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REVIEWARTICLE
Electroconvulsive therapy during pregnancy: a systematicreview of case studies
Kari Ann Leiknes & Mary Jennifer Cooke &
Lindy Jarosch-von Schweder & Ingrid Harboe &
Bjørg Høie
Received: 29 April 2013 /Accepted: 20 October 2013 /Published online: 24 November 2013# The Author(s) 2013. This article is published with open access at Springerlink.com
Abstract This study aims to explore practice, use, and risk ofelectroconvulsive therapy (ECT) in pregnancy. A systematicsearch was undertaken in the databases Medline, Embase,PsycINFO, SveMed and CINAHL (EBSCO). Only primarydata-based studies reporting ECT undertaken during pregnan-cy were included. Two reviewers independently checkedstudy titles and abstracts according to inclusion criteria andextracted detailed use, practice, and adverse effects data fromfull text retrieved articles. Studies and extracted data weresorted according to before and after year 1970, due to changesin ECT administration over time. A total of 67 case reportswere included and studies from all continents represented.Altogether, 169 pregnant women were identified, treated dur-ing pregnancy with a mean number of 9.4 ECTs, at mean ageof 29 years. Most women received ECT during the 2ndtrimester and many were Para I. Main diagnostic indicationin years 1970 to 2013 was Depression/Bipolar disorder (in-cluding psychotic depression). Missing data on fetus/childwas 12 %. ECT parameter report was often sparse. Bothbilateral and unilateral electrode placement was used and
thiopental was the main anesthetic agent. Adverse events suchas fetal heart rate reduction, uterine contractions, and prema-ture labor (born between 29 and 37 gestation weeks) werereported for nearly one third (29 %). The overall child mor-tality rate was 7.1 %. Lethal outcomes for the fetus and/orbaby had diverse associations. ECT during pregnancy is ad-vised considered only as last resort treatment under verystringent diagnostic and clinical indications. Updated interna-tional guidelines are urgently needed.
Keywords Electroconvulsive therapy . Pregnancy .Mentaldisorders . Review . Systematic
AbbreviationsBL BilateralBH Bjørg HøieBPM Beats (heart beats) per minuteDSM-IV Diagnostic Statistical Manual of Mental
Disorders, fourth editionECT Electroconvulsive therapyEEG ElectroencephalogramFHR Fetal heart rateGW Gestation weeksICD-10 International Classification of Diseases,
10th revisionIH Ingrid HarboeKAL Kari Ann LeiknesKTH Karianne Thune HammerstrømLJS Lindy Jarosch-von SchwederM MeanMJC Mary Jennifer CookeMRI Magnetic resonant imagingOCD Obsessive Compulsive DisorderSD Standard deviationUL UnilateralWWE Women with epilepsy
Work conducted at: The Norwegian Knowledge Centre for the HealthServices
K. A. Leiknes (*) : I. Harboe :B. HøieNorwegian Knowledge Centre for the Health Services, Box 7004 St.Olavsplass, Pilestredet Park 7, Oslo 0130, Norwaye-mail: [email protected]
M. J. CookeDepartment for Psychosis, Psychiatric Clinic, Haukeland UniversityHospital, Bergen 5021, Norway
L. Jarosch-von SchwederDivision of Psychiatry, Tiller DPS and Faculty of Medicine, Instituteof Neuroscience, St. Olav’s University Hospital and NorwegianUniversity of Science and Technology (NTNU), P O Box 3008,Lade, 7441 Trondheim, Norway
Arch Womens Ment Health (2015) 18:1–39DOI 10.1007/s00737-013-0389-0
Introduction
For patients with severe psychiatric disorders in the pregnancyperiod, either medication resistant illness, extremely highsuicide risk, psychotic agitation, severe physical decline dueto malnutrition or dehydration, electroconvulsive therapy(ECT) still appears as a strong option (Berle et al. 2011;2003). Previous review publications have advocated ECT tobe a relatively safe during pregnancy (Anderson and Reti2009; Miller 1994; Reyes et al. 2011; Saatcioglu andTomruk 2011). International ECT guidelines have no clearstatements about pregnancy being a contraindication(American Psychiatric 2001; Enns et al. 2010; RoyalCollege of Psychiatrists 2005). Checklists for when ECT isan option during pregnancy have also been provided in text-books of interface between gynecology and psychiatry(Stewart and Erlick Robinson 2001), without mention of anypotential risks to be taken into account.
Prevalence of major depressive episode (MME) duringpregnancy is estimated at 12.4 % (Le et al. 2011). Consideringthat depression is the most common mental disorder (63 %),followed by bipolar disorder (43 %) and schizophrenia (13 %)among deliveries to women with atypical antipsychotic use(Toh et al. 2013), the decision of ECT during pregnancywould not appear uncommon. Although prevalence data onECT administered during pregnancy is not retrievable, andECT clearly rarely used during pregnancy in most clinicalsettings as illustrated by a recent review of contemporaryuse and practice of ECT worldwide (Leiknes et al. 2012),ECT was noted administered during pregnancy at 10 Polishsites (Gazdag et al. 2009) and also in Spain (Bertolin-Guillenet al. 2006).
Administration of psychotropic drugs during pregnancyrequires great caution and benefits must be weighed againstpotential risks, especially in the first trimester (Stewart andErlick Robinson 2001). Although evidence for psychotropicmedication teratogenicity is generally lacking or limited(Gentile 2010), mood stabilizers such as lithium and valproateare strongly discouraged (Berle and Spigset 2003; Gentile2010) and carbamazapine controversial (Gentile 2010;Stewart and Erlick Robinson 2001). As for antidepressants,a recent population-based cohort study data from the DanishFertility Database has found no associated risk with use ofSSRIs during pregnancy (Jimenez-Solem et al. 2013). Forantipsychotics the risk associated with use during pregnancyis unclear (McCauley-Elsom et al. 2010).
In a systematic review concerning children of women withepilepsy (WWE), no support was found for the common viewthat epilepsy per se represented a risk for increased congenitalmalformations (Fried et al. 2004). Conversely, a largepopulation-based register study found a twofold overall riskof malformation in the offspring from WWE compared withthose without epilepsy (Artama et al. 2006). Caesarian section
in WWE has, also been found to be performed twice asfrequently compared with the general population (Olafssonet al. 1998). Total prevalence of major congenital anomalies,is by a large European study (Dolk et al. 2010) reported as23.9 per 1,000 births for 2003–2007 and 80 % live births.Prevalence of congenital heart disease (the most commonbirth defect) to be 4–6/1,000 live births by another USA study(Ermis and Morales 2011).
In a previous review of the literature from 1941 to 2007undertaken by Anderson and Reti (2009), with 57 includedstudies, ECTwas reported administered to 339 women duringpregnancy. The same review also reports a partial positiveECT response for pregnant women together with a very lownumber (N=11) of ECT-related fetal or neonatal abnormali-ties. Whether these numbers can be reaffirmed and whetherthere is enough support for APAs the statement that ECTtreatment has a “low risk and high efficacy in the managementof specific disorders in all three trimesters of pregnancy”(American Psychiatric 2001) is a concern for this presentreview.
Treatment of mental disorders in pregnancy poses a uniqueclinical challenge due to potential effects also on the fetusfrom the intervention. As ECT is utilized worldwide andpredominantly in the treatment of women (Leiknes et al.2012), updated knowledge about safety and risk of ECTtreatment during pregnancy for both the mother and fetus/child is of utmost primary importance.
Against this background, the main objective of this articleis to give a systematic case overview of ECT administeredduring pregnancy, with newer date studies in mind, as well asto report the potential harm (adverse events for mother andfetus/baby).
Materials and methods
Data sources and search strategy
A systematic literature search was undertaken in the followingdatabases: Ovid MEDLINE, Embase (Ovid) PsycINFO(Ovid), SveMed, Ovid Nursing Database and CINAHL(EBSCO) (Table 5 in Appendix 1) in September 2010. Thesearch was updated in January and November 2012 andsupplemented with ISI web of Knowledge, ClinicalTrials.gov, PROSPERO (CRD), WHO ICTRP, POP-database(Table 6 in Appendix 1). Search terms intended for Medlinewere adapted (such) as required for the other databases. Sub-ject headings and free text words used were “electroconvul-sive therapy,” “electroshock,” “electroconvulsive,” “ECT,”combined with “pregnancy” or “pregnant women” and anyof the following “antenatal,” “prenatal,” “perinatal,” “gravid,”or “gestation” limited to human studies and dating until today.The search did not exclude the postpartum period tomake sure
2 K. A. Leiknes et al.
that no articles on the topic were missed. No date limitationwas set to find all possible earliest published cases from the1940s. Relevant references, known to authors of this reviewfrom earlier published reviews on this topic or reference listsin retrieved included papers, were also found by hand.
