Report

Donna Stewart
Pregnancy and Schizophrenia
SUMMARY
Schizophrenia occurs in one percent of the
population during the reproductive years.
Although schizophrenics' fertility is reduced,
most family doctors who practice obstetrics
will occasionally care for a pregnant,
schizophrenic patient. The particular problems
of the prenatal period, labor and delivery, and
postpartum care of these patients are
discussed. The physical, psychological, and
social problems of a schizophrenic patient's
child are outlined, with a recommendation for
careful follow up in the community of both
parent and child. (Can Fam Physician 1984;
30:1537-1542)
SOMMAIRE
Au cours des annees de reproduction, la
schizophrenie se presente chez 1% de la population.
Meme s'il existe une reduction de la fertilite chez les
patients schizophrenes, la majorite des medecins de
famille pratiquant l'obst6trique auront
occasionnellement a suivre une patiente
schizophrene. Cet article discute les problemes
particuliers de la periode prenatale, le travail,
l'accouchement et les soins postpartum. On decrit
les problemes physiques, psychologiques et sociaux
de l'enfant dont le parent est schizophrene, et on
propose certaines recommandations pour un suivi
attentif du parent et de l'enfant dans sa
communaute.

Dr. Stewart is Chief of the
Psychiatric Consultation Liaison
Service at St. Michael's Hospital
and an assistant professor of
psychiatry and obstetrics and
gynecology at the University of
Toronto. Reprint requests to: St.
Michael's Hospital, 30 Bond Street,
Toronto, ON. M5B 1W8.
rr HE CHANCE OF the average
family doctor having a pregnant
schizophrenic patient in his practice is
fairly high, as the expectancy of schi-
zophrenia in the general population is
slightly over one percent during the re-
productive years. I
What special problems does a preg-
nant schizophrenic patient present dur-
ing prenatal care, and is there anything
special about her labor and delivery?
Are there any postpartum difficulties
that may be anticipated and prepared
for and, finally, what is the prognosis
for the schizophrenic patient's child?
This paper will attempt to answer
some of these difficult questions, with
a review of the current literature and
my own experience as a psychiatric
consultant to an obstetrical service.
CAN. FAM. PHYSICIAN Vol. 30: JULY 1984
Fertility and Schizophrenia
It has been known for many years
that the fertility rate of schizophrenic
patients is below average. It is
variously estimated to be 30% to 80%
of the general population's fertility
rate.2 Many factors contribute to this
reduced rate. Psychotropic medica-
tions, including major tranquillizers,
which many schizophrenics require re-
gularly, suppress ovulation through
their effect on the hypothalamus. ' Un-
treated acute psychotic episodes may
interfere with the menstrual cycle, fur-
ther reducing fertility. I Perhaps a more
important reason for reduced fertility
is a lack of opportunity for sexual in-
tercourse. In the past, these patients
were confined to chronic care wards in
mental hospitals, and the sexes were
segregated. Another problem is that
schizophrenics have difficulty forming
relationships, even of the limited sort
required for casual sexual intercourse,
even when suitable partners are avail-
able. Not surprisingly, the marriage
rates of schizophrenics are reduced
and range from 30-40% for men, and
50-60% for females, of the rates for
the general population. Marital fertil-
ity is also slightly reduced in schizo-
phrenics; it is 70-80% of the expected
rate. 2
However, recent changes in the
management of schizophrenic patients
may make conception more frequent.
Chronic schizophrenics are often en-
couraged to take 'drug holidays' to re-
duce the incidence of tardive dyskine-
sia, and many female schizophrenics
begin to menstruate during these drug-
free intervals. Socialization between
male and female patients is now en-
couraged on psychiatric wards, which
usually admit both sexes. The more
permissive sexual behavior in the gen-
eral population probably contributes to
increased frequency of sexual inter-
course in the schizophrenic population
as well, and often contraception is in-
adequate. Abernethy:' found that the
fertility rate of young, female psychia-
tric patients (most of whom were schi-
zophrenic) was higher than she ex-
pected. More than two thirds of the
sample were sexually active. Fifty per-
cent used some birth control method,
but only 18% used contraceptives dur-
ing their last coitus. Clearly, adequate
contraceptive use is important in the
case of these patients. Many schizo-
1537
phrenics who were previously institu-
tionalized now live in the community,
either in group homes housing both
sexes, or in boarding houses, which
often are poorly supervised. All of
these factors probably contribute to an
apparent increase in schizophrenics'
rate of reproduction over the last de-
cade.2
Prenatal Management
Many stresses are common to all
women during pregnancy. These in-
clude endocrine changes related to
thyroid, adrenal and sex hormones,
changes in body size and image, un-
conscious and conscious conflicts as-
sociated with the pregnancy, and con-
cerns about labor and delivery.
