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Some patients may present quite a challenge for the health care team-from the receptionist to the social worker to the nurse and to the physician. An understanding of personality disorders can be helpful for the provider working with a complicated or "difficult" patient. Borderline personality disorder is relatively common in patients presenting with a complicated medical and psychosocial picture. Recognizing borderline personality disorder allows providers to better tailor treatment goals and expectations, manage personal reactions, set effective boundaries, and avoid potential confrontations with the difficult patient. Using a clinical case vignette, this article discusses the prevalence, etiology, diagnosis, and management of borderline personality disorder in the obstetrical and gynecological patient.

D epression occurs in 10%-20% of pregnant women. 1 Postpartum depression occurs in 13% of women, in 22%-34% of women living in poverty, in 26% of adolescents, and in up to 50% of women with known bipolar disorder.2 Depression in pregnancy is associated with the following risks: noncompliance with prenatal care; increased use of drugs, alcohol, and tobacco; poor nutrition; decreased sleep; preeclampsia; preterm birth; low birth weight; low Apgar scores in the newborn infant; elevated cortisol and catecholamine levels in the newborn infant; increased risk for postpartum depression; increased risk of sudden infant death syndrome; and suicide and infanticide by the mother. 3Although there may be risks to the fetus associated with pharmacotherapy, discontinuing a pregnant woman's medication abruptly may put both the mother and fetus at greater risk. For example, Viguera et al. demonstrated that women who abruptly discontinued their medication in less than 2 weeks experienced a 50% risk of relapse within 2 weeks, whereas women who discontinued gradually required 22 weeks to reach the same level of relapse. 4 Furthermore, women who discontinued use of mood stabilizers during pregnancy had an 85% chance of relapsing compared with 37% for those who continued treatment. We discuss the recent data on the potential risks of the most commonly prescribed medications for treating mood disorders in pregnant and lactating women. SELECTIVE SEROTONIN REUPTAKE INHIBITORSMultiple prospective and retrospective controlled studies assessed the use of selective serotonin reuptake inhibitors (SSRIs) in pregnancy (Table 1). Overall, the results are inconsistent, and further well-controlled studies are needed for clarification. Many studies consider multiple SSRIs a homogeneous class of medications, including paroxetine, sertraline, fluoxetine, and fluvoxamine. Two large meta-analyses analyzed SSRIs in general and found no increased risk of major congenital malformations. 5,6 In addition, a recent large multicenter, prospective, controlled, observational study found no increased risk of major congenital malformations in neonates with intrauterine exposure to fluoxetine. 7 Other studies, however, report that late intrauterine exposure to SSRIs is associated with a higher risk of low After reading this article, the practitioner should be able to:• Describe the risks of mood disorders in pregnancy and nursing women.• Explain risks to the fetus, neonate, and nursing infant associated with the most commonly used medications in treatment of depression.• Recall medications that may be safer to use for treatment of depression in pregnant and nursing women. LWW.comThis continuing education activity is intended for psychiatrists and other health care professionals with an interest in psychotropic drug therapy.