Pregnant psychotic female I'm at the 100mg Haldol limit, what do I do next?

[whopper]

I've come to this unfortunate situation. The person might not be pregnant. She's 6 weeks postpartum, but the serum pregnancy test is (+). I re-ordered a new one, but made it a quantitave test, which had a level of 46, which indicates 4-6 (edit 1-4) weeks gestation. That definitively tells me (edit-nothing)anything because if she got pregnant again, it fits in the right time period.

It does though at least give me a reference level, so when I order the test again in 2 days, if the HCG level is about double--then she really is pregnant. If not then its a false (+), retained placental products or just a false (+) that can happen post partum (supposedly for a few weeks).

In the meantime, she's grossly psychotic-paranoid, & often starting fights with other patients. She's on Haldol 20mg TID, and 10mg QIDPRN for psychosis--she pretty much gets all her PRNs.

We have seen some improvement with the haldol but not much.

OK if she's not pregnant by as indicated by the next lab test--I'm in a good situation--I can give her pretty much every med I want. IF not, I'm screwed--an actively psychotic patient who's already pretty much near her Haldol maximum and unless there's other meds I can give, won't expect much more improvement.

Anyone know of any data showing that other antipsychotics are safe with a good body of data?

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[Chimed]

How about ECT for acute psychosis? It's safe for baby and mother...

 

[Faebinder]

Clozapine is THE ONLY class B antipsychotic. Go for it.

 

[whopper]

Geez, I forgot Clozapine was class B--thanks!

Anyways, the IM doctor is giving her class D medical meds. I think its out of laziness. I'm going to have to document for my own protection that I asked her to reconsider her choice of meds.

And a correction, her HCG levels indicate 1-4 weeks of gestation. I wrote 4-6.

The treatment team is really ticked off with me because I'm not giving her more meds. They told me I'm the first attending they've ever had that actually cared if the patient was pregnant & would wait for pregnancy tests before I medicated the patient with anything other than haldol.

 

[kugel]

the IM doctor is giving her class D medical meds.

What other meds? Is something interacting, e.g. creating agitation, or inducing Haldol metabolism?

Does she have any history of better response to another antipsychotic? Best clue about what will work well is always what's worked before.

 

[HurricaneKatt]

Geez, I forgot Clozapine was class B--thanks!

Anyways, the IM doctor is giving her class D medical meds. I think its out of laziness. I'm going to have to document for my own protection that I asked her to reconsider her choice of meds.

And a correction, her HCG levels indicate 1-4 weeks of gestation. I wrote 4-6.

The treatment team is really ticked off with me because I'm not giving her more meds. They told me I'm the first attending they've ever had that actually cared if the patient was pregnant & would wait for pregnancy tests before I medicated the patient with anything other than haldol.

You should NOT feel bad no matter how pissed they are. I think that reflects very poorly on them that they are willing to be so careless. It's good that you care and that you are watching out for the patient and her (potential) child. 👍

 

[strangeglove]

Is this first onset psychosis post-partum?

 

[whopper]

She is new to our system, so we do not have much knowledge on her. Our social worker though is working to get more collateral information.

She has had a history of psychosis. She got pregnant, and no surprise, she decompensated shortly after delivery.

I think that reflects very poorly on them that they are willing to be so careless.

Well all they got is other attendings for comparison--of which they all medicated with Depakote, atypicals, ativan, what have you before the results of the pregnancy test. Then they would stop them after the few days it took to get the lab results. I know, I know, I know--WTF? I actually brought this up to the psychiatric administration that this practice needs to be stopped. This then creates a problem, especially if the patient is groslly psychotic &/or manic because then the only thing you can really give them in Haldol, and some of them refuse haldol--which then delays medication until court ordered meds can be done which takes weeks for court approval.
They're used to not seeing other attendings do what I'm doing, so from their standpoint are judging on a comparison basis.

As much as this situation bugs me with the treatment team, they a really are a very good team. This particular unit is consisdered one of the hardest to work on in the place I'm at. They're dealing with enough problems as it is that staff on other units don't have to deal with.

What other meds? Is something interacting, e.g. creating agitation, or inducing Haldol metabolism?

Atenolol for HTN. Class D!. The IM attending I think is blowing this one off. She's the person in the first place who didn't order a quantitave pregnancy test, only a qualitative--so when it was (+), we didn't have a reference point with the HCG level. OK fine, but when I alerted her to the situation, she ordered that the next pregnancy test not be ordered for 1 week and ordered another qualitative test. The entire time she kept saying, "well I'm sure she's not pregnant, so don't worry". She is basing her decision on a gutt feeling rather than a lab test. Since she's the IM attending, I'm supposed to have her handle the non-psychiatric end, but in this case, I've been overriding some of her reccomendations. I may have to do so with the Atenolol as well.

