ECT and Pregnancy

pregnancy ect

The last systematic review of this topic was in 1994. According to this recent review ECT does seem to be effective for treating mental illness during pregnancy and the risks of adverse events are low. It should be considered in pregnant women with severe mental illness such as psychotic symptoms, catatonia or strong suicidal urges.

Why is this important?

  • The most common mental illness during pregnancy is major depressive disorder. It is estimated that 9% of pregnant patients suffer from major depressive disorder
  • Untreated depression is linked to poor maternal and neonatal outcomes including poor weight gain during pregnancy, higher risk of alcohol and/or drug abuse, preterm birth, lower birth weight, preeclampsy, and hindered mother infant bonding
  • Elevated risk of suicide
  • ECT is efficacious for major depressive disorder and other severe mental disorders
  • Medications carry a potential risk for the fetus especially in the first trimester.

How was this study done?

English-language and English-language translated articles published since 1941 that included data on ECT in pregnancy were located in bibliographic databases, online sites, journal issues, and secondary sources, such as journal articles and book chapters. PubMed and PsycINFO were searched using the terms “ECT,” “electroshock,” “electroconvulsive” or “electroconvulsive shock,” and “pregnancy.”

The search yielded 57 articles that met the inclusion criteria and dated from 1942-2007. The total number of cases described was 339.

Results

  • The mean number of treatments was 10.8 (range 1-35). Gestational age was reported in 71 cases. Fifteen patients received ECT in the first trimester, 37 received ECT in the second trimester, and 19 in the third trimester.
  • Efficacy data were available on 68 of 339 cases. Of these 37 were diagnosed with either MDD or “depression” (with or without psychosis) and the rate of at least partial response was 84%. Twenty-one pregnant women were treated for schizophrenia or schizophreniform disorder and the rate of at least partial remission was 61%.
  • There were 25 of the 339 cases in which fetal or neonatal abnormalities were reported. death (n=11), transient fetal bradycardia and or decelerations (n=8), peritonitis (n=1), club foot (n=1), prematurity (n=1), congenital pulmonary cysts (n=2), congenital blindness (n=1), great vessel transposition (n=2), aorta coarctation (n=1), cortical infarcts (n=1), anencephaly (n=1), VATER syndrome (n=1), and mental retardation (n=1).
  • Of the 11 reported fetal or neonatal deaths, only one was believed to be the direct result of ECT, death followed an episode of status epilepticus in the mother secondary to ECT. The others were believed to be unrelated to ECT
  • Among the nonfatal complications only 8 cases of abnormal transient fetal arrhytmias and one case of multiple interhemispheric infarctions were believed to be related to ECT.
  • There were 18 of 339 maternal cases described with complications likely related to ECT.
  • Of the 8 fetal and 18 maternal cases describing complications likely related to ECT includes 4 cases that each have both a neonatal and maternal complication.

Conclusion (with my 2 cents added)
ECT is an option with severe mental health disorder during pregnancy. Some precautionary measures should be taken with ECT durnig pregnancy:

  • Positioning a woman during the latter stages of pregnancy to minimize aortocaval compression by elevating the right hip and displacing the uterus will also improve placental perfusion and minimize the risk of hypoxia in the fetus.
  • From the third trimester intubation is always necessary. The authors don’t mention this in their article but it should have
  • Tocodynamometry during ECT administration can be used for monitoring uterine activity. In the event of uterine contractions, tocolysis with alfa-2-adrenergic agonists like ritodrine can be administered.
  • Given the potential for general anesthesia to sedate the fetus, obstetric fetal monitoring is necessary during ECT. We don’t always do this, it depends on the trimester and growth of the fetus. We do it at least once every month during a ECT session.

no randomized, controlled trial has yet been conducted evaluating ECT efficacy for treating major mental illness during pregnancy.

Another limitation of this review is reporting bias. Adverse or unusual outcomes post treatment with ECT are much more likely to be reported than normal or uneventful outcomes. This review did not focus on long term outcome.

Obstretic fetal monitoring is one suggestion of debate, how often should this be done, every treatment, all trimesters? Nobody knows. Any idea anyone? Let me know your experiences with ECT during pregnancy in the comments.

Related post on this blog: Electroconvulsive therapy and pregnancy, a case report
Why pregnant women don’t tip over

ResearchBlogging.org
E. L. Anderson, I. M. Reti (2008). ECT in Pregnancy: A Review of the Literature From 1941 to 2007 Psychosomatic Medicine DOI: 10.1097/PSY.0b013e318190d7ca