pregnancy and the postpartum Am J
Psychiatry 2006 ; 163 : 2064 – 2070
122 Gilbert P , Harris J , McAdams L , et al Neuroleptic withdrawal in
schizophrenic patients A review of the literature Arch Gen Psychiatry
1995 ; 52 : 173 – 188
123 Seeman M Relational ethics: when mothers suffer from psychosis
Arch Womens Ment Health 2004 ; 7 : 201 – 210
124 Sit D , Rothschild A , Wisner K A review of postpartum psychosis
J Womens Health 2006 ; 15 : 352 – 368
125 Blackmore E , Jones I , Doshi M , et al Obstetric variables associated
with bipolar affective puerperal psychosis Br J Psychiatry 2006 ; 188 :
32 – 36
126 Sharma V Pharmacotherapy of postpartum psychosis Expert Opin
Pharmacother 2003 ; 4 : 1651 – 1658
127 Jones I , Craddock N Familiality of the puerperal trigger in bipolar
913 – 917
128 Friedman S , Horwitz S , Resnick P Child murder by mothers: a criti-cal analysis of the current state of knowledge and a research agenda
Am J Psychiatry 2005 ; 162 : 1578 – 1587
129 Spinelli M Maternal infanticide associated with mental illness:
pre-vention and the promise of saved lives Am J Psychiatry 2004 ; 161 :
1548 – 1557
130 Spinelli M A systematic investigation of 16 cases of neonaticide Am
J Psychiatry 2001 ; 158 : 811 – 813
131 Gentile S The role of estrogen therapy in postpartum psychiatric
disorders: an update CNS Spectr 2005 ; 10 : 944 – 952
132 Kumar C , McIvor R , Davies T , et al Estrogen administration does not reduce the rate of recurrence of affective psychosis after
child-birth J Clin Psychiatry 2003 ; 64 : 112 – 118
133 Wisner K , Perel J , Peindl K , et al Prevention of postpartum episodes
596
134 Sharma V , Smith A , Mazmanian D Olanzapine in the prevention of
Bipolar Disord 2006 ; 8 : 400 – 404
135 Reed P , Sermin N , Appleby L , et al A comparison of clinical response
to electroconvulsive therapy in puerperal and non - puerperal
psy-choses J Affect Disord 1999 ; 54 : 255 – 260
136 Eros E , Czeizel A , Rockenbauer M , et al A population based case -control teratologic study of nitrazepam, medazepam, tofi sopam,
Obstet Gynecol Reprod Biol 2002 ; 101 : 147 – 154
94 Lindahl V , Pearson J , Colpe L Prevalence of suicidality during
77 – 87
95 Marzuk P , Tardiff K , Leon A , et al Lower risk of suicide during
pregnancy Am J Psychiatry 1997 ; 154 : 122 – 123
96 Appleby L Suicide during pregnancy and in the fi rst postnatal year
BMJ 1991 ; 302 : 137 – 140
97 Appleby L , Mortensen P , Faragher E Suicide and other causes of
mortality after post - partum psychiatric admission Br J Psychiatry
1998 ; 173 : 209 – 211
98 Oates M Suicide: the leading cause of maternal death Br J Psychiatry
2003 ; 183 : 279 – 281
99 Czeizel A , Timar L , Susanszky E Timing of suicide attempts by self
poisoning during pregnancy and pregnancy outcomes Int J Gynaecol
Obstet 1999 ; 65 : 39 – 45
100 Schiff M , Grossman D Adverse perinatal outcomes and risk for
Pediatrics 2006 ; 118 : e669 – e675
101 Gandhi S , Gilbert W , McElvy S , et al Maternal and neonatal
out-comes after attempted suicide Obstet Gynecol 2006 ; 107 : 984 – 990
102 Battaglia J Pharmacological management of acute agitation Drugs
2005 ; 65 : 1207 – 1222
103 Citrome L , Volavka J Treatment of violent behavior In: Tasman A ,
Kay J , Lieberman J , eds Psychiatry , 2nd edn Chichester : John Wiley ,
2003 : 2136 – 2146
104 Sachs G A review of agitation in mental illness: burden of illness
and underlying pathology J Clin Psychiatry 2006 ; 67 : 5 – 12
105 Fauman B Other psychiatric emergencies In: Kaplan H , Sadock B ,
Williams and Wilkins , 1995 : 1752 – 1765
106 Lindenmayer J The pathophysiology of agitation J Clin Psychiatry
2000 ; 61 : 5 – 10
107 Brower M , Price B Neuropsychiatry of frontal lobe dysfunction in
violent and criminal behaviour: a critical review J Neurol Neurosurg
Psychiatry 2001 ; 71 : 720 – 726
108 Lam J , McNiel D , Binder R The relationship between patients ’