I overrode her, ordered a stat quantitative test which gave the results I mentioned. I then put into the CPOE that the patient might be pregnant to prevent any of the other doctors on duty from giving her meds without checking on her pregnancy status.

I reminded the IM doc that she might be pregnant and asked to her reconsider if the patient should be on a class D med. She's been acting as if all along the patient is not pregnant--which she damn well might not be, but is basing this on a "I think the test is wrong" on a gutt feeling approach.

 

[michaelrack]

I don't put too much faith into the FDA pregnancy classifications. Many psychiatrists consider clozaril more clinically risky to give a pregnant woman than other antipsychotics. I don't have any good suggestions for you, other than I wouldn't use clozaril unless you had other indications for it other than it being class B.

agree with chimed that ECT may be helpful.

 

[whopper]

I remember while as a resident at a grand rounds, a particular expert in the field of pregnancy & meds gave a lecture, and asked him what would he do if a patient was pregnant & you reached the limit of haldol with little success & the patient was dangerous.

He laughed & said something to the effect of-I don't know what I'd do, and I hope & pray that situation doesn't happen to me or you-.

I'm really hoping that quantitive test turns out negative--otherwise I think the treatment team & I are in for a very interesting (in the bad Chinese proverb way) 9 months. My gutt tells me she really is not pregnant, though I'm not going to act on that feeling until I got verifiable lab results.

I don't know what the local culture is with ECT, but I was given the idea that ECT is a no-no since this is a state facility, and politically it just doesn't look nice for a patient in a state run unit to be given ECT. Yeah, I know, politics shouldn't factor into this, but work at a place, you don't want to exactly go against the wishes of the administration. Worked at one place in NJ that was a state run involuntary unit, I asked about ECT & they laughed. "You think anyone here's getting ECT? Forget about it".

Should that situation come up & it seems appropriate, I will of course pursue it.

I wouldn't use clozaril unless you had other indications for it other than it being class B.

Not really many other options though. I've been going through the data & except for Haldol there really isn't much data supporting the safety of any other antipsychotic treatment other than ECT. A reason why I'm asking on the forum.

 

[kugel]

Atenolol is the only other med?

As for other antipsychotics, I would seriously consider documenting that "Given that such high doses of Haldol are not helping this patient, the risk to mother/child of continued psychosis and continued violence warrants trying other antipsychotics, even if those meds have less safety data in pregnancy."

If this lady gets herself/others hurt, you need to be able to SHOW in the chart what other options you tried (or didn't try) and why.

And consider asking for an Ethics Committee consultation.

 

[Chimed]

I don't know what the local culture is with ECT, but I was given the idea that ECT is a no-no since this is a state facility, and politically it just doesn't look nice for a patient in a state run unit to be given ECT. Yeah, I know, politics shouldn't factor into this, but work at a place, you don't want to exactly go against the wishes of the administration. Worked at one place in NJ that was a state run involuntary unit, I asked about ECT & they laughed. "You think anyone here's getting ECT? Forget about it".

Should that situation come up & it seems appropriate, I will of course pursue it.


Not really many other options though. I've been going through the data & except for Haldol there really isn't much data supporting the safety of any other antipsychotic treatment other than ECT. A reason why I'm asking on the forum.

I figured some would think my suggestion about ECT was a joke...I'm not surprised you'd have a hard time selling this to those outside of psychiatry. It's true that there just isn't a lot of good evidence of the risk of using Atypicals, which is a huge problem. Certainly using Risperdal could increase prolactin levels...I don't have the papers, but I've also heard some attendings say similar things about Clozaril that Michaelrack said. Perhaps ECT really is the safest? Kinda of a crappy situation that a lot of us will have to deal with at some point...

http://www.womensmentalhealth.org/posts/ect-and-pregnancy/

 

[swingerofbirch]

I am not a doctor, medical student, or anything of that nature. I am a hypochondriac who stumbled onto this forum somehow, and thought I would offer what I thought.

I have always been curious why post partum psychosis is treated with psychiatric medications when it seems that doctors say the cause of the problem is hormonal. If the cause is hormonal, why not try hormonal therapy?

In any case, my only other advice would be to recall the humanity of each patient you deal with. It is traumatizing and demoralizing simply to be a psychiatric patient in and of itself.