Inclusion and exclusion criteria
Inclusion criteria Studies in the following languages wereincluded: English, Norwegian, Swedish, Danish, Dutch,French, Italian, and Spanish. In addition to authors’ Europeanlanguage fluency, the online Google translation tool(http://translate.google.com/) was used when needed.
Exclusion criteria Exclusion criteria include not a data-basedstudy, no or unclear report of ECT undertaken during preg-nancy, pseudocyesis, ECT undertaken only in the postpartumperiod, and not during pregnancy.
Screening of literature
Two reviewers (Kari Ann Leiknes (KAL) and Bjørg Høie(BH)) independently checked the titles, and where available,the abstracts of the studies identified by the electronic data-base searches. All references appearing to meet inclusioncriteria, including those with insufficient details were request-ed in full text. Reviewers (KAL, BH, and Mary J. Cooke(MJC)), consisting of two pairs independently extracted datafrom the retrieved full-text articles according to a pre-designeddata extraction scheme. All discrepancies were resolved byconsensus meeting/discussion, and the final decision wasmade by the first author (KAL). Ingrid Harboe (IH) undertookthe extensive updated literature search. All authors (includingLindy Jarosch-von Schweder (LJS) have contributed to thedata presentation and manuscript text.
Data extraction
Briefly, the following aspects were considered: ECT practiceand use; publication year and country; diagnoses/indication;mother’s age; number of pregnancies (primipara (P1), multipara(P2, 3), etc.); time ECTwas administered according to numberof gestation weeks (GW), 1st trimester (≤13 GW), 2nd trimester(14–26 GW), 3rd trimester (≥27 GW); total number ECTsadministered, ECTadministration frequency (two to three timesweek); ECT parameters (i.e., the manner in which ECT isapplied: brief pulse or sine wave current, device type, electrodeplacement bilateral (BL) or unilateral (UL)); anesthesia type andmonitoring (of bothmother and fetus); time of birth; and adverseevents mother (e.g., genital bleeding, miscarriage, eclampsia,and still birth) and/or baby (e.g., fetal malformations, Apgarscore, etc.). As ECT treatment has changed over the years, as
for use of anesthesia (termed modified ECT as opposed tounmodified ECT,without anesthesia), device and type of current(mainly from sinewave to brief pulsewave), a clinical cut off forpresenting the extracted data was set at 1970.
Results
Study selection
The study selection process, databases searched, and refer-ences identified are given in Fig. 1. Altogether, 1,001 refer-ences were identified: 681 titles and abstracts screened, 100full texts screened, 67 included for data extraction, and 33 fulltexts excluded.
Description of studies
Overview of included case studies (N =67) according to de-scending publication year, country represented, number of preg-nancy cases and fetus and/or baby cases reported are given inTable 1. Overview of full text excluded studies (N=33) andreasons for exclusion are given inAppendix 2. Twelve referenceswere found not relevant to topic (about ECT, but not in pregnan-cy, e.g., in postpartum or other conditions), 13 had insufficient/too sparse data, 3 were impossible to find/full text retrieve, and 5were not relevant, for example, only about anesthesia types orelectrical shock accident injury during pregnancy. Detailed ex-tracted data from each included study, such as diagnostic indi-cation, ECT parameters, report of effect and events are pre-sented in Summary of findings tables (N=67), Appendix 3.
A total of 67 case report studies were included, 42 (63 %)from 1970 to 2013 and 25 (37%) from 1942 to 1970 (Table 1).The literature search included all years, but no studies accord-ing to inclusion criteria of this review were found in the 1970s(see Appendix 2 for two excluded 1970s studies (Levine andFrost 1975; Remick and Maurice 1978) lacking ECT data).Studies from all continents were represented as follows: NorthAmerica (USA and Canada), 32; South America, 1; Europe,25; Asia (including Middle East), 6; Africa, 2; and Australia,1. A total of 169 pregnant women were ECT treated from1942 to 2013. Reports on the fetus or newborn baby/childwere found for only 148 cases resulting in 12 % “missing”fetus/baby data (see Table 1).
Altogether, 169 ECT treated pregnant womenwere identified,exposed to a total number of 1,187 ECTs. Mean and standarddeviation (M (SD)) number of ECTs administered per pregnantwoman was 9.4 (6.4). Mean age (M (SD) in years) of pregnantwomen treated with ECT was 28.9 (6.2) and age range 16½–48 years. Overview of ECT-treated pregnant women, number ofECTs, and diagnoses, after and before 1970 is given in Table 2.
Almost two thirds (63 %) diagnostic indication for ECTwas Depression/Bipolar disorder (including psychotic
Electroconvulsive therapy during pregnancy: a systematic review 3
depression) from year 1970 until today (2013), but Schizo-phrenia and other diagnoses the main indication (54 %) from1942 until 1970 (Table 2). Diagnostic data was not missing inany reports from 1970 to 2013, but missing (15 %) andsometimes very unclear in several earlier reports from 1942to 1970. Category of “other” diagnoses included obsessive–compulsive disorder (OCD) (Barten 1961; Fukuchi et al.2003), generalized anxiety with panic attacks (Bhatia et al.1999; Simon 1948), and Neuroleptic Malignant Syndrome(NMS) (Verwiel et al. 1994).
Altogether 21 out of 54 (39 %) women were nullipara(Para1) in the later years (from 1970 to 2013) (Table 2) andfor one case in 2011 the pregnancy was by in vitro fertilization(Salzbrenner et al. 2011). The latest ECT administered inpregnancy was at 40 GW (Laird 1955; Schachter 1960) andthe earliest at 4 GW (1955). Information about which preg-nancy trimester the ECTwas undertaken or started was foundfor 121 women out of 169 (28 % missing). Overview of theECT reports according to pregnancy trimester for these 121women is given in Table 3. Most women (53%) received ECTduring the 2nd trimester, although use in the 1st trimester wasnot uncommon (16 %) and for some, ECT was conductedthroughout the entire pregnancy (Pinette et al. 2007).
Generally, the data reported in all studies was very variedconcerning the ECT intervention per se, the setting of ad-ministration, monitoring, and outcome for both mother andfetus/child.
ECT practice during pregnancy
The setting in which the ECT was administered was usuallynot recorded. However, ECT undertaken in a surgical-obstetric recovery room or delivery environment was notedby three (Gilot et al. 1999; Wise et al. 1984; Yellowlees andPage 1990).
Monitoring of mother before, during, and after varied. Inaddition, monitoring of fetus varied greatly from some mon-itoring to no fetal monitoring by Vanelle et al. (1991). Therewas some use of cardiotocography (Molina et al. 2010;O’Reardon et al. 2011; Verwiel et al . 1994) butcardiotocography was also noted as not being useful in earlypregnancy (before 24 GW) by Lovas et al. (2011). Mother intilt position during ECT was used in some reports (Brownet al. 2003; Gilot et al. 1999; Livingston et al. 1994; Malhotraet al. 2008; Yang et al. 2011) and by others tilt position wasreported not used (Bhatia et al. 1999; Bozkurt et al. 2007;DeBattista et al. 2003).
ECT parameters, such as electrical current type (brief pulseor sine wave), placement of electrodes (UL, BL, bitemporal,and bifrontal) and device manufacture type used was noted inmost studies of later date but otherwise very sparsely. (Seesummary of findings table, Appendix 3). UL placement ofelectrodes was noted in six studies (Balki et al. 2006; Gahret al. 2012; Pesiridou et al. 2010; Varan et al. 1985; Wise et al.1984; Yellowlees and Page 1990).
