Electroconvulsive treatment during pregnancy: a systematic review.

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Review

Electroconvulsive treatment during pregnancy: a systematic review Expert Rev. Neurother. 14(12), 1377–1390 (2014)

Maurizio Pompili*1, Giovanni Dominici1, Gloria Giordano1, Lucia Longo1, Gianluca Serafini2, David Lester3, Mario Amore2 and Paolo Girardi1 1 Department of Neurosciences, Mental Health and Sensory Organs, Suicide Prevention Center, Sant’Andrea Hospital, Sapienza University of Rome, 1035-1039, Via di Grottarossa, 00189, Rome, Italy 2 Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Section of Psychiatry, University of Genova, Largo Rosanna Benzi 10-16132, Genova, Italy 3 The Richard Stockton College of New Jersey, 101 Vera King Farris Dr, Galloway, NJ 08205, USA *Author for correspondence: Tel.: +39 063 377 5675 Fax: +39 063 377 5342 [email protected]

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Pharmacological treatment of severe psychiatric disorders during pregnancy is complicated by the potential harmful effects of treatment for the fetus. Electroconvulsive therapy (ECT) has been demonstrated to be effective for the treatment of several mental disorders. The aim of this study was to investigate the safety of ECT in the treatment of psychiatric disorders during pregnancy; to compare its efficacy with medication; and to identify the main indications for use in pregnancy. We performed a careful and systematic review of the literature on ECT and pregnancy was conducted. Almost all patients demonstrated total or at least partial remission of symptoms after ECT treatment. No deaths were reported in ECT-treated pregnant women. We conclude that ECT is probably currently under-used in many psychiatric settings because of its stigmatized perception by patients and by mental health professionals. ECT seems to be effective for treating major psychiatric disorders during pregnancy, and the risks of adverse events are low. KEYWORDS: ECT • pregnancy • psychiatric disorders • psychopharmacology • side effect

Pregnancy is an important period characterized by physiological, psychological and social changes for women, followed by an increased vulnerability to psychiatric disorders postpartum [1–3]. Psychiatric disorders are common during pregnancy, affecting 15–29% of all pregnant women [4], and the treatment of these disorders can be a difficult task. Furthermore, patients with a previous psychiatric diagnosis can have an exacerbation of their illness during pregnancy, and the risk is considerably higher in the postpartum period [5,6]. Depression is the most common major mental illness during pregnancy. Research suggests that 9% of pregnant women experience an episode of major depression [7,8]. Moreover, after delivery, approximately 50% of pregnant women are found to be depressed [9]. Untreated depression is associated with both poor maternal and neonatal outcomes such as poor weight gain during pregnancy, a higher risk of alcohol and drug abuse, pre-term birth, lower birth weight, preeclampsia and impaired mother–infant bonding [10,11]. Major depression is also commonly associated with an elevated risk for suicide, and this risk is increased if the patient shows psychotic symptoms [12].

10.1586/14737175.2014.972373

In pregnant women, depression has a prevalence of 7% in the first trimester, 13% in the second trimester and 12% in the third trimester [13]. Estimates of the prevalence of bipolar disorder and psychotic disorder are not as well documented [14]. The treatment of depressed pregnant women is complicated by their tendency to discontinue taking antidepressants, resulting in rates of relapse as high as 70% [15]. The best treatment for mental illness during pregnancy remains controversial. Clinicians are often uncertain about prescribing medications during pregnancy, especially in the first trimester, because of their possible teratogenic effects. These adverse effects include malformations (harelip, cleft palate, floppy infant, Ebstein’s anomaly) and cardiac, lung and kidney alterations [16–18]. Furthermore, the physiological changes observed during pregnancy (such as the alteration of the glomerular filtration rate and protein binding) cause an increase in the side effects of drugs in the mother [19], as well as teratogenicity and fetal toxicity [20]. Drugs that involve a teratogenic risk during the first trimester include benzodiazepines, antipsychotics, lithium and other mood stabilizers [20–25].

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ISSN 1473-7175

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Review

Pompili, Dominici, Giordano et al.

After the first trimester, antipsychotics have been found to cause neonatal motor abnormalities [24,25] and gestational diabetes in the mother [26]. Benzodiazepines are associated with neonatal hypotonia, apnea and temperature regulation disorder [24,25]. Trichloroacetic acid treatment has been reported to cause anticholinergic effects and withdrawal symptoms in newborns [23]. Lithium is associated with premature birth, polyhydramnios, neonatal hypothyroidism and lithium toxicity [23]. The use of antidepressants in pregnancy is associated with an increased risk for spontaneous abortion, premature birth, respiratory distress, endocrine and metabolic disorders such as hypoglycemia, temperature regulation disorder, convulsions and jaundice. They are also associated with an increased risk of cardiac septal defects [26]. However, untreated psychiatric disorders are also associated with adverse effects on the mother and fetus. Untreated psychiatric disorders during pregnancy are associated with poor maternal health [27–29] and poor prenatal care [30–32]. The consequences of untreated psychiatric disorder can be severe, with consequences such as lack of weight gain, premature birth, failure to follow medical recommendations, abuse of tobacco, alcohol and other drugs, suicide and infanticide [33–35]. The fetus and neonate may show abnormal intrauterine development and poor cognitive development, as well as behavioral changes later during childhood and adolescence [36–42], and poor nutrition and health [43,44]. The use of electroconvulsive therapy (ECT) for the treatment of major depression and other mental disorders has been well established [45,46], but has been controversial. The American Psychiatric Association practice guidelines [47,48] recommend ECT as an alternative treatment for major depression and bipolar disorder during pregnancy. It has been claimed that ECT is a treatment with good efficacy and low risk during all three trimesters of pregnancy, as well as postpartum [23,49–51]. Furthermore, the American Psychiatric Association revised guidelines for major depressive disorder (April 2000) report that ‘ECT may be used as an alternative treatment during pregnancy’. This revised guideline does state that ECT has the highest rate of response of any form of antidepressant treatment for most populations [52]. The aim of the present paper was to investigate the role of ECT in pregnancy in order to see whether the recommendation for ECT for pregnant women is justified. Materials & methods

