UNIVERSITY OF ILLINOIS AT CHICAGO
Department of Psychiatry
Fifth Annual Research Forum – Extravaganza 2014
POSTER TITLE
The Clinical Challenges of Treating Catatonia in Pregnancy
DISEASE/KEY
WORDS:
Catatonia, Pregnancy
AUTHORS:
Dr. Amber May, Dr. Marcela Almeida
MENTEE
CATEGORY:
BACKGROUND:
RESEARCH MENTOR:
There are sparse guidelines for physicians treating pregnant patients with catatonia. This is
one of the few reported cases of a pregnant patient with bipolar disorder exhibiting
symptoms of psychosis and catatonia which developed after initiating antipsychotics (Haldol).
Most of our knowledge of treating catatonia in pregnancy comes from the few published case
reports available.
METHODS:
RESULTS:
(Case History)
The patient initially presented as an 18 year old African American female G2P1001 at 33.8
wga with a past psychiatric history of bipolar disorder who was admitted to inpatient
psychiatry unit for suicidal ideation. The patient exhibited mood lability and bizarre
behaviors, including mutism, fixed gaze, poor social boundaries, and sexual preoccupation.
After receiving multiple PRNs of Benadryl and Haldol for behavioral management, the
patient’s exam was notable for waxy flexibility, abnormal posturing, echopraxia, and
utilization behaviors. As catatonia was suspected, PRN Haldol was discontinued and CK levels
were ordered. CK returned > 2200, and the patient was treated with IVFs and Ativan PO for
emergent treatment of catatonia. The patient intermittently manifested psychotic
symptoms, including delusions and paranoia. With continued Ativan treatment, her
symptoms improved and the CK trended down; but when an Ativan taper was attempted, the
catatonic symptoms worsened along with elevation of CK. ECT was proposed as a treatment
option, but the patient and family were uncooperative. After delivery, the patient remained
catatonic and psychotic. After a prolonged battle, the mental health court ruled in favor of
ECT treatment. The patient improved drastically with symptom resolution after 8 treatments
of ECT. She was to be discharged home on Lithium 600 mg qhs with a plan for maintenance
ECT as an outpatient.
UNIVERSITY OF ILLINOIS AT CHICAGO
Department of Psychiatry
CONCLUSIONS:
This case raised many interesting questions: how to fully assess for catatonic features prior to
antipsychotic use, whether or not to treat with ECT during pregnancy, obtaining consent for
ECT in patients with catatonia, and approaching families resistant to ECT when it results in
prolonged duration of untreated psychosis. In catatonia, antipsychotics are generally
avoided. The patient’s catatonia could likely have been due to her psychosis and Haldol PRN
exacerbated the symptoms, rather than induced the catatonia. Haldol had been withdrawn
for over a month and patient’s symptoms did not resolve completely, despite aggressive
treatment with Ativan.
After ECT, the patient’s symptoms resolved. Electroconvulsive therapy (ECT) may be the
preferred treatment in pregnancy since there are not any known adverse fetal effects. As
medication and maternal illness can have adverse effects on the fetus, the clinician-patient
dyad try to weigh the risks and benefits of symptoms versus treatment. ECT typically works
more quickly and efficaciously than pharmacotherapy. Benzodiazopines have been
associated with cleft palate/lip, hypoglycemia, preterm birth, low birth weight, floppy infant
syndrome, and neonatal withdrawal symptoms. It would be helpful to establish a protocol
for the safest approach to treatment for the pregnant patient and the fetus.