886 (2010) + 101 (2012) Total 987 identified references from search +14 hand found =1001Macmaster plus 1Medline 358Embase 406PsycINFO 121British Nursing Index 2Ovid Nursing database 11Nora 3Cinahl 38Cochrane 6SveMed 22Isi w of k 19
320 Duplicates
681 identified references title and abstract screened
581 excluded due to inclusion criteria not met: not about ECT during pregnancy, not a primary study, insufficient data (editorial, letter or commentary)
67 articles included for data extraction and analyses
100 articles full text retrieved and evaluated
33 excluded due to: 12 about ECT, but not during pregnancy13 too sparse data, commentary letter to editor
3 not possible to find or full text retrieve 5 not relevant topic, e.g. about electrical shock injury
Fig. 1 Flow chart of the study selection process
4 K. A. Leiknes et al.
Data on anesthetic agents used combined with musclerelaxant, premedication and 100 % oxygenation was mainlystated in the later date studies (1970 to 2013). Although 13 %of these later date studies (1970 to 2013) were missing anes-thesia data, a trend was seen for the following being mostused: thiopental (22 %), methohexital (15 %), and propofol(17%). Anesthesia induced reduced fetal heart rate (FHR) wasnoted with propofol but not thiamylal in an ECT pregnancycase by Iwasaki et al. (2002). In addition, severe fetal brady-cardia by methohexital but not with following propofol anes-thesia during ECT administration by De Asis et al. (2013). To
Table 1 Overview of included studies (N =67), publication year, coun-try, number of pregnancy, and fetus/baby cases
Primary Authorand Year
Country Number ofpregnancycases
Number of fetus(F) or baby (B)cases
De Asis et al. (2013) USA 1 1
Gahr et al. (2012) Germany 1 1 F
Yang et al. (2011) South Korea 1 1
O’Reardon et al. (2011) USA 1 1
Salzbrenner et al. (2011) USA 1 1
Lovas et al. (2011) Hungary 1 1
Pesiridou et al. (2010) USA 1 1
Serim et al. (2010) Turkey 1 1
Molina et al. (2010) Spain 2 2
Kucukgoncu et al. (2009) Turkey 1 1
Ghanizadeh et al. (2009) Iran 1 1 F
Malhotra et al. (2008) India 2 –
Ceccaldi et al. (2008) France 1 1
Bozkurt et al. (2007) Turkey 1 1
Kasar et al. (2007) Turkey 1 1
Pinette et al. (2007) USA 1 1
Espínola-Nadurilleet al. (2007)
Mexico 1 1 F
Prieto Martin et al. (2006) Spain 1 1
Balki et al. (2006) Canada 1 1 F death
Maletzky (2004) USA 4 1 (3 unknown)
Brown et al. (2003) USA 1 –
DeBattista et al. (2003) USA 1 1
Fukuchi et al. (2003)a Japan(Japanese)
1 –
Ishikawa et al. (2001)a Japan(Japanese)
1 1 F
Iwasaki et al. (2002) Canada 1 1
Polster and Wisner (1999) USA 1 –
Gilot et al. (1999) France 1 1 B death
Bhatia et al. (1999) USA 2 2
Echevarria et al. (1998) Spain 1 1 F death
Livingston et al. (1994) USA 1 1 (twins)
1 B death
Verwiel et al. (1994) Netherlands 1 1
Vanelle et al. (1991) France 5 4
1 F death
Sherer et al. (1991) USA 1 1
Yellowlees and Page(1990)
Australia 1 1
LaGrone (1990) USA 1 1
Griffiths et al. (1989) USA 1 1
Mynors-Wallis (1989) UK 1 –
Varan et al. (1985) Canada 1 1
Dorn (1985) USA 1 –
Wise et al. (1984) USA 1 –
Repke and Berger (1984) USA 1 1
Loke and Salleh (1983) Malaysia 3 3
Table 1 (continued)
Primary Authorand Year
Country Number ofpregnancycases
Number of fetus(F) or baby (B)cases
Impastato et al. (1964) USA 1 1
Evrard (1961) Belgium 1 1
Barten (1961) Netherlands 2 2
Ferrari (1960) Italy 8 7
1 B death
Sobel (1960) USA 33 31
2 B deaths
Schachter (1960) France 1 1
Smith (1956) UK 15 15
Monod (1955) France 4 3
Laird (1955) USA 8 8
Russell and Page (1955) UK 10 –
Charatan and Oldham(1954)
UK 1 1
Wickes (1954) UK 1 1
Yamamoto et al. (1953) USA 1 1
Forman et al. (1952) USA 2 2
Cooper (1952) South Africa 1 1
Porot (1949) Alger 3 3
Plenter (1948) Dutch 3 2
1 F death
Simon (1948) USA 3 2
1 B death
Doan and Huston (1948) USA 7 7
Boyd and Brown (1948) USA 2 1
Block (1948) New York,USA
1 1
Kent (1947) New York,USA
3 2
1 F death
Gralnick (1946) New York,USA
1 1 F death
Polatin and Hoch (1945) New York,USA
2 –
Thorpe (1942) UK 1 1
a Japanese language, English abstract
Electroconvulsive therapy during pregnancy: a systematic review 5
avoid pulmonary aspiration, tracheal intubation was preferredby Malhotra et al. (2008) when pregnancy was beyond 1sttrimester.
Unmodified (without anesthesia) ECT was noted in theearlier studies (from 1942 to 1970), such as in all 8 casesreported by Laird (1955) and in 6 out of 15 cases by Smith(1956). Even use of only muscle relaxant without anesthesiawas noted in 7 ECT pregnancy cases by Doan and Huston(1948).
Fetus, baby/child—monitoring, and follow-up
Fetus or baby/child data was sometimes totally absent even inthe later date studies, such as in Gahr et al. (2012) andGhanizadeh et al. (2009) as well as some earlier ones, forexample Russell and Page (1955). Some reported new bornbaby Apgar score and weight, but most often the informationon the newborn infant was meager and the condition of baby/child noted as normal, “healthy baby,” or nothing abnormal.
Information about monitoring of fetus during ECT variedgreatly from none at all, to obstetric consultations and ultra-sonography between treatment sessions (Espínola-Nadurilleet al. 2007; Kasar et al. 2007; Serim et al. 2010) to before andafter FHR and Doppler monitoring (O’Reardon et al. 2011).
Although most studies had no follow-up data on the chil-dren, some had sparsely noted follow-up at 1 month (Repkeand Berger 1984), 3 months (Yellowlees and Page 1990),18 months (O’Reardon et al. 2011), 2 weeks to 5 months(Sobel 1960), 2½years (Yamamoto et al. 1953), and 6 years
(Evrard 1961). A more detailed follow-up study from 1955 byForssman (1955) of 16 children, whose mothers were givenECT during pregnancy between years 1947 and 1952, wasexcluded since it contained only data on the children withoutany ECT during pregnancy data on the mothers.
ECT risk and adverse events
No deaths of mother/ECT treated pregnant patient were foundin any studies. Overall (all years), child mortality rate was7.1 % (12/169), and from 1970 to 2013 mortality rate was9.4 % (5/54) and from 1942 to 1970, 6.1 % (7/115) (seeTable 1). Lethal outcomes for the fetus and/or baby werestated to have diverse causes, in one case a long lasting severegrand mal seizure (status epilepticus) induced by ECT (Balkiet al. 2006). A combination of insulin coma treatment andECTwas found for 3 early studies in the period 1946 to 1954by Kent (1947), Gralnick (1946), Wickes (1954)—all withsevere very adverse outcome for the fetus/baby. Overview ofall reported adverse events for ECT treated pregnant womenand fetus and/or baby child are given in Table 4.
Report of adverse advents was high for both pregnantwomen and fetus/child in studies of later date period (1970to 2013) compared with earlier date period (1942 to 1970) (seeTable 4). Vaginal bleeding was reported more often during the1st trimester, whereas uterine contractions, premature labourand caesarian sections occurred during 2nd and 3rd trimesters.The use of tocolytic treatment after ECT in order to avoidpreterm labor was also noted by several (Fukuchi et al. 2003;Malhotra et al. 2008; Polster and Wisner 1999; Prieto Martinet al. 2006; Serim et al. 2010; Yang et al. 2011), as well as useof prophylactic tocolytic medication before ECT (Malhotraet al. 2008; Polster and Wisner 1999).