The following search terms were used: ‘Electroconvulsive therapy*’ (which comprises ECT, Electroshock and other Electroconvulsive therapy-related terms) and ‘Pregnancy*’ (which comprises gestation, gravidity). Textbooks on psychiatry were also consulted. The selection of papers suitable for this review was restricted to articles published in English peer-reviewed journals. Where a title or abstract seemed to describe a study eligible for inclusion, the full article was obtained and examined to assess its relevance based on the inclusion criteria. Any discrepancies between the two reviewers who, blind to each other, examined the studies for the possible inclusion, were resolved by consultations with the senior authors. In addition, we also examined reference lists and contacted experts in the field. Two reviewers (GD and GG) independently inspected all citations of studies identified by the search and grouped them according to the topic of the papers. Reviewers acquired the full article for all papers located. Where disagreement occurred, this was resolved by discussion with the senior author (MP) who also independently inspected all articles located and grouped them following the major areas of interest identified by the reviewers. If doubt remained, the study was put on the list of those awaiting assessment pending the acquisition of more information. We also consulted a number of international experts in the field to determine whether the studies selected were relevant for discussing the subject matter. The authors and experts who were consulted performed a careful analysis of the literature and agreed on a number of key subjects relevant to the aim of this paper. A review article [54] recently investigated the use of ECT in pregnancy. However, the review by Leiknes et al. was based only on case reports, whereas our review also included retrospective studies (e.g., Bulut et al. [55] who examined six subjects with major depressive disorder, five with bipolar disorder and one with mood disorders not otherwise specified), observational studies by Bulbul et al. [56] on 19 depressed, 18 bipolar and 2 schizophrenic subjects, as well as the assessment of 4 reviews on the same topic [33,57,54,58]. Furthermore, our inclusion criteria were more selective. Specifically, we included only articles in the English language and excluded items related to postpartum period. Overall, our review article differs from that of Leiknes et al. [54] as it includes a more complete view of the research concerning the use of ECT in pregnancy based on different methodologies (e.g., case reports, retrospective and observational studies).

Selection criteria & quality assessment

In order to provide a new and timely systematic review about the use of electroconvulsive therapy during pregnancy, the PRISMA statement for reporting systematic reviews was followed [53]. We performed a careful MedLine, Excerpta Medica, PsycLit, PsycInfo and Index Medicus search to identify all papers and book chapters in English on the topic for the period of 1975–2013. We selected case reports and articles since 1975 to obtain only papers with modified ECT for a more uniform analysis. 1378

Results Search results

The combined search strategies yielded, after duplicates were removed, a total of 184 articles, of which the most relevant articles were selected for this review. We first reviewed the titles and abstracts and applied the selection criteria outlined above with the exception of study design. This process led to the exclusion of 100 studies from the 184 originally selected. Only a few studies were excluded because they were written in a Expert Rev. Neurother. 14(12), (2014)

Who is given ECT during pregnancy?

Anderson and Reti [57] found that the majority of pregnant patients given ECT were treated for major depressive disorder. Regarding the timing of therapy, 15 patients received ECT in the first trimester, 37 in the second trimester and 19 in the third trimester. Leiknes et al. [54] noted that the main diagnostic indication during the years 1970–2013 for ECT treatment during pregnancy was depression/bipolar disorder (63%) but, prior to that (from 1942 until 1970), schizophrenia and other diagnoses were the main indication (54%).

Identification

Records identified through database searching (n = 187)

Review

Additional records identified through other sources (n = 42)

Screening

Records after duplicates removed (n = 184)

Eligibility

language other than English. In the second stage of the screening process, two new reviewers read the full articles and coded them based on the methodology. Studies that did not meet the methodological standards set by the review were excluded. This process led to the exclusion of 47 studies, resulting in the inclusion of 33 clinical studies (31 case reports, 1 retrospective study and 1 observational study) and 4 reviews for the final systematic review. The stages of the screening process are illustrated in FIGURE 1.

Records screened (n = 84)

Records excluded (n = 100)

Full-text articles assessed for eligibility (n = 37)

Full-text articles excluded, with reasons (47)

Clinical-studies included in qualitative synthesis (n = 33) Included


Electroconvulsive treatment during pregnancy

Systematic review and Meta-analysis included into discussion (n = 4)

Figure 1. Flowchart of the search and selection process.

Complications of ECT Effectiveness of ECT

Deaths

Anderson and Reti [57] found that, for pregnant patients given ECT for major depressive disorder, partial remission or better was reported in 78% of all cases where efficacy data were available. Twenty-one pregnant women were treated for schizophrenia or schizophreniform disorder, and partial remission or better was reported in 61% of the women. Bulut et al. [55] retrospectively examined 12 patients with mood disorders who were treated with ECT during pregnancy. The women had a mean age of 28.1 years and received an average of 9.8 ECTs. Their mean Clinical Global Impression score decreased from 6 to 2.6. Bulbul et al. [56] examined 33 women who were admitted as inpatients. After ECT, a complete response to treatment was seen in 84.2% of patients with major depression (n = 16) and a partial response to treatment in 15.8% of patients (n = 3). For women with bipolar disorder, a complete response to treatment was found in 91.7% of the patients (n = 11) and a partial response to treatment in 8.3% of the patients (n = 1). For women with schizophrenia, a complete response to treatment occurred in 50% of the patients (n = 1) and a partial response to treatment in 50% of patients (n = 1).

No deaths in ECT-treated pregnant women were found in any study.


Fetal complications

Miller [50] reported complications associated with ECT in 28 of 300 women. The most common fetal complications were fetal cardiac arrhythmia (1.6%), which included fetal bradycardia, irregular fetal heart rate and reduced variability. These disturbances were transient and self-limiting. There were no complications after the birth. Miscarriage was reported in 1.6% of the cases, but Miller noted that this miscarriage rate was not significantly higher than that for the general population. Stillbirth or neonatal death occurred in 1.0% of the women treated with ECT during pregnancy, probably as a result of medical complications unrelated to the ECT treatment. Premature labor occurred in 1.3% of the women, but labor did not immediately follow the ECT treatment and was probably unrelated to the ECT. Anderson and Reti [57] reviewed 339 cases and found 25 fetal or neonatal complications (11 fetal deaths, 8 babies with transient fetal bradycardia and/or decelerations, 1 case of peritonitis, 1 case with club foot, 1 premature baby, 2 babies with 1379


Review


congenital pulmonary cysts, 1 case of congenital blindness, 2 cases of great vessel transposition, 1 case of aorta coarctation, 1 case of cortical infarcts, 1 case of anencephaly, 1 case of Vater syndrome and 1 case of mental retardation), but only 11 of these, including two deaths, were probably related to ECT. Leiknes et al. [54] noticed that adverse events, such as fetal heart rate reduction, occasionally occurred, but the overall child mortality rate was 7.1% (the mortality rate was 9.4% during 1970–2013 and 6.1% from 1942 to 1970). In a series of 12 women, Bulut et al. [55] found early delivery in one patient and pes ekinovarus deformity in a newborn that was most probably not causally related to ECT. In their series of 33 women, Bulbul et al. [56] had data on 27 of the women. Two babies had problems (one had congenital hip dysplasia and the other had temporary heart failure because of a supraventricular tachycardia after myocarditis), and one was stillborn. Maternal complications

