(O-G3) Emergency Department Management of Acute Agitation in Pregnancy

Objectives: The purpose of this article is to explore the pathophysiology and etiology of acute agitation in order to better understand the adverse effects of pharmacological management. This review article highlights the adverse effects and preferred treatment algorithms specifically for acute agitation in pregnancy in the emergency department (ED).

Background: Agitation is an increasingly common presentation within EDs, psychiatry units, and long-term care facilities. The prevalence of agitation within the ED compromises around 2.6% of total patient encounters. Acute agitation during pregnancy is increasingly common and should be treated as an obstetric emergency as the distress may jeopardize both the patient and the fetus. The safety of psychotropic medications in pregnancy has not been well established in human models.

Methods: A literature review was conducted to explore the pathophysiology and etiology of acute agitation in order to better understand the adverse effects of typical pharmacological management. An overview of drug interactions, side effects, and benefits was conducted, specifically pertaining to psychotropic medication use in pregnancy related agitation. A preferred treatment algorithm was discussed regarding management of acute agitation in pregnancy in the ED.

Results: While verbal and nonpharmacological management is preferred for the treatment of agitation in the ED, 3-20 per 1000 ED visits for agitation require medical management. The medications administered voluntarily or involuntarily should differ based on the etiology of the agitation, the patient’s age, gender, and comorbidities, and the clinical setting in order to avoid major adverse effects. Adverse reactions include hypoxia, hypotension, bradycardia, QTc prolongation, and airway obstruction. Adverse effects are more common in pregnant females. For mild to moderate agitation in pregnancy, diphenhydramine is an effective sedating agent with minimal short and long-term side-effects. In moderate to severe agitation, high potency typical antipsychotics are preferred due to their neutral effects on hemodynamics. Haloperidol has become the most frequently utilized antipsychotic for such agitation in pregnancy. Second generation antipsychotics are often utilized as second line therapy, including risperidone. Other sedating agents, including benzodiazepines and ketamine have demonstrated adverse fetal outcome in animal models.

Conclusions: All psychotropic medications readily cross the placenta, are present in amniotic fluid, and can enter breast milk in varying degrees. While randomized control studies cannot be ethically conducted on pregnant patients requiring acute sedation, animal models and epidemiologic studies have demonstrated the effects of psychotropic medications on transmission to baby. As the fetal risk associated with multiple doses of psychotropic medications remains unknown, weighing the risks and benefits of each agent, while utilizing the lowest effective dose of a single agent remains critical in the treatment of acute agitation in pregnancy within the emergency department.

References (Optional):

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Funding (Optional): None