I think that retaining normalcy in spite of crisis (faking it until you make it) is vital. So, I would take your patient for a walk every day, have tea with her every day (l theanine in green tea crosses the brain blood barrier and enhances GABA, something I have found most psychiatrists don't seem to know). And help her with self care. Feeling good about yourself and having a sense of accomplishment are all vital. Introspection and insight therapy might also be useful.

It wouldn't hurt to try if what you're doing isn't working. If you assume that your answer is in a box (drugs), then you have already limited your solutions.

Best of luck to her!

As an aside, I would also avoid ECT. It would be heartbreaking to think of her not being able to remember the birth of her child.

 

[whopper]

As for other antipsychotics, I would seriously consider documenting that "Given that such high doses of Haldol are not helping this patient, the risk to mother/child of continued psychosis and continued violence warrants trying other antipsychotics, even if those meds have less safety data in pregnancy."

Something else I considered. I figured Clozaril or ECT would be the next best step.

And should she be pregnant, I'm not making the next decision on my own. I'm going to bring in my boss, and see what else we can do. There's a particular heavyweight in the area that could be consulted if need be. MY boss has brought in all the psychiatrists to brain storm things like this in the past--& there's plenty where I'm at.

I was just hoping someone could offer me a silver bullet here that I haven't considered. I did though get something--forgot Clozaril was Class B. I guess with all the warnings against it, it made me not consider it.

(and Faebinder--good for you--PGY-I and you remembered something the former Chief didn't).

Swingerofbirch--appreciate the comments, didn't know about the green tea thing though I don't think it'd help much in her case. However it is nice to know something about the pharmacology of green tea I didn't know before. I drink a lot of it.

 

[michaelrack]

whopper, if I were in your situation, before clozaril I might try another medium or high potency antipsychotic- navane (medium) or prolixin (high). If these failed, I might try geodon. Then I would consider clozaril. I might try clozaril sooner in the algorithm if the patient had other indications for clozaril (had previously failed several antipsychotics).

Of course, each situation is different and I couldn't make a definite rec without examining the patient. These are only suggestions for further thought/consideration.

Here is a link to a review that might be helpful:

http://www.ncbi.nlm.nih.gov/pubmed/...nel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum


the point I was trying to make in my previous post was that clinically, the FDA B classification for clozaril is meaningless (it may not be legally meaningless, though).

 

[Faebinder]

Thanks whop but it's not that you didnt remember it, but you instinctively dismissed it as you said.

I realize half the world hates clozaril and that's for a darn good reason... I mean who wants to deal with blood draws weekly and later monthly... not to mention the weight gain. I have to admit though, when someone is getting 25 mg of Haldol a day and after 5 days they are still as badly psychotic.. i start thinking maybe you shouldn't be switching next to little babies like rispirdal/geodon.

but you have to realize the advantages in a pregnant female:

1) You are only giving Clozaril temporarily, granted neutropenia incidence risk is highest in the first 6 months but still, this is temporary.

2) Weekly blood draws on a pregnant female for a month then monthly? That's great, you should do them often anyway to make sure she is okay... Pregnant females have elevated WBCs anyway which is theoretically protective.

3) Pregnant females are weighed all the time by the OBGYN.. an abnormal increase in weight will be detected easily. Same with sugars if you are worried about diabetes, the OBGYN (especially for this high risk case) will be checking that all the time because they will be checking for gestational diabetes.

If ECT is not available and the patient is wildly psychotic on haldol, go for Clozapine.

As for legal food for the thought... Haldol is Class C. Two cases of limb reduction malformations have been reported after haloperidol use during the first trimester of pregnancy; however, a causal relationship to the drug has not been established. Clozapine is Class B. Animal studies have produced no evidence of adverse fetal effects. There are no adequate trials of the effect of clozapine in human pregnancy; animal data may not be indicative of human response. Go figure.

 

[Doc Samson]

My algorithm for the pregnant psychotic patient is haldol -> prolixin -> stelazine (but the good Dr. Rack already beat me to the punch). Can't say that I've ever had to initiate clozaril in pregnancy.

BTW - my fallback resource for any psychotropics in terms of pregnancy and breastfeeding is www.womensmentalhealth.com - the women's mental health group at MGH. I believe they do telephone/e-mail consultations too.

 

[mnc2006]

😱slap me if i am crazy......but is there a point in medical termination of pregnancy as the last resort if there is significant risk to mother and further treatment poses substantial risk to the child as well. i mean if you are stuck even with two trials of antipsychotics...