Regarding maternal complications, Miller [50] reported vaginal bleeding in 1.6% of the women. In one case, there was a mild abruptio placentae that caused bleeding; there were cases of rebleeding after each ECT treatment (total of seven treatments). No other source of bleeding was identified for other cases. In another case, the patient had a bleeding similar to the bleeding of a previous pregnancy performed without ECT. In all cases, baby was born healthy. In two cases (0.6%), short uterine contractions after treatment were observed. However, no significant complications were observed. Three cases (1.0%) reported severe abdominal pain related to treatment with ECT. The pain resolved after discontinuation of therapy and the etiology was unknown. In all cases, healthy babies were born. In women with addictions without proper preparation, there was an increased likelihood of aspiration, aortocaval compression and respiratory alkalosis. Anderson and Reti [57] reviewed 339 cases and found that complications occurred in 20 women (1 status epilepticus, 1 hematuria, 2 miscarriages, 12 uterine contractions and/or preterm labor, 2 vaginal bleeding, 1 abdominal pain and 1 placental abruption), of which only 18 seem to be related to the ECT. Leiknes et al. [54] noticed that adverse events, such as vaginal bleeding (during the first trimester), uterine contractions and premature labor, were reported for nearly one-third (29 %) of their cases. Current review

We identified 37 published studies from 1975 to 2013 of pregnant women treated with ECT. The studies consisted of 31 case reports (34 patients, see TABLE 1) and 6 studies of sample of patients (652 patients, see TABLE 2). Efficacy data & main indications

The diagnosis of the patients was: 44.1% major depression (n = 15), 26.5% bipolar disorder (n = 9), 23.5% schizophrenia 1380

or other psychosis (n = 8) and 5.9% ‘other’ (n = 2). The majority of the patients had good results in terms of effectiveness: 61.8% (n = 21) of these clinical cases reported improvement, 17.6% (n = 6) reported improvement although the ECT had been discontinued and 20.6% (n = 7) had no data regarding the efficacy. Complications

We found 22 cases (64.7%) with complications. Most of the complications were mild and limited: 9 transient fetal arrhythmia, 4 alterations in blood pressure in the mother, 2 vaginal bleeding, 2 pelvic pain, 6 uterine contractions and 7 early delivery or caesarean delivery. Serious complications included: 2 prolonged grand mal seizures, 2 deaths of fetus and 2 congenital abnormalities. Two women showed more than one complication. Other complications present in the fetus were multiple cortical infarcts, ascites and transposition of great vessels. The mild complications were well treated in a protected environment, while the most serious complications did not seem to result from the ECT. Discussion

ECT during pregnancy could be a viable alternative in a selected number of patients, and many authors have indicated that ECT is relatively safe and efficacious during all trimesters of pregnancy [51]. To insure safety, treatments should take place in a hospital setting in order to manage any fetal emergencies [50]. The presence of an obstetrician in the medical team is recommended in high-risk patients [59,60]. External fetal cardiac monitoring during the procedure is important because the alterations in fetal heart rate are the most common complications. We found no studies that analyze long-term consequences of ECT in children treated during fetal life with this kind of therapy. Thus, it is not possible to ensure the complete safety of ECT during pregnancy. Many authors have documented the efficacy of ECT during pregnancy. ECT is an effective treatment during pregnancy for the following disorders: major depressive disorder, bipolar disorder and psychosis [50,55–57]. Depressed women treated with ECT have a full or partial response to treatment in 84% of cases, and for schizophrenic women this rate is 61%. These results are similar to response rates in non-pregnant samples of depressed and schizophrenic women [61–63]. In addition, ECT acts more quickly than pharmacotherapy such as antidepressants [64]. On the other hand, some authors have noted several adverse effects of ECT for the mother and the child. General adverse effects like confusion, memory loss, muscle soreness and headache can occur post-ECT in any patient and, in pregnant women, these seem to become worse with continuing treatment [65,66]. Fetal bradyarrhythmia is the most common problem in the fetus caused by ECT [50,54,57,67], while vaginal bleeding, uterine contractions and induction of premature labor seems to be the most frequent adverse maternal events in ECT [50,57,54–56]. Expert Rev. Neurother. 14(12), (2014)


n=1 Bipolar disorder, depressive episode

n=1 Major depression disorder

n=1 Bipolar disorder (depressive episode)

n=1 Bipolar disorder, manic episode

n=1 Schizophrenia



n=1 Bipolar disorder


De Asis et al. (2013)

Gahr et al. (2012)

Salzbrenner et al. (2011)

Lovas et al. (2011)

Yang et al. (2011)

O’Reardon et al. (2011)

Pesiridou et al. (2010)

Ghanizadeh et al. (2009)

Ceccaldi et al. (2008)

Unknown

1st–2nd

9

10

3rd

6

3rd

2nd

18

2nd–3rd

Unknown

12

3rd

3rd

Unknown

2

2nd

2nd

Number of cycles

Pregnancy trimester

Mother: threat of premature birth Fetus: no complications

Mother: vaginal bleeding after each session of ECT Fetus: no complications

Mother: premature uterine contractions Fetus: no complications

Mother: cesarean delivery Fetus: no complications

Mother: no complications Fetus: no complications

Mother: cesarean delivery for preeclampsia Fetus: no complications

Mother: cesarean delivery for preeclampsia Fetus: no complications


Mother: prolonged grand mal seizure Fetus: transient fetal bradycardia

Complications

ECT: Electro convulsive therapy; OCD: Obsessive–compulsive disorder; rTMS: Repetitive transcranial magnetic stimulation.

Sample number and diagnosis

Study (year)

Table 1. Case reports.

[84]

ECT was effective to treat Bipolar disorder during pregnancy

[89]

[88]

Potential maternal problem of vaginal bleeding as a result of ECT The occurrence of any superimposed obstetrical pathology (preeclampsia, premature delivery) should preclude ECT treatment. Given the possible complications, it requires strict supervision of the pregnancy in a hospital setting

[87]

[86]

Good antidepressant response to ECT Premature contractions in association with ECT during the third trimester of pregnancy may be delayed. Patients and treatment team need to be aware of this possibility, particularly when ECT is conducted on an outpatient basis

ECT was effective and safe for treating severe major depression during pregnancy

[85]

[83]

ECT was effective to treat maternal bipolar depression during pregnancy

ECT during pregnancy was effective and safe

[82]

[81]

Ref.

