Balancing Maternal and Fetal Well-Being: Ethical Complexities in Acute Psychosis Management During Pregnancy

Abstract

While pregnancy is a time of well-being and happiness for most, it is a time of increased vulnerability to psychiatric illness for some. Women with psychiatric histories are more vulnerable to mood symptoms and psychosis during the peri- and post-partum period. These have detrimental effects both for the mother and the offspring. Maternal suicide risk, self-harming behaviors, and psychosis are increased compared to the general population. This presents both a psychiatric and obstetric emergency, with implicit clinical and ethical challenges. We present a 33-week pregnant female patient with a past psychiatric history of bipolar I disorder who was brought in by police after assaulting bystanders on the street. She provided a false name and had an alleged history of over 19 hospitalizations in the past year. She initially presented with catatonia, later observed to be aggressive and disorganized. She attempted to self-abort by hitting herself, throwing herself on the floor, and putting lotion in her vagina to help the baby "slide out". The patient was treated with haloperidol, clozapine, and fluoxetine. This case presents the ethical implications of treating pregnant women with acute psychosis and the balance between beneficence, nonmaleficence, autonomy, and justice in an inpatient setting. These ethical dilemmas arise when the physician's obligations to the mother and fetus diverge.

Keywords: antipsychotic use; antipsychotics during pregnancy; ethical considerations; ethical dilemmas; maternal-fetal outcomes; maternal-fetal risks; medical ethical issues; multidisciplinary approach; peripartum psychosis; post-partum psychosis.