Abstract
Women with a history of severe mental illness now have greater opportunities to experience and maintain normal lifestyles, including parenting [1]. Women who have a history of severe mental illness do, however, experience marginalized, deprived lives, social stigma, have limited social relationships and support networks, and poverty, more often than women without a history of severe mental illness [2]. They often experience multiple losses in their lives, including jobs, relationships and their children. The pregnancies are often unplanned, often unwanted, and can become part of their delusional systems [3, 4], making decisions regarding the best approach to pregnancy a complex issue for both the woman and health-care professionals [2].
For these women, parenting itself raises many difficulties [3] and involves many stresses and challenges in their lives. The capacity of women with a severe mental illness to be able to care for their infant is of great concern to all health professionals [5]. While caring for children is generally seen as a rewarding experience, central to women's lives [6], the demands of parenting and coping with a severe mental illness are substantial. A serious mental illness can impair the woman's ability to parent effectively [7, 1].
Perinatal psychiatric disorders are now a leading cause of maternal morbidity and mortality in the United Kingdom, with suicide; for instance, accounting for 28% of maternal deaths during 1997–1999 [8]. The risk of a woman developing a psychotic disorder following childbirth is significantly higher than at other times in the woman's life. Oates reports a 14–35-fold increase in risk. Women with bipolar disorder, puerperal psychosis, and episodic or paranoid schizophrenia are estimated to have a 50% risk of recurrence in the post-partum period. Those women who have schizophrenia and are medicated throughout pregnancy may not be at such a high risk of relapse following childbirth [8]. It is a challenge for health-care professionals to ensure they encourage and support factors that contribute to their well-being, providing care for women and their families while at the same time identifing and reducing those that place the mother and her baby at risk [9].
The need to balance the risk to the baby and risk of relapse for the woman during pregnancy and post partum raises problems and concerns about the use of medication. For example, there are many unanswered questions about the safety of using antipsychotic drugs during pregnancy. More recent studies discuss the complexity of issues surrounding the decisions regarding the maintenance of antipsychotic mediation use in pregnancy [10–12]; however, women experience a variety of advice regarding the best approach to the use of medications during this time [6].
In Western Australia, data was reported from linked psychiatric case registers and obstetric data relating to women with serious mental illness, and the incidence of complications during pregnancy, labour, delivery and the neonatal outcomes. An increased risk of cardiovascular congenital anomalies for women who have a history of schizophrenia was discussed, along with the likelihood of low birth weight babies, which is possibly associated with multiple risk factors including nutritional status, smoking, alcohol use, physical and other pregnancy-related influences. They highlight the need for research, which will provide a better understanding of both genetic and environmental risk factors in this ‘vulnerable’ population of women, to assist with the provision of optimal antenatal and post-natal care [11].
The following is a real-life case study demonstrating failure in good practice, particularly problems with intersectoral collaboration.
Case report
Introduction
Kate∗ was a 32-year-old mother of three with a 5-year history of schizophrenia and was pregnant for the fourth time. She was followed up by the National Register of Antipsychotic Medication in Pregnancy (NRAMP) researchers through the last trimester of pregnancy, birth and the post-partum period. This case report outlines some of the issues and outcomes that Kate's story highlights, in the management of a pregnant woman with schizophrenia.
Early history
Kate's early childhood and development was unremarkable. Her family of origin consisted of father, mother and one sister. There was no known mental illness in her family, although both parents were heavy alcohol users. She left school at age 14 after becoming pregnant and has had no employment since then. Kate began using marijuana during her first pregnancy and was delivered of a healthy baby boy. Over the next 12 years, Kate had two more pregnancies with different partners and had normal deliveries of two more boys. She has lived with her mother on and off, who provided excellent support for her children, as did Kate's sister.