Pregnant women are concerned about
their ability to mother, worried about
their own interests and the possibility
of entrapment, and anticipate changes
in their relationship with their partner
and their parents.4 These are potential
sources of stress to all pregnant
women, and it is not surprising that the
schizophrenic patient often does not
cope well with them.
Diagnosing pregnancy
Clearly, prenatal management must
begin with the diagnosis of pregnancy,
and this in itself presents a problem in
some schizophrenic patients. Many of
these women are unaware of changes
in their body and may deny, or not re-
alize, that they are pregnant. Often it is
difficult to obtain an accurate date of
the last menstrual period, and it is not
uncommon for schizophrenic patients
near term to insist that they have been
having regular periods and that they
have not had sexual intercourse. De-
luded patients may deny the preg-
nancy, or believe that the fetus is spe-
cial (e.g., is a child of God or the
devil). The diagnosis of pregnancy
may be further complicated by the ten-
dency of phenothiazines to produce
falsely positive pregnancy tests.5
Special needs
The prenatal care of schizophrenic
patients may be fraught with difficul-
ties. For patients who are living unsu-
pervised in the community, attendance
at prenatal visits is likely to be irregu-
lar, if it occurs at all. Self-neglect is
common among schizophrenics, and
so nutrition and hygiene may be inade-
quate during pregnancy. The problems
1 538
are magnified if the patient is acutely
psychotic during the pregnancy, par-
ticularly if she has delusions. Intermit-
tent hospitalization may be necessary
during acute exacerbations of psy-
chosis, or for the patient who is not
able to care for herself adequately in
the community. It is important that the
pregnant schizophrenic be followed
carefully if she is not in a psychiatric
hospital. A public health nurse and/or
social worker should be mobilized
promptly if the patient does not appear
regularly at prenatal visits, or if she is
not coping well. Sheltered homes for
pregnant women offer another alterna-
tive, but these facilities are often un-
able to tolerate a psychotic patient.
It is vital to reassure the patient
about the health care team's interest in
her and her pregnancy, because it is
easy for her to suspect that caregivers
are planning to harm either her or the
baby. This is particularly true if any
suggestion is made that the child wel-
fare authorities should be involved in
her care. If such a recommendation
is felt to be necessary for the baby's
safety, there should be considerable
discussion and reassurance before the
authorities are involved.
One of the purposes of prenatal
visits is to encourage the schizophrenic
mother to develop a sense of reality
about the growing fetus, and to realize
that it will be born and have a separate
identity.5 It is helpful to let the woman
listen at each visit to the fetal heart
beat, once it becomes clearly audible.
If family physicians ask about possible
names, practical preparations for the
baby's arrival, and preparations for
labor, they will be able to assess how
well the patient is dealing with some of
the tasks of pregnancy and whether she
has accepted that the baby is real. If
the patient's responses do not make
sense or if she talks about irrelevant
topics, the doctor should gently re-
mind her of the matter being dis-
cussed. It is important not to argue
with the patient's delusions or rein-
force her hallucinations, but to rein-
force reality. Explanations about the
pregnancy, labor and delivery should
be simple and concrete to increase
comprehension and reduce anxiety,
and the patient must never be dis-
cussed where she might overhear and
misinterpret the conversation. A trust-
ing relationship with her physician is
very important, as is consistency in the
members of the health care team.
Psychotropic medications
The thorny question of the effect of
psychotropic medications in preg-
nancy will have to be faced if the pa-
tient is chronically psychotic or be-
comes acutely psychotic. While many
of the large, systematic reviews of
psychotropic drugs used in pregnancy
do not implicate major tranquillizers in
fetal malformations,7 one retrospec-
tive study7 of 13,000 women who took
antipsychotics in the first trimester
found a statistically significant in-
crease in malformation associated with
the aliphatic phenothiazines (e.g.,
chlorpromazine).7 A further study8 of
1,300 women exposed to phenothia-
zines during the first four months of
pregnancy, compared to a control
group, showed that the rate of malfor-
mations was similar in both groups,
but there was a suspicious association
between phenothiazines and cardio-
vascular malformations. The perinatal
morbidity rates, infant birthweights,
and offspring's IQ scores at age four
years were similar for the two
groups.
