Why should a 40‑week pregnant Gravida 1 Para 0 woman with focal epilepsy secondary to post‑traumatic gliosis and mild intellectual developmental disorder, already under outpatient psychiatric care, be referred back to psychiatry from the emergency department?

Psychiatric Referral for 40-Week Pregnant Woman with Focal Epilepsy and Intellectual Disability

This patient requires urgent psychiatric consultation from the emergency department to ensure integrated perinatal mental health care, optimize epilepsy management in the context of her intellectual disability, and coordinate safe peripartum planning for both maternal and neonatal outcomes. 1

Primary Reasons for Psychiatric Referral

Integrated Perinatal Care Coordination

• Women with serious mental illness, including those with intellectual developmental disorders, require integrated interventions with multiple professionals and a case manager to reduce care fragmentation during the perinatal period. 1
• Current care systems refer patients with psychiatric conditions to separate services, which is insufficient for addressing complex needs at term pregnancy. 1
• Continuous, coordinated interventions from preconception through postnatal care are essential, particularly as this patient approaches delivery. 1

Epilepsy-Psychiatry Interface Management

• Focal epilepsy with post-traumatic gliosis can present with psychiatric symptoms that may be misdiagnosed as primary psychiatric illness, requiring specialized evaluation by both epileptology and psychiatry. 2
• Patients with epilepsy and intellectual disability are more likely to experience psychiatric conditions, challenging behaviors, and adverse effects from anti-seizure medications than those without intellectual disability. 3
• The interaction between epilepsy and developmental encephalopathies influences treatment decisions, particularly regarding anti-seizure medication management during the peripartum period. 4

Anti-Seizure Medication Considerations

• Several anti-seizure medications, particularly levetiracetam, topiramate, and perampanel, may contribute to psychiatric disorders including depression, aggressive behavior, and psychosis, requiring close monitoring. 5
• If the patient is on levetiracetam, psychiatric evaluation is critical as this medication can cause behavioral changes (aggression, agitation, anger, anxiety, apathy, depression, hostility, irritability) and rarely psychotic symptoms. 6
• Psychiatry can assess whether current psychiatric symptoms represent medication side effects, seizure manifestations, or independent psychiatric illness. 5, 2

Intellectual Disability-Specific Concerns

• Mild intellectual developmental disorder affects conceptual reasoning (judgment in novel situations), social reasoning (interpersonal communication), and practical reasoning (self-management), all of which are critical for postpartum care planning. 1, 7
• Patients with intellectual disability and epilepsy require assessment of their capacity for infant care, need for additional support services, and risk stratification for postpartum complications. 1
• Psychiatric evaluation can identify strengths and limitations in adaptive functioning to guide discharge planning and postpartum support. 1, 7

Peripartum Risk Stratification

Maternal Mental Health Emergency Risk

• Maternal self-harm (suicide, injury, overdose) remains a leading yet underappreciated cause of maternal mortality, particularly in women with pre-existing psychiatric conditions. 1
• Untreated or inadequately treated psychiatric illness may result in poor adherence to prenatal care, inadequate nutrition, and exacerbations of underlying illness during the high-stress peripartum period. 1
• Mental health conditions often coexist with substance use disorders, further compounding maternal risks that require assessment. 1

Postpartum Planning Requirements

• Women with serious mental illness require access to specialist community services and psychiatric inpatient mother-baby units, with service provision extending up to 2 years postpartum. 1
• At 40 weeks gestation, immediate coordination is needed to ensure psychiatric support is available during labor, delivery, and the immediate postpartum period when risk of decompensation is highest. 1

Emergency Department Psychiatric Consultation Protocol

Assessment Priorities

• Evaluate current psychiatric symptom burden (depression, anxiety, psychosis, behavioral disturbances) and distinguish from seizure manifestations. 2, 8
• Review anti-seizure medication regimen for psychiatric side effects, particularly if levetiracetam is prescribed. 6, 5
• Assess adaptive functioning capacity for postpartum infant care and identify need for additional support services. 1, 7
• Screen for suicidal ideation, self-harm behaviors, and substance use. 1, 6

Coordination Requirements

• Establish immediate communication between psychiatry, neurology/epileptology, and obstetrics to create unified peripartum management plan. 1, 3
• Arrange postpartum psychiatric follow-up before discharge from emergency department. 1
• Identify need for mother-baby unit admission versus outpatient intensive support. 1

Critical Pitfalls to Avoid

• Do not assume psychiatric symptoms are solely manifestations of epilepsy without formal psychiatric evaluation, as non-convulsive seizures can be mistaken for primary psychiatric illness and vice versa. 2
• Do not delay psychiatric consultation until after delivery, as integrated planning must occur before peripartum complications arise. 1
• Do not fragment care by addressing epilepsy and psychiatric needs separately, as this population requires holistic integrated intervention. 1, 3
• Avoid attributing all behavioral or cognitive concerns to intellectual disability without investigating acute psychiatric decompensation or medication effects. 5, 3