 

[Doc Samson]

😱slap me if i am crazy......but is there a point in medical termination of pregnancy as the last resort if there is significant risk to mother and further treatment poses substantial risk to the child as well. i mean if you are stuck even with two trials of antipsychotics...

<slap>

Who's consenting to that? The psychotic patient?

 

[diosa428]

It's been 2 days - is she pregnant?

 

[whopper]

She's not. The 2nd B-hcg test (quantitative) came in and it was lower than the first test. Within 5 minutes of finding out, the treatment team literally were jumping for joy, I put in an order for Zyprexa, Trileptal (with rapid tapering up, she's refusing Depakote) & Thorazine PRN. I don't know if the standard meds are helping because we've had to knock her out so many times with Thorazine. At least though its knocking her out & she's not attacking anyone. In the next few days, during the few hours she is awake, if the duration between her getting agitated increases, I'll see that as a sign that the standard meds are having benefit. So far its at every 2 hrs.

This case brings in a lot of fodder for an M&M. The internal medicine doctor covering the case was not aware of the benefits of a quantitave HCG test vs a qualitative, that you need 2 results with to check the results against each other, and I had to override her reccomendations & orders. This brought in the chief IM doctor at the place who also did not seem aware of that when I discussed the case with her. We just got a new lab covering our lab tests & they were far more cooperative than the old lab--things could've been done on this case that we were not aware of until after the fact.

And the place I'm at doesn't have a urine pregnancy test in house. We've had to wait for days while waiting for the results of a pregnancy test while a patient was grossly psychotic &/or manic & hitting staff & other patients.

All of which I've written to the higher ups. I'm waiting to see how they will respond. I will make a stink about this at the next attending's meeting.

Another funny thing is she's been discharged from our system before--only on haldol 5mg or 10mg which kept her psychosis controlled. This time it took about 100mg a day of Haldol for about 1 week with hardly any observable benefit.

I'm wondering if there is any data on post partum psychosis requiring much higher or different dosages of meds than the regular psychosis in the same patient. I heard there's data showing that with each new pregnancy, post partum psychosis is expected to worsen but I've never read it in print.

 

[whopper]

but is there a point in medical termination of pregnancy as the last resort if there is significant risk to mother and further treatment poses substantial risk to the child as well. i mean if you are stuck even with two trials of antipsychotics...

I honestly don't know what I'd do in a situation where a pregnant & psychotic female is refusing meds, is dangerous, & something happened that made termination of pregnancy an option to be considered...other than that I'd ask my boss what to do, call in an ethics consult & request an emergency guardian.

I figure an Ob-Gyn doctor would have to be called in since they have more experience with this.

 

[Psychintern2006]

< Within 5 minutes of finding out, the treatment team literally were jumping for joy>

As a new attending it must be heard to deal with treatment team pressure ? I have felt the treatment team expectations to be irrational sometimes. Thats something that pushes me away from seeing myself as an inpatient Psychiatrist in the future -what do you think?



<I put in an order for Zyprexa, Trileptal (with rapid tapering up, she's refusing Depakote) & Thorazine PRN.>



Why thorazine PRN? why not Zyprexa IM prn ?

 

[whopper]

Picked Thorazine because she was agitated to the point where about every 2 hrs she was getting into fights with people. I needed to eliminate that danger, and I rapidly tapered up her standing dose of Zyprexa--to the point where it had reached its maximum dosage per day with no additional Zyprexa possible. I try to avoid use of Thorazine as a PRN, but if several other PRNs have been tried such as haldol, at very high doses, I go for that one next.

The above patient has actually stabilized quite well. Took about 1 week of a very quick taper up on a few meds.

However now I just got a pregnant patient that is manic and I'm in a similar situation--already on high doses of Haloperidol, but not the maximum. I fear its going to be a redo of the above.

 

[Doc Samson]

Picked Thorazine because she was agitated to the point where about every 2 hrs she was getting into fights with people. I needed to eliminate that danger, and I rapidly tapered up her standing dose of Zyprexa--to the point where it had reached its maximum dosage per day with no additional Zyprexa possible. I try to avoid use of Thorazine as a PRN, but if several other PRNs have been tried such as haldol, at very high doses, I go for that one next.

The above patient has actually stabilized quite well. Took about 1 week of a very quick taper up on a few meds.

However now I just got a pregnant patient that is manic and I'm in a similar situation--already on high doses of Haloperidol, but not the maximum. I fear its going to be a redo of the above.

Lithium?