There have been scattered reports of
birth defects associated with pheno-
thiazines, but often these drugs have
not been the only medications taken
during the first trimester and the corre-
lation is not clear.7 Although there is
little clinical justification for the use of
diazepam in treating schizophrenia, I
have occasionally seen pregnant pa-
tients who have been prescribed this
drug by doctors who feel that it may be
safer than the major tranquillizers.
This is not true and, in fact, there is
evidence to indicate that diazepam and
other benzodiazepines are associated
with more problems in the fetus and
neonate than are the major tranquil-
lizers. 9 The optimal plan is to manage
the patient during the first trimester
without medication, if possible. In my
opinion, however, if she is acutely or
chronically psychotic and difficult to
manage, the major tranquillizers can
probably be used with reasonable
safety. A psychiatric consultation is
often helpful with these patients, and
in balance, the risk of damage to the
fetus by psychosis is usually greater
than the possible adverse effects of
phenothiazines.
The risk of major tranquillizers to
the fetus is reduced in the second or
third trimester, and the physician can
be less apprehensive about using one if
it is required. However, evidence from
CAN. FAM. PHYSICIAN Vol. 30: JULY 1984
animal experiments indicates that in
the later stages of pregnancy some
phenothiazines may interfere with the
fetus's cerebral cortical development
and reduce problem solving ability.10
Occasionally, transient extrapyramidal
symptoms may be seen in some new-
borns whose mothers received major
tranquillizers before delivery. Ant-
acids inhibit the absorption of oral
phenothiazines, so these drugs should
be taken at least two hours apart.5
Prenatal complications
Several investigators have reported
increased prenatal complications in the
pregnancies of schizophrenic women,
but these appear to be due mostly to
their lower socioeconomic status.11
When they are compared to controls
who are not matched for socioecono-
mic status, schizophrenic women
show significantly more toxemia, va-
ginal bleeding and proteinuria during
pregnancy. However, when controls
are matched for socioeconomic status,
schizophrenic women do not have sig-
nificantly more prenatal complica-
tions. 1 Although the data is limited, it
appears that there is no increase in
prenatal complications for pregnant
schizophrenic women when the bio-
2 TOPICAL
SOLUTION 1%
20 mL
logical father is schizophrenic. 12
Rieder'3 has examined why there is
a twofold increase in fetal and neonatal
deaths in the offspring of schizo-
phrenic mothers; there is no apparent
reason for the death of some of the in-
fants but others have major neurologi-
cal malformations. He postulated that
the reasons for the increase may be the
fetus's genotype, an unfavorable in-
trauterine environment, or possible
medication toxicity. 13
Labor and Delivery
The beginning of labor often goes
unrecognized in the schizophrenic pa-
tient because she is a poor historian
and an unreliable reporter. It is not un-
common for such patients to deliver
out of hospital, or to present late in
labor complaining of abdominal pain,
gas or constipation. For the acutely
psychotic woman near term, ultrason-
ography may be useful in establishing
the expected date of delivery, and ad-
mission one week before the expected
date is often the practice of choice if
the patient is not reliable and is in an
unsupervised setting. Once in labor,
the schizophrenic patient should never
be left unattended, and adequate ex-
planation, reassurance and, if neces-
TOPICAL
SOLUTION 1% WITH
ATOMIZER 40 mL
sary, medication should be given.
Pregnant schizophrenics sometimes
confuse labor pains with the need to
move the bowels, and there is a danger
that babies may be delivered into the
toilet or bed pan. During labor, the op-
timal caregiver is a health professional
who the patient knows and trusts.
In the early stages of labor, the acu-
tely agitated patient who cannot be
soothed by explanation and reassur-
ance is usually best managed with
small doses of major tranquillizers
such as chlorpromazine 50 mg intra-
muscularly. Agitation in the later
stages of labor is best managed with
analgesics, and the major tranquil-
lizers should be used only if necessary
to control psychotic symptomatology.
While some schizophrenic women are
able to deliver without anesthetic,
others require either epidural or, occa-
sionally, general anesthetic. When a
patient has been treated with major
tranquillizers, care must be taken dur-
ing the epidural to avoid hypotension,
and general anesthetic must be admin-
istered cautiously, to avoid aspiration.
