Electroconvulsive therapy (ECT) is one of the most effective treatments for depression, with response rates that are consistently higher than those observed in clinical trials of antidepressants. Furthermore, ECT may be more effective than medications for treatment-refractory depression. The American Psychiatric Association (APA) recommends ECT for patients who have had previous positive response to ECT or who are non-responsive to pharmacological treatments, as well as for those patients who experience severe psychiatric symptoms, including depression with psychosis. suicidal ideation, and mania.
ECT has also been shown to be relatively safe during pregnancy and may offer some advantages over antidepressants in minimizing exposure to psychotropic medications during pregnancy. (Kasar et al 2007, Miller 1994, Repke and Berger 1984). Extra precautions have been suggested for ECT treatment in pregnant patients, including the addition of an obstetrician to the psychiatrist and anesthesiologist team. Before ECT, a pelvic examination should be performed on the patient to check for vaginal bleeding or cervical dilation. Because pregnancy increases the risk of gastric regurgitation and pulmonary aspiration during ECT, some anesthesiologists prefer to intubate the patient after the first trimester in order to maintain a clear airway. Additionally, a pregnant patient should be kept well-hydrated throughout the ECT procedure. A fetal heart monitor is often used, and oxygen administration adjusted accordingly. (Miller 1994, Walker and Swartz, 1994).
Overall the risk to the fetus is low. In a meta-analysis of 300 cases of ECT use during pregnancy (Miller 1994), four cases of premature labor (1.3%) were reported. In all cases, the clinician determined that the premature labor was not related to the ECT. The miscarriage rate for women receiving ECT during pregnancy (1.6% of cases) was not significantly higher than the rate of miscarriage in the general population. Two cases (0.6%) reported uterine contractions directly after ECT, but neither resulted in any significant consequences to either the mother or fetus. Recent case studies of ECT treatment and premature delivery have underscored the need for close monitoring of the mother and fetus but have not lead clinicians to conclude that ECT increases the risk of premature delivery (Kasar et al, 2007). Typically if a patient develops uterine contractions or any signs of preterm labor during or after ECT, treatment with ECT is postponed.
Despite evidence that electroconvulsive therapy (ECT) is a safe and effective treatment for many psychiatric illnesses during pregnancy, many clinicians and patients are still reluctant to pursue this option, concerned that it will harm the fetus or incur extra risk for the patient. Ultimately, the clinician must weigh the risks to both mother and fetus involved in not treating a woman who suffers from severe psychiatric symptoms against the risks involved in ECT treatment, and facilitate the most appropriate clinical intervention for the individual patient.
Erica Pasciullo, BA
Other ECT Resources:
Shock: The Healing Power of Electroconvulsive Therapy by Kitty Dukakis and Larry Tye. Kitty Dukakis is the wife of former Governor of Massachusetts Michael Dukakis. She spoke recently at Mass General Hospital Psychiatry Grand Rounds about her experience as an ECT patient and advocate.