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Peripartum ethical considerations in a pregnant psychotic patient

Marlee Madora

CM is a 41yo G2P1 domiciled in supportive housing with supraventricular tachycardia, chlamydia and chronic severe schizoaffective disorder who presented to the hospital during her second trimester with worsening psychosis.  She expressed the delusion that the father of her child was a celebrity who was not giving her money for food. She was involuntarily hospitalized for decompensated psychosis and refused antipsychotics due to paranoia.  She was taken to court for treatment over objection and was court ordered for treatment with olanzapine. Despite receiving a maximum daily dose of olanzapine, the patient continued to be paranoid, delusional, isolative and unable to care for herself throughout her entire pregnancy.  She had a C-section at term, and was subsequently monitored on the cardiology unit for tachycardia.  After medical stabilization, she was transferred back to psychiatry for management of persistent psychosis. Child Protective Services (CPS) was called and the baby was remanded due to the patient’s severe psychosis with inability to care for herself or the child. The patient then requested to visit her child and breastfeed while her baby was in the neonatal intensive care unit for respiratory issues.  Using a relational ethics framework, the multidisciplinary team decided that the risk of disrupting the mother’s psychiatric treatment, exposing her to psychological harm due to increasing attachment before remanding the child, and risk to child due to potential unpredictable dangerous behavior driven by psychosis outweighed the benefits of visitation and breastfeeding in this challenging clinical case.