Psychiatric history
Approximately 4 weeks after the birth of her third baby (now 5 years old), Kate became floridly psychotic. She was convinced that her baby was being sexually abused. Kate was diagnosed as having drug-induced psychosis and was admitted to an acute inpatient psychiatric unit. Subsequently, Kate had four inpatient admissions in four different health services in two different states of Australia, with a final diagnosis of schizophrenia. Kate received many antipsychotic medications including thioridazine, which was changed to Risperidone 4 mg oral daily prior to and early into her fourth pregnancy. Kate was reasonably well on Risperidone and felt more in control of her life. In particular, she noted great improvement in her thought patterns. She experienced no side effects on Risperidone and was adherent with treatment. Kate attended her general practitioner (GP) regularly and had good rapport with him.
Current pregnancy and delivery
Kate's fourth pregnancy progressed well until 34 weeks gestation. Kate continued to smoke marijuana and nicotine cigarettes throughout her pregnancy. Kate's mental state was reasonable with a Positive and Negative Syndrome Scale (PANSS) total score of 39 during the third trimester, while she was on Risperidone 4 mg oral daily. She rated 6 on the Edinburgh Depression Scale. At 34 weeks gestation, she was told her baby was small for expected dates, estimated to be 26 weeks gestation. Weekly foetal monitoring was commenced and at 37 weeks gestation, labour was induced. Kate gave birth to a female baby weighing 2.2 kg. The baby (Jessie∗) was transferred to a special-care nursery where she was managed for hyperbilirubinemia, thermoregulation and feeding problems. Jessie was discharged at 6 weeks of age back to Kate, who was living with her mother at the time.
Postnatal progress
Between week 6 to week 12 post partum, Kate was well. When contacted during this time, Kate was happy and animated. Her baby was content, feeding well on formula, gaining weight, making sounds and playing. Kate reported that the maternal and child health nurse and paediatrician plus special care nurses were happy with baby Jessie's’ progress.
At 12 weeks post natal, Kate stated she had attended a new GP nearby, who recommended she cease her medications. Five weeks later, after ceasing her medication, her mental state deteriorated. She had a disagreement with her mother who ‘threw her out of the house’. Kate was acutely distressed, as was her baby. She called an ambulance and was assessed as being unable to care for herself or the baby. She was admitted to an acute impatient unit as an involuntary patient.
At 17 weeks post natal, Kate's PANSS total score was 105, which comprised 31 positive score total, 11 for negative score and 63 for general symptoms. Kate lacked insight as to why she had been admitted as an involuntary patient. She rated 12 on the Edinburgh Postnatal Depression Scale. Kate was recommenced on Risperidone 1 mg twice daily on admission and was simultaneously commenced on Olanzapine 20 mg wafer form per day. The Risperidone was ceased and Olanzapine increased to 40 mg wafer form per day.
At the time of writing, Kate is still acutely unwell and in an inpatient unit, separated from her baby. In total, mother and baby were together for a period of 6 weeks.
Conclusion
This case example describes some of the complex issues surrounding the management of a woman who has a history of psychotic disorders, managed with an atypical antipsychotic medication, through her pregnancy, birth and early parenting. The combination of poor psychosocial history, including existing involvement with child protection agencies, psychiatric diagnoses and admissions, medications and substance abuse present many issues affecting outcomes for both the woman and child during the perinatal period. The need for information regarding the use of atypical antipsychotic medications, which has the potential to improve the outcomes for women with severe mental illness and their children, is of vital importance.
The story of Kate's experience of pregnancy and early motherhood is not an unfamiliar one. This research may be highly significant; the value and importance of gathering information that will lead to improved management in pregnancy and the first year after birth may well be directly related to better outcomes for the well-being of mother and baby.
The management of women with psychosis in pregnancy, the experiences and outcomes of this vulnerable group of women and their babies; and the mental health clinicians caring for them, are being further explored and identified. The National Register of Antipsychotic Medication in Pregnancy project at the Alfred Psychiatry Research Centre in Victoria, Australia, represents a critical first step towards the development of best practice in the management of psychosis during pregnancy and the post partum.
Liaison between all professionals involved in the care of mothers with psychotic disorders during and after pregnancy is essential to provide the best care for them and their families [4]. The identification of a history of serious mental illness and a planned management strategy can assist to reduce the risk of an acute psychotic episode, and contribute to improved outcomes for the woman and her family.
Footnotes
∗Names changed.