Introduction
Psychotic symptoms can occur during both manic and depressive phases of bipolar disorder. Manic episodes are often associated with grandiose delusions and hallucinations, while depressive episodes typically produce mood-congruent psychosis, such as fixed beliefs of guilt or having committed a terrible crime [1,2]. Managing pregnancy and caesarean section in a patient with an active psychotic episode is particularly challenging due to impaired cooperation, consent issues, and interactions with psychotropic medications. We want to report this case to emphasize the need for a multidisciplinary, individualised perioperative plan for safe conduct of caesarean delivery in such patients and to share lessons that may guide obstetric and anaesthetic practice.
Case Report
A 35-year-old woman with the diagnosis G2P1L1 at 37+2 weeks of gestation and a history of previous lower-segment caesarean section, bipolar disorder, and cephalopelvic disproportion was scheduled for elective caesarean section with tubal sterilisation. Pre-anaesthetic evaluation revealed no medical comorbidities. The patient was haemodynamically stable, and haematological and biochemical investigations were within normal limits. Airway assessment showed adequate jaw movement, three-finger mouth opening, and Mallampati class III.
She was a known case of bipolar disorder with an insidious onset and continuous course for four years and was receiving quetiapine 200 mg and olanzapine 2.5 mg at bedtime. She had remained free from psychotic breaks for the preceding two years. On the advice given during preoperative assessment, all psychiatric medications were withheld 24 hours before surgery, which precipitated an acute psychotic episode on the day of the procedure. The patient denied being pregnant, refused to change into theatre attire, and declined entry into the operating room. She accused the treating team for her condition and issued legal threats. In view of her impaired capacity, informed assent addressing the situation was signed by her husband.
To control agitation, lorazepam 4 mg was administered intramuscularly; however, she remained only partially sedated. In the operating theatre, rapid sequence induction was performed using propofol and oxygenation followed by succinylcholine 1.5 mg/kg, and the trachea was intubated with a 7.0 mm cuffed PVC endotracheal tube. Anaesthesia was maintained on volume-controlled ventilation. Oxytocin 15 IU intravenously was administered after clamping of the umbilical cord. Following delivery of the baby, midazolam and atracurium were given for intraoperative amnesia and muscle relaxation. A healthy female neonate weighing 2.99 kg was delivered with APGAR scores of 7 and 8 at one and five minutes, respectively. Neuromuscular reversal was achieved with neostigmine and glycopyrrolate.
Postoperatively, the patient was observed in the operating theatre for 20 minutes and was reviewed by the psychiatric team. She received intramuscular promethazine and haloperidol for behavioural control, and her antipsychotic medications were restarted. The parents were advised to use expressed breast milk for neonatal feeding, and direct breastfeeding was discouraged. If unavoidable, a minimum gap of four hours between breastfeeding and medication intake was advised.
The patient arrived in an extremely agitated state and initially had no secured intravenous access, which made perioperative management difficult. The psychiatric team was urgently consulted to provide psychological support, reduce anxiety, and help control active psychotic symptoms prior to surgery. Lorazepam 4 mg was administered intramuscularly to calm her and facilitate transfer to the operating theatre; however, she remained only partially sedated. While assisting her into theatre attire, it was unexpectedly found that she was wearing four layers of undergarments containing cooked garlic leaves, cotton balls, and matchboxes, reflecting disorganised psychotic behaviour. She continued to resist attachment of monitors for vital-sign recording. After considerable effort, the team managed to secure a 20-gauge intravenous cannula by engaging and coaxing the patient, following which sedation could be initiated. To prevent further struggle and to ensure safety of both mother and staff, her hands were gently restrained with boxer bandages during the procedure. Her regular psychotropic medications were restarted after specialist review.
Discussion
Assessment of the patient’s current mental health status is a critical step before undertaking caesarean section, as the severity of psychotic symptoms directly influences understanding and ability to provide valid consent [3]. When a parturient is judged to lack decision-making capacity because of active psychiatric illness, measures consistent with legal and ethical frameworks are required to safeguard her autonomy and rights. Safety remains paramount for both the patient and the operating team, necessitating anticipatory planning to prevent harm arising from agitation or non-cooperation. Early psychiatric consultation is therefore invaluable, allowing specialist input into communication, sedation, and perioperative control of psychosis [3]. The conduct of caesarean delivery in such circumstances demands a multidisciplinary approach integrating obstetric, psychiatric, and anaesthetic expertise to optimise maternal and neonatal outcomes [4]. Selection of anaesthesia must consider concurrent psychotropic therapy and the possibility of drug interactions or exacerbation of symptoms, and a tailored strategy using appropriate agents can minimise risks while ensuring comfort and procedural safety [5]. Psychotic features may arise during either manic or depressive episodes of bipolar disorder. Mania is typically associated with grandiose delusions and hallucinations, whereas depressive phases often produce mood-congruent psychosis, such as fixed beliefs of guilt or having committed a serious crime.
This case illustrates that managing caesarean section in a parturient with bipolar disorder and an active psychotic episode requires a well-planned multidisciplinary approach addressing both medical and mental-health aspects. Anaesthetic techniques must be individualised with attention to possible interactions between psychotropic drugs and anaesthetic agents that may exacerbate psychosis. Close collaboration between obstetricians, psychiatrists, and anaesthesiologists is essential to optimise outcomes for both mother and baby.
Conclusion
Caesarean delivery in women with bipolar disorder and an active psychotic episode presents significant ethical, behavioural, and anaesthetic challenges. Abrupt preoperative discontinuation of psychotropic medications may precipitate acute decompensation and impede routine care. A coordinated multidisciplinary strategy with timely sedation, consent safeguards, and tailored general anaesthesia can enable safe surgery and favourable maternal–neonatal outcomes.
Contributors: PJ: manuscript writing and patient management; PG: manuscript editing; AKB: manuscript editing and critical inputs into the manuscript. PJ will act as a study guarantor. All authors approved the final version of this manuscript and are responsible for all aspects of this study.
Funding: None; Competing interests: None stated.
References
- Goodwin FK, Jamison KR. Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression. 2nd ed. New York: Oxford University Press; 2007.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington (DC): American Psychiatric Publishing; 2013.
- Appelbaum PS. Clinical practice. Assessment of patients’ competence to consent to treatment. N Engl J Med. 2007;357(18):1834-1840.
- Vigod SN, Seeman MV, Ray JG, Anderson GM, Dennis CL, Grigoriadis S, et al. Temporal trends in general and specific obstetric complications in women with schizophrenia and bipolar disorder. Am J Psychiatry. 2014;171(6):614-621.
- Lippmann M, Perel A. Anesthesia in patients with psychiatric disease. Curr Opin Anaesthesiol. 2010;23(3):391-396.