For women with mental illness, childbearing can create special challenges. At NYU Langone Health, advanced clinical expertise—and close collaboration between psychiatric and women’s health teams—ensure that expectant and new mothers receive optimal care.
Providing Inpatient Treatment to a Woman with a Late-Term Pregnancy and Psychosis
A woman at 37 weeks’ gestation was brought to the emergency department by ambulance during an episode of mania and psychosis. The patient, a mother of three children, previously received a diagnosis of bipolar disorder and experienced several psychiatric hospitalizations. During the days prior to admission, she expressed delusional and suicidal thoughts and held a knife to her own throat in the presence of her family.
She was referred to the inpatient psychiatric unit at NYU Langone’s Tisch Hospital by the consultation–liaison team after being assessed by the obstetrics and gynecology team. “When she came to us, she was disorganized in her speech and behavior, alternately agitated and mute,” recalls Michael F. Walton, MD, adult psychiatry consult and the unit’s medical director.
As with any standard encounter, a multidisciplinary panel consisting of psychiatrists, psychiatric social workers, psychologists, psychotherapists, psychiatric nurses, and a consulting physician for obstetric and medical issues, evaluated the patient. The team determined that the use of antipsychotics was warranted despite the patient’s pregnancy, since the dangers posed by her psychosis outweighed any risk the medications might pose to the fetus.
After a week, the woman had partially recovered; following discussions with her husband and her mental health and medical teams, she chose to have a scheduled C-section. Several days later, she continued to struggle with psychiatric problems. She returned to the psychiatric unit three days later having delivered a healthy daughter, and was again catatonic. After being administered a benzodiazepine, which restored her ability to communicate, she consented to a course of electroconvulsive therapy (ECT).
The treatment was rapidly effective. “Within a few days, the patient was eager to get home to her family,” says Dr. Walton. “Three weeks after admittance, she was discharged to Reproductive Psychiatry Program treatment and follow up with her obstetrician and gynecologist. Today, she’s taking her medications and doing well.”
Providing Outpatient Treatment to a Woman with Bipolar Disorder and Difficulty Getting Pregnant
Another patient’s experience illustrates NYU Langone’s approach to outpatient treatment for women with psychiatric illness, from preconception through postpartum. This woman had a history of bipolar disorder II and panic disorder, without agoraphobia, but her symptoms had long been well controlled by a combination of medications.
In her mid-30s when she decided to have a child, she asked her then-psychiatrist to wean her off the medications in preparation for her planned pregnancy. After a recurrence of depression and severe anxiety resulted, she was referred to Marra G. Ackerman, MD, adult psychiatrist and site director of Women’s Mental Health.
“The patient was having daily panic attacks, and she avoided going to sleep because she was afraid she’d die,” says Dr. Ackerman. “She had to take a leave of absence from her job. So, I suggested that we look for a medication regimen that could stabilize her mood without excessive risk to a developing fetus.” Previously, the woman had been taking valproic acid, which is associated with increased risk of neural tube defects, and oxcarbazepine, which has very limited available evidence in human pregnancy but is considered a probable teratogen, and clonazepam. Instead, Dr. Ackerman treated her with a combination of sertraline, quetiapine XR, and clonazepam.
“We had a very detailed discussion prior to the patient pursuing a pregnancy,” Dr. Ackerman recalls. “I explained that while no medication is entirely without risk, the danger to her and her future infant were much greater if her condition was left untreated. Untreated bipolar disorder is associated not only with poor maternal care and greatly elevated risk of postpartum depression, mania, and even psychosis, but with physiological risks to the fetus, such as gestational diabetes and preterm birth.”
The new regimen helped the patient weather what proved to be a complicated fertility course. She underwent several unsuccessful intrauterine inseminations. In-vitro fertilization also failed. At last, she was implanted with a donated embryo, carried the pregnancy to term, and delivered a healthy baby girl by scheduled C-section. Dr. Ackerman consulted closely with the patient’s obstetrician and gynecologist through each stage of the process.
Postpartum, the patient began experiencing mild mood and anxiety symptoms, as well as weight gain and elevated glucose levels. Dr. Ackerman, in consultation with the woman’s primary care physician, switched her from quetiapine back to valproic acid, while continuing the sertraline and clonazepam. The patient’s condition normalized, and—once her daughter was old enough for daycare—she was able to return to work.