Table 2 ECT-treated pregnant women, number of ECTs, and diagnosesbefore and after 1970
Years1970to 2013
Years1942to 1970
All years
Number of ECT treated pregnantwomen (N)
54 115 169
Age in years (M (SD)) 28.8 (6.0) 28.9 (6.4) 28.9 (6.2)
Total number of ECTs administered 446 741 1,187
Number of ECTs administered(M (SD))
8.5 (4.2) 10.2 (7.2) 9.4 (6.4)
Diagnoses in percent (%)
Depression, bipolar 63 35 43
Schizophrenia, psychosis 28 50 43
Other (anxiety, obsessive–compulsive disorder, etc.)
9 4 6
(Missing diagnoses) (−) (11) (8)
Percent (%) Para1 within numberof women
39 % 17 % 24 %
Number of fetus and/or baby reported 47 101 148
Number and percent (%)missing within
7 (13 %) 14 (12 %) 21 (12 %)
Table 3 ECT-treated women (N =121) by pregnancy trimesters
1st trimester(≤13 GW)
2nd trimester(14–26 GW)
3rd trimester(≥27 GW)
Number of women(N (%))
19 (16 %) 64 (53 %) 38 (31 %)
Age in years (M (SD)) 29.3 (5.1) 28.3 (5.9) 28.4 (6.8)
Number of ECTs(M (SD)) administered
10.7 (6.4) 11.1 (7.5) 7.1(3.1)
Para percent (%)
Primipara (P1) 37 (P1) 36 (P1) 32 (P1)
Multipara (≥P2) 42 (≥P2) 37 (≥P2) 47 (≥P2)(Missing) (21) (27) (21)
Diagnoses (%)
Depression, bipolar 63 66 63
Schizophrenia,psychosis
32 28 30
Other 5 5 3
(Missing) (0) (1) (4)
6 K. A. Leiknes et al.
Tab
le4
Overviewof
reported
adverseeventsforECT-treatedpregnant
wom
enandfetusand/or
baby
foundin
allincluded(N
=67)studies
Yearperiod
ofevents
Studiesby
firstauthorwith
eventreportedaccordingto
trim
ester
Com
ments
Years1970
to2013
Years1942
to1970
Allyears
1st(unknow
n)2nd
3rd
Event
type
mother(n
(%))
Vaginalbleeding
3(7
%)
5(23%)
8(12%)
Ghanizadehetal.
(2009),
Echevarriaetal.
(1998),and
Ferrari(1960)a
Sherer
etal.(1991)and
BoydandBrown
(1948)
a
Porot(1949)a
2eventsinPorot(1949)
and2events
inBoydandBrown(1948);
vaginalb
leedingaftereach
ECT
sessioninGhanizadehetal.(2009)
andin
1case
Ferrari(1960);
abruptio
placentaein
Sherer
etal.(1991)
Uterine
contractions
14(30%)
2(9
%)
16(24%)
Fukuchietal.(2003)Ceccaldietal.(2008),
PolsterandWisner
(1999),S
hereretal.
(1991),Ishikaw
aetal.
(2001),and
Boyd
andBrown(1948)
a
Pesiridouetal.(2010),Yang
etal.(2011),Serim
etal.
(2010),M
olinaetal.(2010),
Kasar
etal.(2007),
PrietoMartin
etal.(2006),
andBhatia
etal.(1999)
2eventsinBhatia
etal.(1999),Boyd
andBrown(1948),and
Molina
etal.(2010)
Abdom
inalpain
2(4
%)
4(18%)
6(9
%)
Lovas
etal.(2011)
andBozkurtetal.
(2007)
Impastatoetal.(1964)a
andPlenter
(1948)
aSo
bel(1960)a
2eventsin
Sobel(1960)
Miscarriage
3(7
%)
2(9
%)
5(7
%)
Vanelleetal.(1991)
Echevarriaetal.
(1998)
Balki
etal.(2006),Plenter
(1948),aandKent
(1947)
a
1eventinKent(1947)awith
also
insulin
comatreatm
ent
Preeclampsia
2(4
%)
–2(3
%)
Lovas
etal.(2011)
Pinette
etal.(2007)
Prem
aturelabor(born
between29–37GW)
13(28%)
6(27%)
19(28%)
Schachter(1960),a
Laird
(1955),a
andDoanand
Huston(1948)
a
Ceccaldietal.(2008)
Gilo
tetal.(1999),Livingston
etal.(1994),LaG
rone
(1990),and
Boydand
Brown(1948)
a
Pesiridouetal.(2010),Yang
etal.(2011),Kasar
etal.
(2007),P
inetteetal.(2007),
PrietoMartin
etal.(2006),
Bhatia
etal.(1999),Sh
erer
etal.(1991),Yellowlees
andPage(1990),and
Wise
etal.(1984)
3eventsinDoanandHuston(1948)
a
Caesarian
sectionbirths
9(20%)
3(14%)
12(17%)
Lovas
etal.(2011)
O’Reardon
etal.(2011),
Gilo
tetal.(1999),
LaG
rone
(1990),L
aird
(1955),aForman
etal.
(1952),aandKent
(1947)
a
Yangetal.(2011),Salzbrenner
etal.(2011),Serim
etal.
(2010),K
asar
etal.(2007),
andShereretal.(1991)
6born
between29–37GW;
emergencycaesarianin
Yang
etal.(2011)and1eventinKent
(1947)
also
insulin
comatreatm
ent
Totaln
umberof
events(N
)46
2268
Eventsratio
pernumberof
ECT
treatedpregnant
wom
enwith
ingroup
0.85
(46/54)
0.19
(22/115)
0.40
(68/169)
Eventsratio
(excluding
Caesarian
section)
pernumberof
ECT
0.69 (3
7/54)
0.16 (1
9/115)
0.33 (5
6/169)
Electroconvulsive therapy during pregnancy: a systematic review 7
Tab
le4
(contin
ued)
Yearperiod
ofevents
Studiesby
firstauthorwith
eventreportedaccordingto
trim
ester
Com
ments
Years1970
to2013
Years1942
to1970
Allyears
1st(unknow
n)2nd
3rd
treatedpregnant
wom
enwith
ingroup
Event
type
fetus/baby
child
,num
ber,andpercent(n(%
))
Fetalcardiac
arrhythm
ias,
bradycardia(reduced
fetalh
eartrate(FHR))
13(54%)
2(18%)
15(43%)
Bozkurtetal.(2007)
andDorn(1985)
DeB
attistaetal.(2003),
Iwasakietal.(2002),
Gilo
tetal.(1999),
andLivingston
etal.(1994)
DeAsisetal.(2013),Serim
etal.(2010),Molinaetal.
(2010),Ishikaw
aetal.(2001),
Prieto
Martin
etal.(2006),
Bhatia
etal.(1999),Sherer
etal.(1991),andBarten
(1961)
a
Severe
reducedFH
Rwith
methohexitalb
utnotw
ithpropofol
anesthesiain
DeAsis
etal.(2013),2eventsin
Molina
etal.(2010),reducedFHRwith
propofol
butn
otwith
thiamylal
anesthesiain
Iwasakietal.
(2002),and
2eventsin
Barten
(1961)
a
Meconium-stained
amniotic
fluid
–1(9
%)
1(3
%)
Barten(1961)
a
Stillbirthandneonataldeath
(miscarriage/abortion,fetal
deathNOTincluded
here)
6(25%)
2(18%)
8(23%)
Gralnick(1946)
aGilo
t(1999),Livingston
etal.(1994),Sim
on(1948),a
andKent
(1947)
a
Ferrari(1960)aandSo
bel(1960)a
2deaths
atfull-term
.Timebaby
died
afterbirth:0days
inLivingston
etal.(1994),Gralnick(1946)
aand
Sobel(1960)a ;2days
inSimon
(1948)
a ;8days
inFerrari(1960)a
duetobronchopneum
onia;9
days
inGilotetal.(1999)
dueto
metabolicpostsurgical
complications
aftermeconium
peritonitistreatmentinSobel
(1960)
a :1anencephalic,1
lung
cysts,andbronchopneum
onia,
died
shortly
afterbirth
Neonatalrespiratory
distress
–1(3
%)
LaG
rone
(1990)
Bilirubinemi
1(4
%)
–1(3
%)
Verwieletal.(1994)
Generalmentalimpairment
(retarded)
–2(18%)
2(5
%)
Yam
amotoetal.(1953)a
andWickes(1954)
aEye
strabism
usandmentally
impaired
(child
2½years)
(Yam
amotoetal.1953).a
Blin
dnessandsevere
mentally
retarded
(3yearsold)
(Wickes
1954)ain
acase
with
also
insulin
comatreatm
entearly
inpregnancy
Fetalm
alform
ations
(teratogenicity
)4(17%)
3(27%)
7(20%)
Schachter
(1960)
aLivingstonetal.(1994)
andLaG
rone
(1990)
Yangetal.(2011),Pinette
etal.