Also, the physician must expect the
patient to require a longer recovery
period after general anesthetic than
other patients.
U
Canadas most widely
prescribed topicalanti-mycotic
pepclat-yoi
 Sameroff and Zax14 demonstrated
that schizophrenic patients have more
complications during delivery than
controls do, although the chronicity of
the mental disorder is more strongly
related to the number of complications
than is any particular psychiatric diag-
nosis. 14 Garmezy'5 postulated that
psychotic women's general lack of
competence tends to lead to a lack of
medical concern and failure to have
complications of pregnancy properly
treated. He also pointed out that many
of these women present in labor with
poor nutritional status. Wrede and
Mednick16 found that schizophrenic
women have more delivery complica-
tions than the average population and,
in Scandinavian countries at least,
these complications are unrelated to
socioeconomic status. Parnas 17 re-
ported that the most common variable
in the delivery of schizophrenic
women is abnormal fetal position.
Miscarriage, and fetal and neonatal
deaths unrelated to obstetrical compli-
cations are more common among schi-
zophrenics. 13 Sobel 18 reported a
higher frequency of stillbirth and
neonatal deaths among the children of
schizophrenic mothers. Mednick2 6
pointed out that schizophrenics' chil-
dren who had the most severely abnor-
mal development also had the most se-
vere perinatal complications. It has
been known for some time that infants
born to schizophrenic mothers are
small for gestational age and that these
infants are at risk for slow develop-
ment.24
Postpartum Management
The postpartum period is a difficult
time for all women, and the schi-
zophrenic patient is vulnerable to psy-
chotic breakdown and regression dur-
ing this period. If psychosis occurs,
the focus of the symptoms is usually
the baby and the woman's ability to
mother.4 The symptoms of postpartum
psychosis are often florid and may ap-
pear early. The prodromal symptoms
are sleep disturbance, restlessness, fa-
tigue, depression, irritability and labile
mood. Later symptoms are suspicion,
confusion, incoherence, irrational
statements, delusions, hallucinations,
thought disorder, a decrease in appe-
tite and, occasionally, delirium. The
schizophrenic mother is often con-
cerned about the baby's health, and
may suffer guilt about lack of love or a
wish not to care for the baby, inade-
1540
quacy, delusions that the baby is dead tration of major tranquillizers. It is
or defective, and hallucinations that usually safest for an acutely psychotic
command her to harm the baby. She patient to discontinue breastfeeding.
also may deny the birth. It is important The concentration of any drug in
that the patient who shows any psy- breast milk depends on the solubility
chotic symptoms has access to her of the drug, the protein binding of the
baby only under direct nursing super- drug, and the pH of the drug compared
vision and that an early psychiatric to plasma pH, which is 7.4, and breast
consultation and treatment are ob- milk's pH, which is 6.8. Acidic drugs
tained. The treatment of acute schi- concentrate less in breast milk and are
zophrenic exacerbation in the post- generally safer. A general rule is that
partum period usually requires trans- the concentration of a drug in breast
ferring the patient to the psychiatric milk is no more than approximately
unit, administering a major tranquil- ten percent of the mother's plasma
lizer and, occasionally, giving electro- level, but there are wide variations.
convulsive therapy to those who are The breast milk concentration of both
unresponsive to medication or have a butyrophenones and phenothiazines
strong affective component to their ill- are less than one third of maternal
ness. It is often helpful to treat psycho- plasma concentration.27 Although no
tic exacerbation in the schizophrenic significant neonatal side effects have
mother by admitting her and her baby been reported due to breastfeeding by
to a psychiatric unit where they can be mothers taking major tranquillizers,9
managed together. This gives the some animal studies show the side ef-
woman a chance to learn to look after fects of butyrophenones may be trans-
her baby under supervision, and helps ferred through breast milk.7
her to gain confidence before dis- The schizophrenic patient who is in
charge home once the psychosis has remission and does not require major
abated. 19 If there is any serious ques- tranquillizers to maintain the remission
tion about the infant's safety, the child can breastfeed if she desires and, in-
welfare authorities must be notified deed, should be encouraged to do so if
before mother and baby are dis- she expresses any interest.
