(199) Decision-making capacity in pregnancy for patients with intellectual disability

Abstract: Objective: Approximately 750,000 women of reproductive age have an intellectual disability (ID) in the United States.1 While rates of pregnancy among women with ID are similar to the general population, women with ID tend to be younger, unpartnered, of low socioeconomic status, have more limited access to care, and experience higher rates of adverse pregnancy and infant outcomes.2 Despite these disparities, few studies guide management of pregnant women with ID. Therefore, we aim to provide an overview for consultation-liaison (CL) psychiatrists of care considerations for pregnant individuals with ID.

Methods: We present a case of a 27-year-old G2P0 woman with moderate ID secondary to fetal alcohol syndrome who was evaluated by the CL psychiatry service at our institution’s obstetrical hospital for capacity to refuse a cesarean section. Clinical presentation, management, and outcomes are reviewed. A presentation of relevant studies on decision-making capacity in pregnancy for patients with ID will be provided alongside a discussion of ethical considerations and standards.

Results: Our patient was admitted for induction of labor at 37 weeks of gestation due to complications from gestational diabetes. During the second stage of labor, she stopped pushing or engaging in any form of care for several hours. Her obstetrics team and doula unsuccessfully attempted to engage her to resume. She was evaluated by the psychiatry team and found to lack capacity to refuse cesarean section. Cesarean section was ultimately conducted under general anesthesia after she became combative in the operating room. Child protective services was notified.

Conclusion: Individuals with ID require both considerate medical and psychiatric management in general often with a trauma informed approach. This is even more important in the setting of pregnancy. Legal and ethical concerns may arise, and CL psychiatrists can help other providers navigate these concerns. Involving a surrogate decision-maker in labor planning may optimize outcomes. CL psychiatrists can educate patients and care teams with decisional capacity assessments and psychiatric management of individuals with ID.

References:

McKenzie, K., Milton, M., Smith, G., & Ouellette-Kuntz, H. (2016). Systematic review of the prevalence and incidence of intellectual disabilities: Current trends and issues. Current Developmental Disorders Reports, 3(2), 104–115. https://doi.org/10.1007/s40474-016-0085-7

Tarasoff, L. A., Ravindran, S., Malik, H., Salaeva, D., & Brown, H. K. (2020). Maternal disability and risk for pregnancy, delivery, and postpartum complications: A systematic review and meta-analysis. American Journal of Obstetrics and Gynecology, 222(1). https://doi.org/10.1016/j.ajog.2019.07.015

Presenting Author(s)

Meghan Keil, MD

PGY4 Resident
UPMC Western Psychiatric Hospital
Pittsburgh, PA, United States

Co-Author(s)

Sharvari Shivanekar, MD

Assistant Professor of Psychiatry
University of Pittsburgh
Pittsburgh, Pennsylvania, United States
Priya Gopalan, MD, FACLP

Associate Profesor of Psychiatry
University of Pittsburgh Medical Center, Western Psychiatric Hospital
Pittsburgh, Pennsylvania, United States
CM

Christina Megli, MD/PhD

Research Assistant Professor
University of Pittsburgh School of Medicine
Pittsburgh, Pennsylvania, United States
Darcy M. Moschenross, MD PhD

Assistant Professor of Psychiatry
University of Pittsburgh Medical Center/ Western Psychiatric Hospital
Pittsburgh, Pennsylvania, United States