Ethical and Legal Considerations in the Refusal of Antipsychotic Treatment During Pregnancy: A Case Report

Acute psychosis during pregnancy creates a complex clinical scenario that requires simultaneous consideration of maternal psychiatric stabilization and fetal well-being. Guidance remains limited on the management of acutely psychotic pregnant patients who lack decision-making capacity and refuse care, particularly in settings without on-site obstetric resources. We describe the case of a 35-year-old woman with schizoaffective disorder and post-traumatic stress disorder who was involuntarily committed for acute behavioral disturbance and found to be approximately 14 weeks pregnant during evaluation. She remained acutely psychotic, with persistent paranoid and grandiose delusions, impaired self-care, and disruptive, sometimes aggressive behavior. A formal capacity assessment determined that she lacked the capacity to make informed decisions about psychiatric treatment or pregnancy-related care. She refused antipsychotic medication, laboratory testing, and prenatal care, and de-escalation efforts were unsuccessful. Because the treating facility lacked on-site obstetric services and pharmacologic treatment carried fetal risks that the patient could not weigh, the team pursued transfer to a facility with both psychiatric and obstetric capabilities rather than a forced-medication hearing. After 20 days, she was transferred under commitment to a state hospital. This case illustrates that pregnancy transforms an already difficult involuntary-treatment decision into a multidimensional legal, ethical, and systems problem and highlights that early pregnancy screening, predefined transfer pathways, and multidisciplinary review should guide management when acute psychosis and pregnancy intersect.