charged. When there is serious con-
cern, discharge must be delayed until a The Schizophrenic's Child
safe solution is found. 19 Involuntary
hospitalization is occasionally re- There is substantial evidence that
quired. children born to psychotically dis-
When a schizophrenic patient is in turbed parents are at a higher lifetime
remission at the time of delivery and risk for psychopathology of all
remains in remission, a period in the types. 1' The genetics of schizophrenia
hospital's rooming-in area allows have been well studied and there is
bonding, infant care education, and consensus that the children of two
schizophrenic parents have a 40%
direct supervision of her ability to look
after the infant before discharge chance of developing schizophrenia,
while the children of one schizo-
home. 19 Most importantly, it increases
phrenic parent have a seven to 17%
the patient's confidence in her ability
to mother. Regular home visits from risk of developing schizophrenia, de-
pending on the type of schizophrenia
the public health nurse can greatly help
these women adjust to the inevitable the parent has and the spouse's charac-
problems that follow the birth of a teristics. 20
baby. Additional community supports Reider2 5 has said that perinatal
should also be arranged if they seem events are better predictors of low IQ
helpful. Clearly, the support and in- in offspring of schizophrenics than is
volvement of a non psychotic partner, socioeconomic status, but in the gen-
if he is available, is very important and
eral population, socioeconomic status
ought to be encouraged by those caringis a better predictor. However, chil-
for the mother and infant. dren of normal women married to
Postpartum visits should occur at schizophrenic men are also at
least weekly until both physician and increased risk for lower IQs; this fact
patient feel the situation is stable. indicates that both genetics and subop-
timal environment" affect develop-
Breastfeeding ment.
Obviously, a conflict may arise be- The infant who is born to and reared
tween breastfeeding and the adminis- by disturbed parents is certainly at
CAN. FAM. PHYSICIAN Vol. 30: JULY 1984
greater environmental risk. II In 1975,
Ragins reported that the care given by
schizophrenic mothers during the first
year of life offered less environmental
stability and nurturance than care
given by normal controls.21 The
schizophrenic mothers were less spon-
taneous and expressive and provided
little sensory or motor stimulation for
their infants. 22
Disturbed mothers differ from nor-
mal mothers in their attitudes toward
child rearing. Cohler found that a
group of disturbed mothers, most of
whom were schizophrenic, rated the
establishment of a mutual mother-
child relationship as being less impor-
tant than normal mothers did.23 The
schizophrenic women also placed less
emphasis on fostering independence in
the child, and were more likely to deny
ambivalent feelings about child care.
The schizophrenic mothers were asked
to rate their children on a temperament
questionnaire and tended to describe
their children as "difficult" and
"slow to warm up" more frequently
than did women without a psychiatric
illness.23 Children under 18 months
whose mothers are schizophrenic have
been rated as being less responsive to
verbal command, less spontaneous and
imitative, and as showing more distress
at separation from their mothers than
control infants.21 Mednick26 examined
the children of schizophrenics at age
one year and found there was a higher
incidence of retarded development.
Less than optimal caregiving may lead
to disturbed behavior and a wide vari-
ety of psychiatric disorders, including
the later diagnosis of schizophrenia in
a small proportion of offspring.
Although some schizophrenic
parents, particularly when they are in
remission, provide an adequate envi-
ronment for their children, others, par-
ticularly when they are actively psy-
chotic, neglect or otherwise abuse
their children. The family doctor is
often in a good position to monitor the
physical, emotional, and intellectual
development of the child with a schi-
zophrenic parent, and should pay par-
ticular attention to inadequately ex-
plained physical injuries, evidence of
neglect, or delayed milestones. These
children should have periodic visits
from public health nurses or, in cases
of more serious disturbance, from
child welfare workers. Occasionally
1542
the child may need to be taken into
protective custody. If he remains with
the parents, there is little doubt that he
manages best when the psychotic
parent is in remission, and every at-
tempt should be made to treat and con-
trol the parent's psychotic exacerba-
tions.
Conclusion
Many problems present in the care
of the pregnant schizophrenic. In gen-
eral, the prenatal care, labor, delivery
and postpartum management are ide-
ally suited to a team approach. In par-
ticular, a psychiatrist, obstetrician, pe-
diatrician, public health nurse, social
worker and child welfare worker may
be invaluable to some of these patients
and their children. Not only is the fam-
ily doctor in an ideal position to coor-
dinate the team's efforts, but he or she
may have intimate knowledge of the
patient's physical and psychiatric con-
dition, the social setting in which she
lives, and the psychological and physi-
cal complications that can occur in
both the woman and her child. ( et al: Perinatal complications and clinical
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CAN. FAM. PHYSICIAN Vol. 30: JULY 1984