CASE: Abnormal movements
Pregnant and unsure of her due date, Ms. A, age 35, presents to the emergency room complaining of hourly uterine contractions for the last 3 days and new onset vaginal bleeding. Ms. A is admitted to the obstetrics (OB) service for preterm labor at 34 and 3/7 weeks as dated by a triage ultrasound.
During initial examination by the OB service, Ms. A’s blood pressure is 155/112 mm Hg with a pulse of 126. Her cervix is dilated to 4 centimeters. Her physical exam is notable for rapid, repetitive, involuntary movements in her upper extremities and to a lesser degree in lower extremities. Ms. A is started on IV fluids and hydralazine, 10 mg/d, for elevated blood pressure. Later that day, she delivers a preterm female weighing 2,360 grams in a spontaneous vaginal delivery without any complications.
After delivery, the OB service requests a psychiatric consultation to evaluate Ms. A’s “blunted affect,” history of heavy alcohol use, and abnormal movements. During examination, Ms. A is alert and oriented to her surroundings. She states that this was her eleventh pregnancy; however, she is unable to recall details of most previous pregnancies. She also cannot remember any significant medical, surgical, or mental health history. Ms. A appears distracted, has difficulty participating in the interview, and gives contradictory histories to different team members. She is well groomed but shows repetitive circular movements of her hands, feet, and jaw that are nearly continuous. In addition, Ms. A has intermittent lip biting and smacking. Her speech is delayed, with increased latency of her responses to basic questions.
Her mood is neutral, her affect is blunted, and she denies any current suicidal or homicidal ideations, delusions, and auditory or visual hallucinations. Although her chart indicates a history of alcohol abuse, she denies this history and current drug or alcohol use. Her Mini-Mental State Exam score is a 22/30, missing points in her ability to copy shapes and write a sentence, complicated by her chorea-like upper body movements. She also demonstrates marked inattentiveness and is unwilling to cooperate with spelling “world.” On physical exam, her gait is wide-based but steady.
The authors’ observations
Determining the cause of Ms. A’s abnormal movements, delayed speech, and neutral mood initially proves difficult because she is minimally cooperative with the interview and we find discrepancies between information she provides and her medical records from previous OB admissions. It is unclear whether these inconsistencies are because of her faltering memory—which she admits has worsened in the last year—or unwillingness to provide a complete medical history.
We consider possible substance intoxication given her documented history of substance use. However, an extended drug screen is negative and her laboratory values do not suggest heavy alcohol use.
HISTORY: Depression and confusion
The next day, Ms. A is more cooperative with the interview. She says that she began feeling depressed 8 years ago, around the time her brother was killed in a violent crime. She denies previous psychiatric hospitalizations, but says she attempted suicide 4 years ago by stabbing herself in the throat with a fork. After that attempt, she was referred to an outpatient psychiatrist whom she continues to see intermittently. She says that her abnormal movements started 2 years before she first saw her outpatient psychiatrist.
She says she has been prescribed several medications, but remembers only taking quetiapine for depressive symptoms and insomnia. After a discussion with her psychiatrist about the possible effects of quetiapine on the fetus, she discontinued the drug approximately 8 weeks into her pregnancy. Quetiapine decreased her movement symptoms slightly, and she feels her movements have become uncontrollable since discontinuing it.
She reports increased feelings of sadness, worthlessness, guilt, decreased energy, irritability, and difficulty sleeping during her pregnancy. She denies current or past psychotic symptoms or mania. Ms. A says she has noticed problems with her memory as well as increased confusion over recent months. She often gets lost and cannot remember where she lives after leaving her home.
Based on hospital records, we learn that an MRI of the brain without contrast was completed 1 year ago to “evaluate choreiform movements.” The scan showed mild atrophy and abnormal signal within the caudate and putamen, as well as volume loss. We consult with the neurology service to evaluate Ms. A’s abnormal movements and her previous abnormal brain imaging. The neurologic exam notes that Ms. A has orofacial dyskinesias and near-continuous choreiform movements in her arms and hands. Her gait remains wide-based and she is unable to tandem walk. Because Ms. A shows no new neurologic symptoms, the neurology service does not feel that additional neuroimaging is indicated.