I am an ob/gyn. One of my areas of interest is psychopharmacology and it application in ob/gyn. I have a few drugs I can use, but there are times I get in over my head.

My patient is 28 y.o., BMI of 35, no medical issues other than irregular menses and severe pelvic pain. Psychiatrically, she has schizophrenia, bipolar disorder, panic disorder, insomnia and PTSD. She also has a hx of opiate abuse. On presentation she is appropriate, good hygeine, intelligent. Affect is flat.

Her regimen is lithium 900 qhs, Lamotrigine 100mg bid, Abilify 10 mg, clonazepam 1 mg po qhs, suboxone 2mg strip 1/2 at night, buspirone 10 mg po bid.

She is in school and reportedly doing well from a mood perspective. No auditory hallucinations, depression improved, anxiety improved. Her complaint today is severe pelvic pain and that she hasn’t slept in 2 nights. I’m making adjustments to increase the suboxone to 1mg bid, increasing the clonazepam to 2 mg and increasing Abilify to 15. I’ve been working with her for about 6 months. She has tried multiple other regimens.

She wants to get pregnant. Of course I’m extremely anxious in helping her because I don’t want her to become symptomatic. I’m going in with a scope and told her I would do a procedure to help her ovulate better.

From an ethical perspective, should I be facilitating her wishes in this regard? I’m doing it but I’m wondering if I’m potentially creating a huge problem.

I’m open to suggestions and criticisms; I understand she should be in more qualified hands. I am aware of the risks of benzos with Buprenorphine; she was on the clonazepam before she revealed her opiate history. I have reduced the lithium to 300 qhs, trying to form a suitable pregnancy regimen.

Thank you.

Addendum-I would like to thank everyone for their kind replies and suggestions. I called an academic center that is about 2 hours from where I practice. I called the patient and she is ok with being referred. I’m glad I made the post so that you could set me straight and point me in the right direction. I’ll write an update. Have a nice evening everyone!