Successful treatment with ECT; no response to rTMS

ECT has been demonstrated to be relatively safe. One risk to the fetus is cardiac deceleration during the grand mal seizure. A change of anesthetic agent from methohexital to propofol attenuated the seizure duration resulting in the elimination of further events of fetal cardiac deceleration and a successful outcome for both mother and fetus

General findings



Review

1381

1382



n=1 Psychotic episode (malignant catatonia)

n=1 Bipolar disorder



n=1 OCD

n=1 Schizophrenia

Kasar et al. (2007)

Pinette et al. (2007)

Espıńola-Nadurille et al. (2007)

Balki et al. (2006)

Prieto Martin et al. (2006)

DeBattista et al. (2003)

Fukuchi et al. (2003)

Ishikawa et al. (2001)

3rd

3rd

Unknown

1st–2nd

3rd

2rd

3

6

2

5

9

3

Unknown

7

3rd

Unknown

4

13

Number of cycles

3rd

1st–2nd

Pregnancy trimester

Mother: patient A experienced uterine contractions. Patient B no complications Fetus: Fetus A decreased fetal heart rate variability and uterine contractionrelated late cardiac deceleration. Fetus B no complications

Mother: uterine contraction refractory to tocolysis Fetus: fetal bradycardia

Mother: abnormal uterine contractions Fetus: late deceleration on the fetal cardiotocogram occurred, but rapid intravenous administration of ritodrine led to the cessation of abnormal uterine contraction

Mother: no complications Fetus: Brief fetal heart rate decelerations associated with maternal ECT-induced convulsions


Mother: status epilepticus Fetus : died


Mother: no complications Fetus: multiple cortical, deep hemispheric and cerebellar infarcts

Mother: premature labor Fetus: no complications

Mother: pelvic pain Fetus: transient fetal arrhythmia

Complications


n=2 Major depression disorder (patient A) Diagnosis = major depression disorder and panic disorder (patient B)


Bozkurt et al. (2007)

Bhatia et al. (1999)


Study (year)

Table 1. Case reports (cont.).

[96]

[97]

Modified ECT can be an alternative treatment for pregnant patients with OCD

Inhalation anesthesia is beneficial for ECT in the last stage of pregnancy to reduce uterine contractions caused by potential uterine relaxation effect of anesthetics

[98]

[95]

ECT during pregnancy should be performed with caution


[94]

[93]

ECT is effective and safe

Discusses the possible causes and the management of status epilepticus after ECT during pregnancy and its implications for maternal and fetal outcome

[92]

[91]

ECT during pregnancy should be performed with caution ECT is effective

[90]

[71]

Ref.

ECT is a relatively safe and effective treatment during pregnancy if steps are taken to decrease potential risks

Acute and maintenance ECT may be the choice of treatment in pregnant patients who are severely depressed or psychotic

General findings


Review Pompili, Dominici, Giordano et al.

Expert Rev. Neurother. 14(12), (2014)


n=1 Bipolar disorder with psychotic symptoms

n=1 Schizophrenia






n=1 Psychosis and homicidal impulses



Gilot et al. (1999)

Polster and Wisner (1999)

Moreno et al. (1998)

Livingston et al. (1994)

Sherer et al. (1991)

Yellowlees and Pages (1990)

Griffiths et al. (1989)

Varan et al. (1985)

Repke and Berger (1989)

Wise et al. (1984)

3rd

12

5

12

1st–2nd

2nd–3rd

6

9

7

8

3

2nd–3rd

3rd

3rd

1st

1st

Unknown

9

2nd

3rd

Number of cycles

Pregnancy trimester



Mother: no complications Fetus: transient fetal arrhythmia



Mother: uterine contractions and active uterine bleeding, possibly representing recurrent abruptio placentae occurring in association with the treatment. Transient acute episodes of maternal hypertension between 180/90 and 190/ 100 mmHg, were documented within minutes after application of each electroconvulsive treatment. Fetus: no complications

Mother: no complications Fetus: Twin A had transposition of great vessels (died) twin B had aorta coarctation (both noted pre-ECT) (survived)

Mother: no complications Fetus: Spontaneous abortion

Mother: Preterm labor Fetus: neonatal bradycardia

Mother: emergency caesarean Fetus: fetal ascites, died 9 days later

Complications



Study (year)


[74]


ECT is safe and effective

ECT has little effect on fetal status

Without adverse effect to the mother and the baby, there is a risk–benefit advantage to ECT use

There are acute neurohumoral changes in specific hormones associated with ECT in pregnancy, but none of these changes appeared to adversely affect the fetus

[107]

[106]

[105]

[104]

[103]

[102]

ECT during pregnancy improves maternal condition and does not adversely affect fetal wellbeing

ECT was highly effective and careful monitoring of both the mother and the fetus demonstrated that this was a safe procedure

[101]

[100]

[99]

Ref.

ECT during pregnancy is controversial


ECT during pregnancy is controversial

General findings



Review

1383


[109]

ECT was highly effective and careful monitoring of both the mother and the fetus demonstrated that this was a safe procedure Unknown 3rd n=1 Unknown Levine and Frost (1975)

Mother: alterations in blood pressure and heart rate. Fetus: fetal arrhythmia occurred, apparently unrelated to changes in maternal PaO2, and resolved spontaneously

[108]

ECT is effective 5-6-6 2nd–3rd n=3 Schizophreniform disorder (patient A) Schizophrenia (patient B) Diagnosis = schizophrenia (patient C) Loke and Salleh (1983)


General findings Number of cycles Pregnancy trimester Sample number and diagnosis

Complications 1384


Study (year)



Ref.

Review

Transient fetal heart rate decreases probably result mainly from hypoxia [68]. The electroconvulsive current does not pass through the uterus [69,70], and so other physiological and pathophysiological factors have to be considered as causes for this problem. Some studies propose that ECT can increase the risk of fetal and maternal cerebral hemorrhage and bronchospasm and cardiac events during pregnancy [71,72]. However, other authors disagree on this [73]. In one patient with severe psychotic depression unresponsive to pharmacotherapy, ECT was followed by uterine contractions and vaginal bleeding. The same patient had also transient acute hypertension episodes (between 180/90 and 190/100 mmHg) [74]. Electroconvulsive therapy appears to be a relatively safe and efficient treatment in pregnant women if some security measures are taken to limit the potential risks. These security measures should include: pelvic examination, discontinuation of anticholinergic drugs (if not needed), uterine tocodynamometry, intravenous hydration and administration of antacid. In addition, external fetal cardiac monitoring, elevation of the pregnant woman’s right hip, intubation and reduction of excessive hyperventilation are recommended. Moreover, the informed consent for this type of treatment should include the patient’s capacity to understand and evaluate the risks and benefits for themselves and for the fetus [50]. In addition, the role of anesthetic agents used for ECT should be analyzed. Methohexital sodium and propofol, the two most common anesthetic agents used for ECT [75], are drugs with short-acting effects, but they can cross the placental barrier [76,77]. Furthermore, blood levels of these drugs in the fetus and newborn are associated with maternal serum levels [78,79]. The incidence of fetal malformations after ECT during all trimesters of pregnancy, in comparison to control populations, was lower [80]. Based on the number and pattern of congenital anomalies in the examined cases, ECT does not appear to have an associated teratogenic risk. Furthermore, in the cases examined, stillbirth or neonatal death was not directly related to ECT but rather to other medical conditions [50]. Although the effectiveness of ECT during pregnancy has been established, it is not commonly recommended as the first line of treatment for pregnant women. More studies are needed to determine the comparison between ECT and pharmacotherapy in terms of effectiveness and safety. Limitations

This review has several limitations. First, the review is based on case reports and two retrospective studies. The case reports are not homogeneous, and the treatments were carried out in different historical periods. In retrospective studies, clinical variables are not always readily available. We did not carry out a meta-analysis because the data from most of the studies did not permit such an approach. The studies used different measures and different outcomes, assessed patients at different time Expert Rev. Neurother. 14(12), (2014)


Retrospective study

Observational study

Systematic review 67 case reports

Systematic review 339 case reports

Review of 4 case reports

Review of 300 case reports

Bulut et al. (2013)

Bulbul et al. (2013)

Leiknes et al. (2013)

Anderson and Reti (2009)

Maletzky (2004)

Miller (1993)

ECT: Electroconvulsive therapy.

