Psychotic conditions during pregnancy. Medical and ethical aspects
GKOLIA I., KARPOUZA V., STAVROU E., KANISTRAS A.

Introduction: Psychiatric emergencies concerning patients with a positive or negative psychiatric history can arise during pregnancy. When faced with the symptoms of an acute psychiatric disorder the doctor must consider the possibilities of organic disorders or substance abuse. Generally, patients with psychiatric illness have difficulty caring for themselves and hospitalization may be needed - at least initially. Brief psychiatric hospitalization can be an important factor in improving obstetric outcome by providing an opportunity for collecting obstetric information and promoting ongoing prenatal care. During the investigation of these situations a lot of medical and moral issues emerge.

Case reports: Four pregnant patients in psychotic condition were admitted in the psychiatric department (C Psychiatric Ward, Psychiatric Hospital of Thessaloniki). Psychotic behavior was dangerous for both the health of mother and the baby. Problems of not receiving medication and the degree of pressure that should be exercised in order to limit dangerous behavior emerged. In all cases aloperidol in doses of 10-20 mg, biperiden in doses of 4-8mg were prescribed and in three cases lorazepam in doses of 2.5-5 mg was also prescribed. The medication was tapered till delivery.

Finally, in one case a preterm delivery occured in the psychiatric ward. All cases including this one had a good outcome. Upon remission of psychotic symptomatology, they were discharged and they cooperated during follow-up until delivery.

Discussion and conclusions: A medical problem that occurs is medication during pregnancy. The question of which psychotropic medications are safe is likely to remain unanswered. There are ethical limitations to performing the type of prospective controlled studies required to provide a definite answer to a scientific question of this type. At the present time, in all patients with worsening psychiatric illness during pregnancy, outpatient psychotherapy, hospitalization and milieu therapy should be attempted prior to use of psychotropic medication. Psychotic illness itself may increase the risk of poor fetal outcome to a greater extent than does antipsychotic use. Use of psychotropic medications during pregnancy is appropriate in many clinical conditions and should include thoughtful weighing of prenatal exposure risk versus risk of relapse following drug discontinuation. When medication has to be decided as in our study, the use of high-potency neuroleptics (such as aloperidol) seems preferable. In order to cope with anxiety and insomnia, benzodiazepines were prescribed occasionally, but they were avoided during delivery. An effort was made to limit polypharmacy and decrease the dose of essential drugs, following full assessment. Finally, the importance of the therapeutic relationship between the doctor and the pregnant patient cannot be overstated and will decrease reliance on psychotropic medication in many cases.

There are also many ethical aspects and questions arising such as:

• Should a pregnant psychiatric patient be forced to receive psychotropic medication against her will?
• Should a pregnant patient be forced to be admitted in a psychiatric clinic against her will and which efforts and manipulations are proper to guarantee her safety? Her safety is often in danger either as a consequence of mental illness or the manipulations of clinical staff.
• How can one guarantee follow-up treatment after delivery as well as the ability of the psychotic mother to take care of her newly born child?

Many of these questions have already been discussed. In clinical practice the management of these cases is often complicate and they should be treated in psychiatric clinics of general hospitals so that any possible obstetric complication could be managed.