(2007),and
Sobel(1960)
aHyalin
emem
branediseaseand
congenitalh
ypertrophicpylonic
stenosis(Yangetal.2011);small
leftcerebellu
m,bi-hemispheric
deep
whitemattercorticalinfarct
8 K. A. Leiknes et al.
Discussion
Main findings
Altogether 169 ECT treated pregnant women of mean age29 years, were identified. They were treated with mean num-ber of ECTs 9.4, as treatment for mainly (62 %) severe“psychotic” depression/bipolar disorder. Half (53 %) of preg-nant women received ECT during the 2nd trimester. ECT inthe 1st trimester was not uncommon (16 %) and for some,ECT was conducted throughout the entire pregnancy. Alto-gether, 24%womenwere nullipara (Para1). Fetus and/or babyreport was found missing for 12 %. Child mortality rate wasoverall (all years) 7.1 %. A total of 67 adverse events werefound among 169 women (rate, 0.40). Most common adverseevent for mother was premature labor (born between 29 and37 GW) 19/67 (28 %) and tocolytic treatment often noted. Atotal of 35 adverse events were found among the reported 148fetus/baby children (rate 0.24). The most common reportedadverse event for fetus/baby child occurring during the ECTintervention was reduced FHR 15/35 (43 %).
Whether the reduced FHR event is attributable to the ECTintervention per se or to the anesthetic agent or to both is notpossible to say from such descriptive case studies. Due to thecomplexity of the ECT indication, the intervention per se,previous or concomitant psychotropic medication or othercomplicating somatic or genetic factors, direct causal infer-ence is not possible to take from case studies. This being saidthough, having in mind that the risk of fetal malformation inWWE is twofold higher (Artama et al. 2006), and caesariansection performed more often among WWE (Olafsson et al.1998), the potential risk involved with ECT induced epilepto-genic seizures must in each case be considered. Such asillustrated in the recent publication by De Asis et al. (2013),where the ECT induced prolonged seizure duration occurredalongside severe reduced FHR and emergency Caesarian sec-tion prepared, but later abandoned when the FHR returned tonormal. An earlier study (Balki et al. 2006) also reports severeECT induced status epilepticus with lethal outcome for thefetus/child.
As for the overall occurrence of serious adverse events,such as stillbirth/neonatal death 8/35 (23 %) and fetal malfor-mation 7/35 (20 %), the rates appear higher than that reportedin the general population, i.e. 2.3 % major congenital abnor-malities and 80 % live births (2010) and 0.6 % congenitalheart disease (Ermis and Morales 2011). Some included stud-ies though claim the miscarriage rate not to be higher than inthe general population (Malhotra et al. 2008) and ECT to beless risky than pharmacological treatment (Kasar et al. 2007).However, figures from case studies cannot directly be com-pared with figures from large observational prevalence stud-ies. This being said, close monitoring of mother and fetusduring and after ECT treatment taking into regard the trimesterT
able4
(contin
ued)
Yearperiod
ofevents
Studiesby
firstauthorwith
eventreportedaccordingto
trim
ester
Com
ments
Years1970
to2013
Years1942
to1970
Allyears
1st(unknow
n)2nd
3rd
(Pinetteetal.2007);transpositio
nof
greatv
essels,analatresia,
sacraldefect,and
coarctationof
aorta(Livingstonetal.1994);
infantgrow
thretardation(LaG
rone
1990);severe
mentald
efect,
congenitalg
laucom
a,cleftp
alate
(Schachter
1960)a;anencephalia
(Sobel1960)a;congenitallung
cysts(Sobel1960)a
Totaln
umber(N
)events
fetus/baby
2411
35
Eventsratio
pernumber
offetus/baby
child
with
ingroup
0.51
(24/47)0.11 (1
1/101)
0.24 (3
5/148)
aCasestudiesfrom
1942
until
1970
Electroconvulsive therapy during pregnancy: a systematic review 9
situation, is crucial to bear in mind, such as use ofcardiotocography, ultrasound between treatments, tilt positionfor mother including tocolytic treatment to prevent pretermlabor. All these monitoring factors varied greatly in the in-cluded studies.
Direct effect of anesthetic agents on the fetus is stillrelatively unknown (Iwasaki et al. 2002). FHR variabilityand reduction under the ECT intervention is often mentionedas something to expect to happen. Propofol’s known asso-ciated risk of bradycardia calls for alertness from a fetalcardiovascular viewpoint and extra caution is needed wherethe fetus is immature or has cardiovascular complications.Thiopental (22 %), methohexital (15 %), and propofol(17 %) are the most used anesthetic agents. However, casestudies with both anesthesia in favor of propofol (De Asiset al. 2013) and that against it (Iwasaki et al. 2002) arepublished.
Some factors to bear in mind in the different pregnancytrimesters are mentioned below:
1st trimester Knowledge about when and how to administerECT in early pregnancy, in order to reduce riskfor both mother and fetus, is limited.Cardiotocography monitoring for the fetus, inthis early period (before 24 GW) is not sofeasible (Lovas et al. 2011). Risk of post ECTvaginal bleeding (indicative of abruptio placen-ta) and abortion (Vanelle et al. 1991) is men-tioned. The complexity of any causal attribu-tion to ECT is illustrated in the case by Yang(Yang et al. 2011) reporting congenital hyalinemembrane disease and hypertrophic pyloricstenosis in a premature baby delivered by emer-gency section, since the mother had been treat-ed with an extensive amount of antipsychoticand antidepressant medication prior to admis-sion due to a 15 year long history ofschizophrenia.
2nd trimester Transient FHR reduction (bradycardia) arisingduring the ECT and subsiding afterwards iscommonly reported from this trimester period,likewise post-ECT uterine contractions. Theneed for both pre- and post-ECT tocolytictreatment in order to avoid preterm labor isconsiderable (Fukuchi et al. 2003; Malhotraet al. 2008; Polster and Wisner 1999; PrietoMartin et al. 2006; Serim et al. 2010; Yanget al. 2011).
3rd trimester Tilt position is recommended by several,especially in the last trimester in order toreduce risk of gastric reflux. Also inhalationanesthesia is pointed out by Ishikawa et al.(2001) to be beneficial in the last stages of
pregnancy in order to reduce uterine con-traction and potential uterine relaxation ef-fect of anesthetics.
The overall total number of included studies (N =67) inour review is larger than the 57 by Anderson and Reti(2009). However, overall total number of ECT treatedpregnant women (N =169) is much less than the 339 bythe same authors (Anderson and Reti 2009). Unlike theAnderson and Reti (2009), numbers of ECT treated preg-nant women referred to by others in the general text ofthe case article, have not been included in this review.Strictly according to the predetermined review criteria,only direct case reports by the study authors are includedin the total count number (169) of pregnant ECT treatedwomen by us. For example, only one case is included inthis review from the publication by Impastato et al. (1964)as opposed to 159 cases by Anderson and Reti (2009),and we have not included the Forssman (1955) follow-upof 16 infants/children on ECT treated mothers, since thisstudy contains no ECT pregnancy data, i.e. data on themothers treatment. Likewise the study by Levine and Frost(1975) is excluded by us, since it only contained informa-tion about anesthesia type and cardiovascular responses toECT in a 3rd semester pregnancy and no otherinformation.
Previous studies, such as that by O’Reardon et al.(2011) and previous reviews (Anderson and Reti 2009;Miller 1994; Saatcioglu and Tomruk 2011) as well asinternational guidelines (American Psychiatric 2001; Ennset al. 2010; Royal College of Psychiatrists 2005) andrecent textbooks (Stewart and Erlick Robinson 2001) haveregarded ECT to be relatively safe during all trimesters ofpregnancy. Contrary to this standpoint, our review andoverview of recorded adverse events from all case studiescall for great clinical caution. Voices of concern, similar toours, appear also in the included study Pinette et al.(2007) and APA statements regarding ECT as a safeintervention during pregnancy questioned. The previousheld opinion by the Miller (1994) review concerningpotential complications from ECT during pregnancy tobe minimized by improved technique, are also questionedby our results.