Study design

Study (year)

n = 300

n = 4 Mood disorder

n = 68 diagnosis data n = 7 Bipolar disorder n = 37 Major depression disorder n = 18 Schizophrenia n = 3 schizoaffective n = 1 psychosis (undefined)

n = 169 Mood disorder

n = 19 Major depression disorder n = 12 Bipolar disorder n = 2 Schizophrenia

n = 6 Major depression disorder n = 5 Bipolar disorder (2 depressive episode; 3 manic episode) n = 1 Mood disorder not otherwise specified


Table 2. Studies of samples of patients.

1st-2nd-3rd

1st-2nd-3rd

Unknown

Unknown

10.8

1st-2nd-3rd

Unknown

1st-2nd-3rd

9.4

3–20

1st-2nd-3rd

1st-2nd-3rd

Number of cycles

Pregnancy trimester

Mothers: 28 had complications associated with ECT: mild vaginal bleeding; abdominal pain and selflimited uterine contractions. Without proper preparation, there was also increased likelihood of aspiration, aortocaval compression and respiratory alkalosis Fetuses: transient fetal arrhythmia

Mothers: no complications Fetuses: no data

Mother: pregnancy was complicated in 20 women: status epilepticus, hematuria, miscarriage; uterine contractions; preterm labor; vaginal bleeding; abdominal pain; placental abruption Fetus: fetal or neonatal complications in 25 fetuses; death; transient fetal bradycardia; other abnormality

Mother: uterine contractions 29% Fetus: missing data 12%; fetal heart rate reduction and premature labor 29%. Child mortality rate 7.1%

Mother: no complications Fetus: 1 stillbirth; 2 diseases after birth

Mother: 1 early delivery fetus: 1 pes ekinovarus deformity (probably not related to ECT)

Complications

[33]

[57]

ECT seems to be effective for treating major mental illness during pregnancy and the risks of adverse events are low

ECT is a relatively safe and effective treatment during pregnancy if steps are taken to decrease potential risks

[54]

ECT during pregnancy should be considered only as last resort treatment under very stringent diagnostic and clinical indications

[58]

[56]

ECT during pregnancy to treat psychiatric disorders was an effective treatment. No risk of preterm birth

ECT is safe and effective

[55]

Ref.

ECT effective and safe in pregnant women with mood disorders

General findings



Review

1385

Review


points and had a number of methodological problems which often made the results difficult to interpret. Moreover, the studies considered only inpatients, analyzed only a few variables and did not include a control group. Finally, there are a limited number of articles in the literature concerning the topic of this review.


Conclusion

The most common indication for ECT in pregnant women is non-response to or intolerance of antidepressants or other psychotropic medication. Therefore, its use should be evaluated in patients who cannot continue medical treatment for their disorder (major depression, bipolar disorder, suicidal crises) or to prevent the side effect of psychiatric drugs in the mother and teratogenicity and toxicity consequences in the fetus. ECT should be considered more often than is the case currently in pregnant women because of the lack of teratogenic effects on the fetus. Given current knowledge, no treatment regimen can be considered completely safe. ECT may cause some risk to the fetus (cesarean delivery, transient fetal arrhythmia, etc.) and to the mother (uterine contractions, mild vaginal bleeding, abdominal pain, transient acute episodes of maternal hypertension, etc.) but, according to the studies reviewed here, is relatively safe and effective and could be a viable alternative in a selected number of pregnant women. Expert commentary

Pregnancy is an important event with an increased vulnerability to psychiatric disorders. Psychiatric disorders are common during pregnancy, affecting 15–29% of all pregnant women. The most frequent diagnoses in pregnant women are major depression, bipolar disorders and schizophrenia or other psychosis. Major depression is associated with an elevated risk of suicide, and this risk is increased if the patients show psychotic symptoms. Although pregnancy is a common condition in women, few studies on maternal and child complications have been conducted during this period. The treatment of these disorders during pregnancy can be a difficult task. In fact, the physiological changes observed during this period (such as the alteration of the glomerular filtration rate and protein binding) cause an increase in the side effect of drugs in the mother, as well as teratogenicity and fetal toxicity. ECT is also associated with side effects, but most of the complications are mild and limited (e.g., fetal arrhythmia, alterations

in blood pressure in mother, vaginal bleeding, pelvic pain, uterine contraction and delivery or caesarean delivery). The anesthetic agents used for ECT (methohexital sodium and propofol) are drugs with short-acting effects, but they can cross placental barrier. Clinicians are often uncertain about prescribing medications during pregnancy, especially in the first trimester, but many clinicians have indicated that ECT is safe during all trimesters of pregnancy. Woman treated with ECT have a high full or partial response to treatment, and the outcomes are similar to response rates in nonpregnant samples. Electroconvulsive therapy appears to be relatively safe and effective during pregnancy, but more research is needed on this topic. Five-year view

Recent research reports that ECT has an important role nowadays. Far from being a disused practice, ECT now appears to reduce the mortality rate from all causes, including suicide, in patients with post-traumatic stress disorder and major depressive disorder when comparing the mortality rates with patients suffering from the same disorders who did not receive ECT1 ECT was occasionally misused in the past, and there is still opposition toward ECT, but it is now time to inform clinicians that proper application of ECT should constitute one part of the clinical armamentarium. During pregnancy, the clinical challenges are particularly difficult and pose ethical dilemmas, but we need to provide the best therapy for each individual and, regardless of prejudices, the patient’s health and safety is our primary goal. Over the next 5 years, we believe new research should lead to the development of protocols and guidelines to help clinicians in their decision-making. If new research provides evidence that ECT has, even a modest role to play in selective cases, ECT should become a more common treatment. Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending or royalties. No writing assistance was utilized in the production of this manuscript.

1

Dr. Naser Ahmadi and colleagues. American Psychiatric Association 2014 Annual Meeting. Abstract SCR14-4. Presented Monday, 5 May 2014. 1386



Review

Key issues • Severe psychiatric disorders are relatively common during pregnancy, with some studies reporting a morbidity of 15–29% among all pregnant women. • Pharmacological treatment of severe psychiatric disorders during pregnancy is complicated by the potential harmful effects of the treatment for the fetus (e.g., teratogenicity, toxicity and withdrawal syndromes). • Many authors have indicated the efficacy and the safety of electroconvulsive therapy (ECT) during all trimesters of pregnancy.