 

[michaelrack]

Picked Thorazine because she was agitated to the point where about every 2 hrs she was getting into fights with people. I needed to eliminate that danger, and I rapidly tapered up her standing dose of Zyprexa--to the point where it had reached its maximum dosage per day with no additional Zyprexa possible. I try to avoid use of Thorazine as a PRN, but if several other PRNs have been tried such as haldol, at very high doses, I go for that one next.

.

I'm not sure exactly what you mean by "max dose", are you referring to the max FDA indicated dose?? From a practical standpoint, I don't think there is any safety benefit from adding on thorazine IM vs zyprexa IM to this patient's antipsychotic regime. But there may be a legal benefit, so I guess you gotta do what you gotta do.

 

[whopper]

I'm not sure exactly what you mean by "max dose",

Egocentric of me to not explain.

The institution has a maximum dose guideline of 40mg/day. That's what I meant. She's already at that level so more Zyprexa PRN is not an option. The manufacturer has a reccomended maximum dose of 20mg/day, though I believe in CATIE the manufacturer recommended 30 mg/day.

To further clarify, my intent was to sedate her quickly. The day Thorazine was added to her PRNs & for the next few days the number of attacks from the patient went from about 3-5 a day to 0-2 a day. Its now to the point where there have been no attacks for over 1 week.

Lithium?

Crossed my mind. The data from what I'm aware puts the danger of lithium in the first trimester. She's in the beginning of the 2nd. I got to admit though that this is unexplored territory for me so I am very hesitant. I didn't thank you for the MGH website you posted above. It has been very helpful.

Just adding a bit of drama to the post, the Ob-Gyn resident that was covering this patient from the previous place she was at reported that she was not pregnant & miscarried, but did not treat the miscarriage based on the patient's refusal, yet the patient clearly lacks capacity. I saw that in the report, demanded to the IM doctor that if she miscarried, she lacks capacity & needs to be evaluated by an Ob-Gyn doctor--> the IM doc ordered her rushed back to the same hospital, and after that hospital did an ultrasound, they found a live fetus in the 15th week of gestation.

I guess I can add that to the extreme stories I got of medically cleared patients. Almost ranks up there with the guy who was cleared who jumped off a building, had 2 broken legs & the ER doctor cleared that guy without any workup or even a physical exam, reporting that there was nothing wrong with him.

 

[FURY 161]

Egocentric of me to not explain.



I guess I can add that to the extreme stories I got of medically cleared patients. Almost ranks up there with the guy who was cleared who jumped off a building, had 2 broken legs & the ER doctor cleared that guy without any workup or even a physical exam, reporting that there was nothing wrong with him.

My God, this sounds like my hospital. 👍

 

[whopper]

My God, this sounds like my hospital.

When I was a first year resident & saw things like this happen, I started thinking to myself "what kind of bull is this? That doctor ought to have his liscense removed!"

Lo & behold my fellow residents in the same program but in a different hospital were having the same problem. Another doctor in my program who had worked in several systems, including UPenn, Dartmouth among several others had a sit down talk with me & told me this same thing has happened in every single hospital he's worked at. Then I found out colleages in other programs were having the same problem.

I've seen problems where I could understand why the clearance was made, e.g. I had a patient who had lymphoma that metastasized to the brain. What ER doctor or psychiatrist is going to detect that one in the few hours where the person is observed in the ER? She was acting out of it in the ER, and so that ER doc thought this was psychotic. Only reason how I figured that one out was after 2-3 days of observation, we noticed fluctuating mental status. She had pancytopenia which I figured might give a clue as to a medical etiology. (OK up to that part I understand--later on-->The medical doctor refused to transfer the patient, the attending in a move that took gutts wrote that he was going to discharge the patient from the psyche unit because the psyche unit couldn't treat her illness which would've forced the medical doctor to either medically clear her on the record, or force that doctor to admit the patient to the medical floor. A few weeks later the patient died on the medical floor. Classic case of a turf war.)

But the patient with the broken legs, that and several other cases I've seen, I can't see how the mistake was made in a manner that followed standard of care. How can a doctor who truly did a physical exam write it was normal if the person had 2 broken legs?

 

[Faebinder]

Oh my favorite was a vegal stimulator case for seizures. Apparently, the patient has not been to see a psychiatrist in more than 30 years, and last was admitted for alcohol and depression NOS.... without going to further details, the patient came in 5 days after the vegal stimulator was placed and touched someone who had a similar and felt a shock. She complains of being afraid to touch metal and they cleared her medically without getting the neurologist she sees or the surgeon who placed the stimulator to come see the patient and claimed it was a psych problem. I was speechless.