Check lists
The study by Salzbrenner et al. (2011) provides a 10-pointchecklist for pregnant women undergoing ECT. Similarly,a 14-item list for general measures and routine anestheticmeasures in order to avoid gastric reflux is provided byO’Reardon et al. (2011). The need for close clinical col-laboration between gynecology/obstetrics, anesthesiology
10 K. A. Leiknes et al.
and psychiatry together with clear responsibility is evident.Textbook checklists for when ECT is an option duringpregnancy (Stewart and Erlick Robinson 2001) needupdating of potential risks to be considered.
Our results reveal that all potential risk arising from thecomplexity of ECT intervention, the grand mal seizure,anesthetic and concomitant or previous psychotropic medi-cations, is of great concern and must be taken into accountfor both mother and fetus/child, and weighed against theclinical benefits, when deciding to administer ECT duringpregnancy.
Ethical issues
Ethical considerations and possible ethical violations forboth mother and the unborn non-consenting child are notdiscussed. Conflicting opinions can easily arise, such asthat described by Polster and Wisner (1999) where theobstetrician advised that ECT be discontinued after prema-ture labor treatment in the obstetrics unit, but ECT wascontinued by the psychiatric unit. All arguments from thisreview support the need for holistic clinical decision mak-ing and caution when ECT is considered as an optionduring pregnancy.
Strengths and limitations
The strength of this paper is the thorough, systematicreview of all published literature without any data limita-tion. Data extracted from the included studies have strictlybeen limited to primary case presentations by the authorsand not secondary “known to the authors” numbers re-ferred to by the authors in the body text. Likewise allother literature review studies on the subject without anyprimary case data have also been excluded. The mostconsistent findings in all included studies was the numberof ECTs administered, thereafter the diagnostic indication,pregnancy length, ECT parameters, anesthesia type, condi-tion of both mother and child, the latter was somewhatmore dependable in newer date studies. The strength ofcase study design is the reporting of rare and adverseevents, however limitations as for this design must clearlybe taken into account.
A limitation is uncertainty in the very oldest publishedcases, where case presentation is mixed with cases“known to authors” in the manuscript text, to completelydocument all cases since the introduction of ECT in 1938.The earliest published case reports are also much morelikely to be mixed with other treatment forms, such asinsulin coma, which is not used and out of date today andthese mixed treatment reports therefore not so relevant fortoday’s practice. No prospective or controlled study designof ECT in pregnancy are found, case studies alone in this
field provide the knowledge background. Case studies aresusceptible to reporting and publication bias, and onlydescriptive aggregation of study data is possible, nometa-analyses. As cases of ECT during pregnancy wherethe treatment went well are most likely not published, theincluded studies in this review might very well be overrepresented with adverse event reporting.
Clinical implications
ECT during pregnancy should be a last resort treatment. Forexample in cases of severe depression, catatonia, medicationresistant illness, extremely high suicide risk, psychotic agita-tion, severe physical decline due to malnutrition or dehydra-tion or other life threatening conditions (for example malig-nant neuroleptic syndrome), where other treatment options arenot possible or very inadequate. All potential risks of the ECTtreatment, taking into account both mother and fetus, shouldbe weighed against benefits. The ECT should be administeredin a hospital emergency setting or delivery room. Informationto patients of all possible risks involved should be consideredcompulsory. ECT during pregnancy should be administeredby a highly skilled and competent specialist team consisting ofpsychiatrist, gynecologist/obstetrician, and anesthesiologist.Monitoring of patient under ECT treatment and also in therecovery room should include midwife and psychiatric nurse.The establishment of a multi-disciplinary specialist team bear-ing full treatment and follow-up responsibility is fundamentalfor the safety of the intervention.
Conclusions
Case reports on ECT administered during pregnancy providevital knowledge. ECT during pregnancy is advised consideredonly under very stringent diagnostic and clinical indications,weighing all potential risks against benefits. Updated clinicalguidelines are urgently needed in this field.
Acknowledgments This study has been possible because of researchcommissioning on the topic “ECT for depression” from the NorwegianDirectorate of Health to the Norwegian Knowledge Centre. We thank theNorwegian Knowledge Centre’s research librarian Karianne ThuneHammerstrøm (KTH) for designing and undertaking the first primaryliterature search.
Competing interests None.
Funding statement This research received no specific grant from anyfunding agency in the public, commercial, or not-for-profit sectors.
Open AccessThis article is distributed under the terms of the CreativeCommons Attribution License which permits any use, distribution, andreproduction in any medium, provided the original author(s) and thesource are credited.
Electroconvulsive therapy during pregnancy: a systematic review 11
Tab
le5
Search
strategy
in2010
OvidMEDLIN
E(R)1946
toSeptem
berweek3,2010
EMBASE
1974
to2010
week38
PsycIN
FO1806
toSeptem
berweek4,2010
Wiley,CochraneLibrary,
Issue3of
4,Jul2
010
Ovidnursingdatabase
1950
toSeptem
berWeek32010
EBSC
O;C
inahl,October
2010
1Electroconvulsive
therapy/
Electroconvulsive
therapy/
Exp
electroconvulsiveshock/
MeSHdescriptor
electroconvulsive
therapyexplodealltrees
Electroconvulsive
therapy/
S5andS1
0
2(Electroconvulsive$
orelectr$convulsive$).tw
.(Electroconvulsive$
orelectr$convulsive$).tw
.(Electroconvulsive$or
electr$convulsive$).tw
.(Electroconvulsive*or
electr$
convulsive*):ti,ab
(Electroconvulsive$or
electr$convulsive$).tw
S6or
S7or
S8or
S9
3(Electroshock$
orelectr$
shock$).tw.
(Electroshock$
orelectr$
shock$).tw.
(Electroshock$
orelectr$
shock$).tw.
(Electroshock*
orelectr*
shock*):ti,ab
(Electroshock$
orelectr$
shock$).tw.
TI(pregnan*or
gravid*or
gestation*)
orAB(pregnan*or
gravid*
orgestation*)
4ect.tw.
ect.tw.
ect.tw.
ect:ti,ab
ect.tw.
TI(antenatal*or
prenatal*
orperinatal*)or
AB(antenatal*
orprenatal*or
perinatal*)
5or/1–4
or/1–4
or/1–4
(#1OR#2
OR#3
OR#4)
or/1–4
(MH“expectant
mothers”)
6exppregnancy/
exppregnancy/
exppregnancy/
MeSHdescriptor
pregnancy
explodealltrees
exppregnancy/
(MH“Pregnancy+”)
7Pregnantw
omen/
exp“param
etersconcerning
thefetus,newborn
and
pregnancy”/
exppregnancyoutcom
es/
MeSHdescriptor
pregnant
wom
enexplodealltrees
Expectant
mothers/
S1or
S2or
S3or
S4
8(A
ntenatal$or
prenatal$
orperinatal$).tw.
(Antenatal$or
prenatal$
orperinatal$).tw.
Prenatalexposure/
(Antenatal*or
prenatal*or
perinatal*):ti,ab
(Antenatal$or
prenatal$
orperinatal$).tw.
ABecto
rTIect
9(Pregnan$or
gravid$
orgestation$).tw.
(Pregnan$or
gravid$or
gestation$).tw.
(Antenatal$or
prenatal$
orperinatal$).tw.
(Pregnan*or
gravid*
orgestation*):ti,ab
(Pregnan$or
gravid$
orgestation$).tw.
TI(electroshock*
orelectr*shock*)
orAB(electroshock*
orelectr*
shock*)
10or/6–9
or/6–9
(Pregnan$or
gravid$
orgestation$).tw.
