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Sunday, August 12, 2007

Electroconvulsive therapy and pregnancy, a case report

Electroconvulsive therapy during pregnancy should be performed with caution. In a case report a woman with a first time pregnancy received ECT during pregnancy. She was on maintenance ECT, every 2 weeks during her pregnancy she received ECT. She had a bipolar depression and was only partially responsive to conventional medical therapy.
Fetal heart rates were recorded after each treatment but it was unclear how soon after the treatments and at what gestational age this testing began.
At 36 weeks she had an elevated blood pressure and elevated protein on a 24-hour analysis. Labor was inducted because of preeclampsia. The newborn unexpectedly had severe neurological deficits associated with multiple brain infarcts.

Preeclampsia is a disorder that occurs only during pregnancy and the postpartum period and affects both the mother and the unborn baby. Affecting at least 5-8% of all pregnancies, it is a rapidly progressive condition characterized by high blood pressure and the presence of protein in the urine. Preeclampsia and other hypertensive disorders of pregnancy are a leading global cause of maternal and infant illness and death.

A cause and effect relationship between ECT and the inter hemispheric infarcts cannot be established. Whether ECT in this case led to tetanic uterine contractions causing a fetal bradycardia or possibly induced a fetal arrhythmia, resulting in fetal brain injury, is purely speculative. This chain of events does not seem likely because uterine contractions of sufficient strength to severely limit placental blood flow probably would have been noticed by the patient. Other possible explanations for this complication could be the preeclampsia, and medication use is not mentioned in this case report.

There are no prospective or controlled studies exploring the effects of ECT on pregnancy and the foetus. Many case reports have been written but these data do not provide evidence for definitive conclusions. According to the editorial in the same issue of this case report:

How likely is it that a study could be done to show a statistically significant association between ECT and fetal brain injury? If the rate of neurological impairment in an unexposed control group was in the range of 1 in 1,000 births and the rate of injury in infants of ECT-exposed women was 10 times higher, a prospective cohort study would have to enroll over 1,000 women in both the treated and control groups to demonstrate this difference with statistical significance. Given the rarity of ECT use in pregnancy, such a study would obviously not be feasible.

Nevertheless the American Psychiatric Association has published guidelines for management of a pregnant patient undergoing ECT.
These guidelines are aimed at minimizing potential complications including aspiration and altered uteroplacental blood flow. Specific recommendations include

1. Consultation with an obstetrician before initiation of treatment.
2. Treatments performed in a facility with immediate access to obstetric care for emergencies.
3.  Monitoring of fetal heart rate before and after treatments. Increase in monitoring at viability to include a non stress test with tocometry after treatments. Perform a Level 2 ultrasonography between 18 weeks and 22 weeks gestational age.
4.  Routine anesthetic measures (leftward tilt of trunk, adequate oxygenation, hydration, and muscle relaxation, nonparticulate antacid, consider intubation in the third trimester).

But above all ECT in pregnancy should only be used in cases of emergency in which any delay is life threatening or when medication has failed. Given the risks of non treatment of major depression and the undefined risk of ECT in pregnancy, we must, as the authors of this case report suggest, use drug therapy as our first-line approach to treatment. The neonatal risks with pharmacotherapy are real, but adverse effects generally do not have long-term consequences. Most importantly, in contrast to ECT, large-scale studies on drug therapy have been performed, allowing the risks to be quantified.

Let's be careful out there. Sgt. Phil Esterhaus, Hill Street Blues.

Pinette MG, Santarpio C, Wax JR, Blackstone J. Electroconvulsive therapy in pregnancy. Obstet Gynecol 2007;110:465–6.

Is Electroconvulsive Therapy in Pregnancy Safe?[Editorial]
Obstetrics & Gynecology. 110(2, Part 2) (Supplement):451-452, August 2007.

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