• Depressed women treated with ECT have a full or partial response to treatment in 84% of cases. In schizophrenic women treated with ECT, this rate of response is 61%. • The most common adverse effects in mothers are confusion, memory loss, muscle soreness, headache, hypertension, vaginal bleeding, placental abruption, uterine contractions and induction of premature labor. • The most common adverse effects in the fetus are transient fetal heart rate decreases, multiple cortical infarcts, ascites, transposition of great vessels, stillbirth and neonatal death. • The indication for ECT in pregnant women is to replace drug therapy in patients who cannot continue pharmacological treatment for their disorder (major depression, bipolar disorder, suicidal crises) or to prevent the side effects of psychiatric drugs in the mother and teratogenicity and toxicity in the fetus. • The efficacy and safety of ECT seems good as compared with pharmacotherapy.

pregnancies ending in live births. Am J Psychiatry 2007;164:1515-20

References Papers of special note have been highlighted as: • of interest •• of considerable interest 1.

2.

3.

4.

5.

Cox JL. Psychiatric morbidity and pregnancy: a controlled study of 263. semi-rural Ugandan women. Br J Psychiatry 1979;134:401-5 Cooper PJ, Campbell EA, Day A, et al. Non-psychotic psychiatric disorder after childbirth. A prospective study of prevalence, incidence, course and nature. Br J Psychiatry 1988;152:799-806 Munk-Olsen T, Laursen TM, Pedersen CB, et al. New parents and mental disorders: a population-based register study. JAMA 2006;296:2582-9

11.

Nonacs R, Cohen LS. Assessment and treatment of depression during pregnancy: an update. Psychiatr Clin North Am 2003;26:547-62

12.

Brockington IF, Kumar R. Drug addiction and psychotropic drug treatment during pregnancy and lactation. In: Brockington IF , Kumar R, editors. Motherhood and Mental Illness. Academia Press, Inc; London: 1982

13.

Bennett HA, Einarson A, Taddio A, et al. Prevalence of depression during pregnancy: systematic review. Obstet Gynecol 2004;103:698-709

17.

Shiono PH, Mills JL. Oral cleft and diazepam use during pregnancy. N Engl J Med 1984;311:919-20

18.

Laegreid L, Olegard R, Conradi N, et al. Congenital malformations and maternal consumption of benzodiazepines: a case-control study. Dev Med Child Neurol 1990;32:432-41

19.

Elrad H, Gleicher N. Physiologic changes in normal pregnancy. In: Gleicher N, editor. Principals of medical therapy in pregnancy. Plenum Press; New York (NY): 1985

20.

Miller LJ. Clinical strategies for the use of psychotropic drugs during pregnancy. Int J Psychiatry Med 1991;9:275-98

21.

Delgado - Escueta AV, Janz D. Consensus guide lines: preconception counseling, management and care of the pregnant woman with epilepsy. Neurology 1992;42: 149-60

14.

Santvana S, Shamsah SP, Firuza P, Rajesh P. Psychiatric disorders associated with pregnancy. J Obstet Gynecol India 2005;55: 218-27

Gold KJ, Marcus SM. The effect of maternal mental illness on pregnancy outcomes. Expert Rev Obstet Gynecol 2008;3:391-401

22.

•

An important review that shows the mental and physical risks of lack of treatment in pregnant women with psychiatric disorders.

Chambers CD, Johnson KA, Dick LM, et al. Birth out comes in pregnant women taking fluoxetine. N Eng J Med 1996;335: 1010-15

23.

15.

Cohen L, Altshuler L, Harlow B, et al. Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment. JAMA 2006;295:499-507

Altshuler LL, Cohen L, Szuba MP, et al. Pharmacological management of psychiatric illness during pregnancy: dilemmas and guide lines. Am J Psychiatry 1996;153: 592-606

24.

•

A good comparative study that underlies the importance of treatment during pregnancy.

Miller LJ. Pharmacotherapy during the perinatal period. Dir Psychiatry 1998;18: 49-64

Carter D, Kostaras X. Psychiatric disorders in pregnancy. BCMJ 2005;47:96-9

7.

Wisner KL, Gelenberg AJ, Leonard H, et al. Pharmacologic treatment of depression during pregnancy. JAMA 1999;282:1264-9

9.

Kurki T, Hiilesmaa V, Raitasalo R, et al. Depression and anxiety in early pregnancy and risk for preeclampsia. Obstet Gynecol 2000;95:487-90

Patel DA, Patel AR. Letter chlorazepate and congenital malformations [letter]. JAMA 1980;244:135-6

Vesga-Lo´pez O, Blanco C, Keyes K, et al. Psychiatric disorders in pregnant and postpartum women in the United States. Arch Gen Psychiatry 2008;65:805-15

6.

8.

10.

16.

O’Hara MW, Neunaber DJ, Zekoski EM. Prospective study of postpartum depression: prevalence, course, and predictive factors. J Abnorm Psychol 1984;93:158-71 Dietz PM, Williams SB, Callaghan WM, et al. Clinically identified maternal depression before, during and after


1387


Review


25.

Cohen LS, Rosenbaum JF. Psychotropic drug use during pregnancy: weighing the risks. J Clin Psychiatry 1998;59:18-28

26.

Oyebode F, Rastogi A, Berrisford G, Coccia F. Psychotropics in pregnancy: safety and other considerations. Pharmacol Ther 2012;135:71-7

37.

38.

O’Connor TG, Heron J, Golding J, Glover V. Maternal antenatal anxiety and behavioural/emotional problems in children: a test of a programming hypothesis. J Child Psychol Psychiatry 2003;44:1025-36 Huot RL, Brennan PA, Stowe ZN, et al. Negative affect in offspring of depressed mothers is predicted by infant cortisol levels at 6. months and maternal depression during pregnancy, but not postpartum. Ann N Y Acad Sci 2004;1032:234-6

27.

Kurki T, Hiilesmaa V, Raitasalo R, et al. Depression and anxiety in early pregnancy and risk for preeclampsia. Obstet Gynecol 2000;95:487-90

28.

Kelly RH, Russo J, Katon W. Somatic complaints among pregnant women cared for in obstetrics: normal pregnancy or depressive and anxiety symptom amplification revisited? Gen Hosp Psychiatry 2001;23:107-13

39.

29.

Fitzsimons HE, Tuten M, Vaidya V, Jones HE. Mood disorders affect drug treatment success of drug-dependent pregnant women. J Subst Abuse Treat 2007;32(1):19-25

40.

30.

Kelly RH, Danielson BH, Zatzick DF, et al. Chart-recorded psychiatric diagnoses in women giving birth in California in 1992. Am J Psychiatry 1999;156:955-7

Punamaki RL, Repokari L, Vilska S, et al. Maternal mental health and medical predictors of infant developmental and health problems from pregnancy to one year: does former infertility matter? Infant Behav Dev 2006;29:230-42

41.

Repokari L, Punamaki RL, Poikkeus P, et al. Ante- and perinatal factors and child characteristics predicting parenting experience among formerly infertile couples during the child’s first year: a controlled study. J Fam Psychol 2006;20:670-9

31.