gender and violence leading to staff injuries Psychiatr Serv 2000 ; 51 :
1167 – 1170
109 Onyike C , Lyketsos C Aggression and violence In: Levenson J , ed
Textbook of Psychosomatic Medicine Arlington, VA : American
Psychiatric Publishing , 2005 : 171 – 191
110 Alarcon R , Hart D The infl uence of culture in emergency psychiatry
Psychiatr Issues Emerg Care Sett 2006 ; 5 : 13 – 22
111 Petit J Management of the acutely violent patient Psychiatr Clin
North Am 2005 ; 28 : 701 – 711
112 Marder S A review of agitation in mental illness: treatment
guide-lines and current therapies J Clin Psychiatry 2006 ; 67 : 13 – 21
113 Nelstrop L , Chandler - Oatts J , Bingley W , et al A systematic review
of the safety and effectiveness of restraint and seclusion as
interven-tions for the short - term management of violence in adult psychiatric
Based Nurs 2006 ; 3 : 8 – 18
114 Allen M , Currier G , Carpenter D , et al Treatment of behavioral
emergencies 2005 J Psychiatr Pract 2005 ; 11 : 5 – 108
115 Lukens T , Wolf S , Edlow J , et al Clinical policy: critical issues in the
diagnosis and management of the adult psychiatric patient in the
emergency department Ann Emerg Med 2006 ; 47 : 79 – 99
116 Rund D , Ewing J , Mitzel K , et al The use of intramuscular
benzo-diazepines and antipsychotic agents in the treatment of acute
Trang 10146 Gentile S Prophylactic treatment of bipolar disorder in pregnancy
Disord 2006 ; 8 : 207 – 220
147 Trixler M , Gati A , Fekete S , et al Use of antipsychotics in the
1193 – 1206
148 Diav - Citrin O , Shechtman S , Ornoy S , et al Safety of haloperidol and penfl uridol in pregnancy: a multicenter, prospective, controlled
study J Clin Psychiatry 2005 ; 66 : 317 – 322
149 Altshuler L , Cohen L , Szuba M , et al Pharmacologic management
of psychiatric illness during pregnancy: dilemmas and guidelines
Am J Psychiatry 1996 ; 153 : 592 – 606
150 Gentile S Clinical utilization of atypical antipsychotics in pregnancy
and lactation Ann Pharmacother 2004 ; 38 : 1265 – 1271
151 McKenna K , Koren G , Tetelbaum M , et al Pregnancy outcome of women using atypical antipsychotic drugs: a prospective
compara-tive study J Clin Psychiatry 2005 ; 66 : 444 – 449
152 Howard L , Webb R , Abel K Safety of antipsychotic drugs for
preg-nant and breastfeeding women with non - affective psychosis BMJ
2004 ; 329 : 933 – 934
153 Aichhorn W , Whitworth A , Weiss E , et al Second - generation anti-psychotics: is there evidence for sex differences in pharmacokinetic
and adverse effect profi les? Drug Saf 2006 ; 29 : 587 – 598
137 Dolovich L , Addis A , Vaillancourt J , et al Benzodiazepine use in
pregnancy and major malformations or oral cleft: meta - analysis of
cohort and case - control studies BMJ 1998 ; 317 : 839 – 843
138 Iqbal M , Sobhan T , Ryals T Effects of commonly used
benzodiaz-epines on the fetus, the neonate, and the nursing infant Psychiatr
Serv 2002 ; 53 : 39 – 49
139 Cohen L , Friedman J , Jefferson J , et al A reevaluation of risk of in
utero exposure to lithium JAMA 1994 ; 271 : 146 – 150
140 Viguera A , Cohen L , Baldessarini R , et al Managing bipolar disorder
during pregnancy: weighing the risks and benefi ts Can J Psychiatry
2002 ; 47 : 426 – 436
141 Yonkers K , Wisner K , Stowe Z , et al Management of bipolar
disor-der during pregnancy and the postpartum period Am J Psychiatry
2004 ; 161 : 608 – 620
142 Newport D , Viguera A , Beach A , et al Lithium placental passage and
obstetrical outcome: implications for clinical management during
late pregnancy Am J Psychiatry 2005 ; 162 : 2162 – 2170
143 Pennell P 2005 AES annual course: evidence used to treat women
with epilepsy Epilepsia 2006 ; 47 : 46 – 53
144 Crawford P Best practice guidelines for the management of women
with epilepsy Epilepsia 2005 ; 46 ( Suppl 9 ): 117 – 124
145 Tatum W Use of antiepileptic drugs in pregnancy Expert Rev
Neurother 2006 ; 6 : 1077 – 1086