(#6OR#7
OR#8
OR#9)
or/6–9
TI(electroconvulsive*or
electr*
convulsive*)
orAB
(electroconvulsive*or
electr*
convulsive*)
115and10
5and10
or/6-10
(#5and#10)
5and10
(MH“electroconvulsive
therapy”)
125and11
From
11keep
1–11
App
endix1
12 K. A. Leiknes et al.
Tab
le6
Search
strategy,updatein
2012
Databases
Ovid(federated
search):BritishNursing
Index
(1985–Decem
ber2012);Embase
(1974–2012
Decem
ber18);
OvidMEDLIN
E(R)(1946–Present);O
vidNursing
Database
(1948–Decem
berweek22012);PsycINFO
(1806–Decem
berweek22012)
Wiley,CochraneLibrary
Decem
ber2012
EBSC
O;C
inahl,Decem
ber
2012
SveMed,D
ecem
ber
2012
ISIweb
ofKnowledge(SCI-EXPA
NDED,S
SCI,
AandHCI.)
1(Searchstrategy
andsearch
term
sthesameforalld
atabases
asin
Table1)
(Searchstrategy
andsearch
term
sthesameforall
databasesas
inTable1)
(Searchstrategy
andsearch
term
sthesameforall
databasesas
inTable1)
Electroconvulsive
therapy
Topic=(Electroconvulsive
Therapy
orelectroshock*
or“electr*
shock”*)
ANDTo
pic=(pregnan*
orgestation*
orgravid*or
antenatal*or
prenatal*
orperinatal*)
2Tim
espan=
1975–2012
Electroconvulsive therapy during pregnancy: a systematic review 13
Appendix 2
Table 7 Excluded studies (N=33)
First author (year published) Comments and reason for exclusion: (1) about ECT, but not in pregnancy, e.g., in postpartum or other conditions; (2)commentary, no primary data, too sparse data, review without primary data, letter to editor; (3) parallel otherlanguage publication, not possible to find or full text retrieve; and (4) not relevant topic, about anesthesia types orother topic, e.g., electrical shock injury in pregnancy
Bader et al. (2010) (2) No study data
Passov (2010) (2) Conference abstract about 2 cases of ECT in pregnancy, insufficient data
Pinette and Wax (2010) (2) Letter to editor, without study data
Anderson and Reti (2009) (2) Literature review, not primary study
Nielsen et al. (2007) (2) Literature review, not primary study
Richards (2007) (2) Editorial, not primary study
Maletzky (2004) (1) About ECT, but not pregnancy
Ginsberg (2007) (2) Commentary about another article by Pinette et al. (2007)
Howe and Srinivasan (1999) (1) About Cotard’s Syndrome, ECT given in postpartum after delivery by cesarean section
Berle (1999) (1) Four cases of severe postpartum depression, ECT given in postpartum
Cutajar et al. (1998) (1) Case of severe depression in young woman with mild learning disabilities, given ECT in the post-partum period
Ratan and Friedman (1997) (1) About Capgras syndrome in puerperium, ECT given in postpartum period
Anonymous (1997) (2) Editorial commentary, no primary author, about electrical shock injury
Johnson (1996) (1) Case of mania in pregnancy, ECT given in postpartum period
Finnerty et al. (1996) (1) Case 33 years, pregnant (para 3) with bipolar disorder. ECTwas planned given during pregnancy but due tospontaneous rupture of membranes and Caesarian section at 29 gestation weeks (baby reported ok), ECTwasadministered in postpartum period.
Bernardo et al. (1996) (1) Imaginary pregnancy, not pregnant
Bruggeman and de Waart (1994) (2) Letter to editor about another article
Eskes and Nijhuis (1994) (2) Commentary to case study by Verwiel et al. (1994)
Yoong (1990) (4) Not about ECT, but electrical shock injury and baby died 24 hours after delivery
Kramer (1990) (2) Letter to editor about use of ECT in pregnancy
Sneddon and Kerry (1984) (1) 55 cases of puerperal psychosis treated with ECT in postpartum
Raty-Vohsen (1982) (4) General treatment of postpartum psychoses
Levine and Frost (1975) (4) Only about anesthesia type and cardiovascular responses to ECT in 3rd semester pregnancy
Remick and Maurice (1978) (2) Letter to editor, without study data
Cohn et al. (1977) (1) About postpartum
Protheroe (1969) (1) Puerperal psychoses follow-up study and ECT given in postpartum
Anderson (1968) (2) Dissertation abstract
Marcelino Da Silva andAlexandre (1950)
(3) Not able to retrieve/find
Impastato and Gabriel (1957) (1) About ECT in postpartum
Forssman (1955) (4) Not relevant topic, only information on follow-up of 16 children whose mothers were given ECT in pregnancybetween years 1947 to 1952
Forssman (1954) (3) Parallel publication in Swedish to English article of later date by Forssman (1955)
Stone and Walker (1949) (4) Article not human (rats) study data
Walker (1992) (3) Same clinical case presented as in article by Livingston et al. (1994)
14 K. A. Leiknes et al.
Tab
le8
Summaryof
findings
tables
ofincluded
case
studiesN=67
(sorteddescending
byyear)
Prim
ary
author
and
year
Studytype:
Case(s)
Num
ber(N
)Country
Background
Age
inyears
Para
pregnancynumber(P),
Gestatio
nweeks
(GW),
Diagnoses,ratingscales
(e.g.,Ham
ilton
Depression
(HDRS)),M
edication,etc.
ECTparameters
Num
berof
ECTs,treatment
frequency,electrode
placem
entb
ilateral(BL)or
unilateral(UL),
Brief
pulseor
sine
wave
current,device,etc.
Anesthesiaandmonito
ring
Anesthesia,
Oxygenatio
n,monito
ring
ofmother(patient)andfetus
(fetalheartrate(FHR)),etc.
Mothercommentsand
adverseevents
Vaginalbleeding,
Uterine
contractions,
Abdom
inalpain,
Prem
aturelabor,
Miscarriage,
Meconium-stained
amnioticfluid,etc.
Fetus,baby/child
comments
andadverseevents
FHRin
beatsperminute
(bpm
),fetalcardiac
arrhythm
ias,andfetal
malform
ations
Stillbirth,neonataldeath,
neonatalrespiratory
distress,etc.
Generalcommentsand
treatm
entefficacy
Postpartum
treatm
ent,
symptom
remission
orrelapse,other
inform
ation,etc.
DeAsisetal.
(2013)
Case
USA
20years,P2
,GW
23Bipolar
disorder
(6year
history)
Patient
requestedECTdue
toprevious
term
ination
ofpregnancyandfear
ofteratogeniceffects
ofmedication
14ECTs
(given
from
23to
39GW)
Right
UL
Device:MectraSp
ectrum
5000Q
Anesthesia:methohexitaland
musclerelaxant
succinylcholineforfirst2
ECTs
andthen
changedto
propofol
foralln
extE
CTs
On2ndECTat24
GW,
prolongedseizureduratio
n201sandfetalh
eart
deceleratio
n(profound
bradycardia)
after120s.
Medazolam
givento
stop
seizure.
Emergencycesarean
deliv
ery
prepared,but
not
undertaken
whenFH
Rnorm
alized
Babydeliv
ered
atfull
term
Apgar
10Anesthetic
agentchanged
from
methohexitalto
propofol
dueto
serious
FHRdeceleratio
n
Gahretal.
(2012)
Case
Germany
35years,P1
,GW
4(atadm
ission)
Recurrent
depressive
disorder
(6year
history)
Treated
with
Fluoxetin
e(20mg/day)
last2years.
rTMSaddontherapyto
fluoxetinefor5weeks
during
pregnancydidnot
respondto
24sessions
ofrTMS[5
rTMSsessions/
week,frequency=15
Hz;
intensity
=110%
ofresting
motor
threshold(40%
ofmax.stim
ulator
output)
15ECTs
(started
at14
GW)
Right
UL,3
times
weekly
Device:ThymatronDGECT
unit,
Somatics,LLC.
Stim
ulus
intensity
between30
and65
%of
max.stim
ulator
output.S
eizure
duratio
n21–32s
Anesthesia:Alfentanil
augm
entedwith
propofol
withoutthe
useof
volatileanesthetics.
Musclerelaxantsuccinylcholine.
100%
oxygenation
Monito
ring:sonographic
fetalcontrol
Mother:Magnetic
resonant
imaging(M
RI)scan
ofthe
brainnorm
al(beforeECT)
After
24GW
nomore
inform
ationaboutm
other
Noreportof
fetaltraum
aup
to24
GW
After
24GW
noinform
ation
aboutfetus/baby
Rem
ission
ofsymptom
sby
Beck
DepressionInventoryscores
from
56(beforeECT)to4
(1weekafterlastECT)
Yangetal.