32.

33.

•

34.

35.

36.

Kelly RH, Danielsen BH, Golding JM, et al. Adequacy of prenatal care among women with psychiatric diagnoses giving birth in California in 1994. and 1995. Psychiatr Serv 1999;50:1584-90 Kim HG, Mandell M, Crandall C, et al. Antenatal psychiatric illness and adequacy of prenatal care in an ethnically diverse inner-city obstetric population. Arch Womens Ment Health 2006;9:103-7 Miller LJ. Psychiatric disorders during pregnancy. In: Stewart DE, Stotland NL, editors. Psychological aspects of women’s health care: the inter face between psychiatry and obstetrics and gynecology. American Psychiatric Press; Washington (DC): 1993 A good edition that analyzes the importance of interfacing among psychiatrists, gynecologists and obstetricians in the women’s health care. Richards D. Is electroconvulsive therapy in pregnancy safe? Obstet Gynecol 2007; 110(2. Pt 2):451-2

42.

43.

44.

45.

1388

Weinstock M. Gender Differences in the Effects of Prenatal Stress on Brain Development and Behaviour. Neurochem Res 2007;32(10):1730-40 Monuteaux MC, Blacker D, Biederman J, et al. Maternal smoking during pregnancy and offspring overt and covert conduct problems: a longitudinal study. J Child Psychol Psychiatry 2006;47:883-90 Connor PD, Sampson PD, Streissguth AP, et al. Effects of prenatal alcohol exposure on fine motor coordination and balance: a study of two adult samples. Neuropsychologia 2006;44(5):744-51 Potter WZ, Rudorfer MW. Electroconvulsive therapy – a modern medical procedure. N Engl J Med 1993;328:882-3

46.

Fink M, Indications for use of ECT. Psychopharmacol Bull 1994;30:269-75

47.

American Psychiatric Association. Practice guidelines for major depressive disorder in adults. Am J Psychiatry 1993;150(Suppl): 1-26

Pearlstein T. Perinatal depression: treatment options and dilemmas. J Psychiatry Neurosci 2008;33:302-18 Weinberg MK, Tronick EZ. Emotional characteristics of infants associated with maternal depression and anxiety. Pediatrics 1998;102:1298-304

Brand SR, Engel SM, Canfield RL, Yehuda R. The effect of maternal PTSD following in utero trauma exposure on behavior and temperament in the 9-month-old infant. Ann N Y Acad Sci 2006;1071:454-8

48.

American Psychiatric Association; Practice guidelines for the treatment of patients with bipolar disorder. Am J Psychiatry 1994; 151(Suppl):1-26

49.

Walker R, Swartz CM. Electroconvulsive therapy during high risk pregnancy. Gen Hosp Psychiatry 1994;16:348-53

50.

Miller LJ. Use of electroconvulsive therapy during pregnancy. Hosp Community Psychiatry 1994;45(5):444-50

51.

American Psychiatric Association; A task force report on the practice of electroconvulsive therapy: recommendations for treatment, training, and privileging. 2nd edition American Psychiatric Association; Washington, DC: 2001

52.

American Psychiatric Association. Practice guideline for the treatment of patients with major depressive disorder (revision). Am J Psychiatry 2000;157(4 Suppl):1-45

53.

Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ 2009;339:b2700

54.

Leiknes KA, Cooke MJ, Jarosch-von Schweder L, et al. Electroconvulsive therapy during pregnancy: a systematic review of case studies. Arch Womens Ment Health 2013

••

One of the most recent review about the role of ECT treatment during pregnancy.

55.

Bulut M, Bez Y, Kaya MC, et al. Electroconvulsive therapy for mood disorders in pregnancy. JECT 2013;29(2):19-20

••

A new retrospective study that examines the use of ECT in pregnant women with mood disorders.

56.

Bulbul F, Copoglu US, Alpak G, et al. Electroconvulsive therapy in pregnant patients. Gen Hosp Psychiatry 2013;35(6):636-9

••

A new observational study that explores the effectiveness and safety of ECT during pregnancy.

57.

Anderson EL, Reti IM. ECT in pregnancy: a review of the literature from 1941 to 2007. Psychosom Med 2009;71(2):235-42

••

A good systematic review that investigates the incidence of adverse effects in ECT treatment during pregnancy.

58.

Maletzky BM. The first-line use of electroconvulsive therapy in major affective disorders. JECT 2004;20(2):112-17

59.

Lamprecht HC, Ferrier IN, Swann AG. The use of ECT in depressive illness. In: Scott AIF, editor. The ECT handbook - The third report of the Royal College of Psychiatrists’ Special Committee on ECT. 2nd edition Bell & Bain; London: 2005. p. 9-24



60.

61.


62.

Heath C, Yonkers KA. Somatic treatments in depression: concerns during pregnancy and breastfeeding. In: Yonkers KA, Little BB, editors. Management of psychiatric disorders in pregnancy. Arnold; London: Oxford: 2001. p. 82-104

75.

Abrams R. Electroconvulsive Therapy. 4th edition Oxford University Press; New York: 2002

76.

Persad E. Electroconvulsive therapy in depression. Can J Psychiatry 1990;35:175-82

Jauniaux E, Gulbis B, Shannon C, et al. Placental propofol transfer and fetal sedation during maternal general anaesthesia in early pregnancy. Lancet 1998;352:290-1

77.

Pagnin D, de Queiroz V, Pini S, Cassano GB. Efficacy of ECT in depression: a meta-analytic review. J ECT 2004;20: 13-20

Herman NL, Li AT, Van Decar TK, et al. Transfer of methohexital across the perfused human placenta. J Clin Anesth 2000;12: 25-30

78.

Holdcroft A, Robinson MJ, Gordon H, Whitwam JG. Comparison of effect of two induction doses of methohexitone on infants delivered by elective caesarean section. Br Med J 1974;2:472-5

79.

Sanchez-Alcaraz A, Quintana MB, Laguarda M. Placental transfer and neonatal effects of propofol in caesarean section. J Clin Pharm Ther 1998;23:19-23

63.

Tharyan P, Adams CE. Electroconvulsive therapy for schizophrenia. Cochrane Database Syst Rev 2002;(2):CD000076

64.

UK ECT Review Group. Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis. Lancet 2003;361:799-808

•• 65.

66.

67.

68.

A good systematic review that studies the use of ECT in depressive disorders. Forssman H. Follow-up study of sixteen children whose mothers were given electric convulsive therapy during gestation. Acta Psychiatr Neurol Scand 1955;30:437-41 Impastato DJ, Gabriel AR, Lardaro HH. Electric and insulin shock therapy during pregnancy. Dis Nervous Sys 1964;25:542-6

69.

Goldman RD, Einarson A, Koren G. Electric shock during pregnancy. Can Fam Physician 2003;49:297-8

70.

Lam CM, Chow KM. Electric shock during pregnancy. Can Fam Physician 2003;49:737

71.

Bozkurt A, Karlidere T, Isintas M, et al. Acute and maintenance electroconvulsive therapy for treatment of psychotic depression in a pregnant patient. J ECT 2007;23:185-7

72.

87.

Pesiridou A, Baquero G, Cristancho P, et al. A case of delayed onset of threatened premature labor in association with electroconvulsive therapy in the third trimester of pregnancy. J ECT 2010;26(3): 228-30

88.

Ghanizadeh A, Ghanizadeh MJ, Moini R, Ekramzadeh S. Association of vaginal bleeding and electroconvulsive therapy use in pregnancy. J Obstet Gynaecol Res 2009; 35(3):569-71

89.

Ceccaldi PF, Dubertret C, Keita H, Mandelbrot L. Use of sismotherapy during pregnancy for severe depression. Gynecol Obstet Fertil 2008;36(7-8):773-5

90.

Kasar M, Saatcioglu O, Kutlar T. Electroconvulsive therapy use in pregnancy. J ECT 2007;23(3):183-4

91.

Nelson K, Holmes LB. Malformations due to presumed spontaneous mutations in newborn infants. N Engl J Med 1989;320:19-23

Pinette MG, Santarpio C, Wax JR, Blackstone J. Electroconvulsive therapy in pregnancy. Obstet Gynecol 2007; 110(2 Pt 2):465-6

92.

81.

De Asis SJ, Helgeson L, Ostroff R. The use of propofol to prevent fetal deceleration during electroconvulsive therapy treatment. JECT 2013. 29(4

Espıńola-Nadurille M, Ramı´rez-Bermu´dez J, Fricchione GL. Pregnancy and malignant catatonia. Gen Hosp Psychiatry 2007;29(1): 69-71

93.

82.

Gahr M, Blacha C, Connemann BJ, et al. Successful treatment of major depression with electroconvulsive therapy in a pregnant patient with previous non-response to prefrontal rTMS. Pharmacopsychiatry 2012; 45(2):79-80

Balki M, Castro C, Ananthanarayan C. Status epilepticus after electroconvulsive therapy in a pregnant patient. Int J Obstet Anesth 2006;15(4):325-8

94.

Prieto Martin RM, Palomero Rodriguez MA, de Miguel Fernandez P, et al. Electroconvulsive therapy in the third trimester of pregnancy: a case report. Rev Esp Anestesiol Reanim 2006;53(10):653-6

95.

DeBattista C, Cochran M, Barry JJ, Brock-Utne JG. Fetal heart rate decelerations during ECT-induced seizures: is it important? Acta Anaesthesiol Scand 2003;47(1):101-3

96.

Fukuchi T, Okada Y, Katayama H, et al. A case of pregnant woman with severe obsessive-compulsive disorder successfully treated by modified-electroconvulsive therapy. Seishin Shinkeigaku Zasshi 2003; 105(7):927-32

97.

Ishikawa T, Kawahara S, Saito T, et al. [Anesthesia for electroconvulsive therapy during pregnancy–a case report]. Masui 2001;50(9):991-7

98.

Bhatia SC, Baldwin SA, Bhatia SK. Electroconvulsive therapy during the third trimester of pregnancy. J ECT 1999;15(4): 270-4

99.

Gilot B, Gonzalez D, Bournazeau JA, et al. Case report: electroconvulsive therapy during pregnancy. Encephale 1999;25(6):590-4

80.

Minick G, Atlas M. What’s the best strategy for bipolar disorder during pregnancy? J Fam Practice 2007;56:665-8 Freeman RK, Garite TJ, Nageotte MP. Fetal Heart Rate Monitoring. 3rd edition Williams & Wilkins; Baltimore: Lippincott: 2003

Tecoult E, Nathan N. Morbidity in electroconvulsive therapy. Eur J Anaesthesiol 2001;18:511-18

73.

Abrams R. Unsupported claims of ECT risk. letter to the editor JECT 2005;21:253

74.

Sherer DM, D’Amico ML, Warshal DP, et al. Recurrent mild abruptio placentae occurring immediately after repeated electroconvulsive therapy in pregnancy. Am J Obstet Gynecol 1991;165:652-3


Review

83.

••

Salzbrenner S, Breeden A, Jarvis S, Rodriguez W. A 48-year-old woman primigravid via in vitro fertilization with severe bipolar depression and preeclampsia treated successfully with electroconvulsive therapy. J ECT 2011;27(1):1-3 The only case report that analyzes the suicide risk in a pregnant woman treated with ECT.

84.

Lovas A, Almos PZ, Peto Z, et al. Anesthesia for electroconvulsive therapy in early pregnancy. J ECT 2011;27(4):328-30

85.

Yang HS, Seo HJ, Lee YK. Anesthetic care for electroconvulsive therapy during pregnancy -A case report-. Korean J Anesthesiol 2011;60(3):217-20

86.

O’Reardon JP, Cristancho MA, von Andreae CV, et al. Acute and maintenance electroconvulsive therapy for treatment of severe major depression during the second and third trimesters of pregnancy with infant follow-up to 18. months: case report and review of the literature. J ECT 2011;27(1):23-6

1389

Review 100.

Polster DS, Wisner KL. ECT-induced premature labor: a case report. J Clin Psychiatry 1999;60(1):53-4

101.

Moreno ME, Munõz JM, Valderrabanos JS, Gutierrez TV. Electroconvulsive Therapy in the First Trimester of Pregnancy. JECT 1998;14(4):251-4

102.



103.

Livingston JC, Johnstone WM Jr, Hadi HA. Electroconvulsive therapy in a twin pregnancy: a case report. Am J Perinatol 1994;11(2):116-18 Yellowlees PM, Page T. Safe use of electroconvulsive therapy in pregnancy. Med J Aust 1990;153(11-12):679-80

1390

104.

Griffiths EJ, Lorenz RP, Baxter S, Talon NS. Acute neurohumoral response to electroconvulsive therapy during pregnancy. A case report. J Reprod Med 1989;34(11): 907-11

105.

Varan LR, Gillieson MS, Skene DS, Sarwer-Foner GJ. ECT in an acutely psychotic pregnant woman with actively aggressive (homicidal) impulses. Can J Psychiatr Rev Can Psychiatr 1985;30(5):363-7

106.

Repke JT, Berger NG. Electroconvulsive therapy in pregnancy. Obstet Gynecol 1984; 63(3 Suppl):39S-41S

107.

Wise MG, Ward SC, Townsend-Parchman W, et al. Case report of ECT during high-risk pregnancy. Am J Psychiatry 1984;141(1):99-101

108.

Loke KH, Salleh R. Electroconvulsive therapy for the acutely psychotic pregnant patient: a review of 3. cases. Med J Malays 1983;38(2):131-3

109.

Levine R, Frost EA. Arterial blood-gas analyses during electroconvulsive therapy in a parturient. Anesth Analg 1975;54(2): 203-5


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