(2011)
Case
SouthKorea
33years,P1
,GW
28Schizophrenia
History
of15
years
schizophrenia,hospitalized
5tim
esdueto
psychotic
symptom
s.Medicated
with
risperidone,benzotropine,
7ECTs
during
2weeks
168m
Cseizure75
sPatient
intiltp
osition
with
pad
underrightsidehip
Anesthesia:Thiopental
4mg/kg
andmuscle
relaxant
succinylchlorine
1mg/kg,100
%oxygenation
Monito
redwith
electrocardiography,pulse
oxym
etry,blood
pressure.
1hafter1stE
CTsession
uterinecontractions,
regarded
aspre-term
labor.
Tocolytic
treatm
entw
ith50
mgritodrineand500ml
intravenousdextrose.
FHRvariability
140–
160bpm
underECT.
Babyprem
ature,1,940g
Hyalin
emem
branecongenital
diseaseandhypertrophic
pyloricstenosis
Babyat2monthsoperated
with
pyloromyotomy
procedure
App
endix3
Electroconvulsive therapy during pregnancy: a systematic review 15
Tab
le8
(contin
ued)
Prim
ary
author
and
year
Studytype:
Case(s)
Num
ber(N
)Country
Background
Age
inyears
Para
pregnancynumber(P),
Gestatio
nweeks
(GW),
Diagnoses,ratingscales
(e.g.,Ham
ilton
Depression
(HDRS)),M
edication,etc.
ECTparameters
Num
berof
ECTs,treatment
frequency,electrode
placem
entb
ilateral(BL)or
unilateral(UL),
Brief
pulseor
sine
wave
current,device,etc.
Anesthesiaandmonito
ring
Anesthesia,
Oxygenatio
n,monito
ring
ofmother(patient)andfetus
(fetalheartrate(FHR)),etc.
Mothercommentsand
adverseevents
Vaginalbleeding,
Uterine
contractions,
Abdom
inalpain,
Prem
aturelabor,
Miscarriage,
Meconium-stained
amnioticfluid,etc.
Fetus,baby/child
comments
andadverseevents
FHRin
beatsperminute
(bpm
),fetalcardiac
arrhythm
ias,andfetal
malform
ations
Stillbirth,neonataldeath,
neonatalrespiratory
distress,etc.
Generalcommentsand
treatm
entefficacy
Postpartum
treatm
ent,
symptom
remission
orrelapse,other
inform
ation,etc.
zolpidem
,trazodone,
quetiapine
before
admission.O
lanzapine
also
taken
FHRanduterine
contractility
byultrasound
underandafterECT
Emergencycaesariansectionat
35GW,3
weeks
afterlast
ECT
O’Reardon
etal.
(2011)
Case
USA
39years,P3
(previoustwins),
20GW
Severedepression,
psychomotor
agitation,
dysphoric.
HAM-D
24,B
DI48,B
AI50,
non-responsive
toantid
epressantm
edication
(sertraline,
paroxetin
eplus
quetiapine
augm
entatio
n).G
raves
disease,treatedwith
propylthiouracil.
Previous
major
depressive
episodes
6and4years
before
current.1stepisode
postpartum
onset,2nd
during
twin
pregnancy
resulting
inelectiv
ecaesariandeliv
ery
18ECTs,started
in21
GW
onaoutpatient
basis
Lastp
renatalE
CT(num
ber18)
at35
GW
BLbifrontal
Device:MECTA
Spectrum
5000Q
Anesthesia:methohexitaland
succinylcholine.Cricoid
pressureappliedto
reduce
risk
ofaspiration.From
15th
ECTandonwards,
inthe3rdtrim
ester,aspiratio
nrisk
reducedby
oralsodium
citrateand
intravenous
ondansetronand
metoclopram
ide.
FHRmonito
ring
before
and
afterECTwith
Doppler
monito
runtil
GW
30.
Patient
monito
ring
with
tocometry
foruterine
activ
ity
Caesarian
section(due
to2
previous
caesarian
deliv
eries)at37
GW
(2GW
afterlastECT)
Patient
developedsm
allleft
sidedpneumothoraxduring
deliv
ery
Babygirl,6
lb7oz.
Apgar
scores
norm
al.
Child
followed
upfor
18months,norm
aldevelopm
ent–
language,
fine
motor
andsocial
developm
entswith
innorm
allim
its–no
developm
entald
elays
Improvem
entafter
3ECT
sessions,H
AM-D
24score
reducedfrom
40to
20with
similarchangesin
otherscores.
13continuatio
nECTs
administeredin
postpartum
period
over
6months,thereafter
pharmacotherapy
for
depression
andanxiety
ECTcommentedas
safe.
Provides
alisto
frecommendatio
nsforE
CT
during
pregnancy
Salzbrenner
etal.
(2011)
Case
USA
48years,P1
,GW
32Severe
bipolardepression,
suicidal.
History
ofhypothyroidism
,obesity,h
ypertension,
diabetes
mellitus.
Invitrofertilizatio
n(IVF)
9ECTs
BL
ECTgiven3tim
esweekly
Brief
pulsewave
Device:MECTA
spectrum
5000Q
ECTstoppedafter9thsession
dueto
cognitive
decline
Anesthesia:
Methohexitaland
succinylcholine
Alsohypertensive
medication
with
labetalolu
ntil6th
ECT,
thereafter
replaced
with
remifentanild
ueto
increasedbloodpressure
afterECT
FHRmonito
red.
Caesarian
sectionat38
GW
and
6days,d
ueto
preeclam
psia
andbreech
presentatio
n
Nobirth/Apgar
data.
Child
exam
ined
at4and
9months,and
developm
entreportedas
norm
al
Conceived
viaIV
Fwith
donoregg.
Postpartum
prophylacticoral
medication(lith
obid)to
avoidmaniasymptom
s.Provides
a10
pointchecklist
forpregnant
wom
enundergoing
ECT
Lovas
etal.
(2011)
Case
Hungary
31years,P1
,GW
7–22
Bipolar
disorder
History
ofsevere
mania
21ECTs
2series,
7given2tim
esweeklyand14
given1tim
eweekly
BL
Anesthesia:
Propofol
andsuxamethonium
.Pre-oxygenization.In
last6
ECTs
rapidsequence
Abdom
inalpain
in4th
ECTsession.
Babyboy,Apgar
9.Medication:
Quiatipineand
lamotrigine
medicationin
3rdtrim
ester.
16 K. A. Leiknes et al.
Tab
le8
(contin
ued)
Prim
ary
author
and
year
Studytype:
Case(s)
Num
ber(N
)Country
Background
Age
inyears
Para
pregnancynumber(P),
Gestatio
nweeks
(GW),
Diagnoses,ratingscales
(e.g.,Ham
ilton
Depression
(HDRS)),M
edication,etc.
ECTparameters
Num
berof
ECTs,treatment
frequency,electrode
placem
entb
ilateral(BL)or
unilateral(UL),
Brief
pulseor
sine
wave
current,device,etc.
Anesthesiaandmonito
ring
Anesthesia,
Oxygenatio
n,monito
ring
ofmother(patient)andfetus
(fetalheartrate(FHR)),etc.
Mothercommentsand
adverseevents
Vaginalbleeding,
Uterine
contractions,
Abdom
inalpain,
Prem
aturelabor,
Miscarriage,
Meconium-stained
amnioticfluid,etc.
Fetus,baby/child
comments
andadverseevents
FHRin
beatsperminute
(bpm
),fetalcardiac
arrhythm
ias,andfetal
malform
ations
Stillbirth,neonataldeath,
neonatalrespiratory
distress,etc.
Generalcommentsand
treatm
entefficacy
Postpartum
treatm
ent,
symptom
remission
orrelapse,other
inform
ation,etc.
Medicated
with
quetiapine
750mg/d,diazepam
10mg/dayatGW
6,haloperidolg
iven
for
5days.
ECTgivendueto
persistent
severe
manicandpsychotic
symptom
s
Device:Siem
ensKonvulsator
2077s.
Interm
ittentcurrent.
Not
intubatedforthefirst1
5ECTs.
Last6
ECTs
ranitid
ine
20mg,metoclopram
ide
20mg
inductionanesthesia
techniqueused.
Monito
ring:
Electrocardiography,blood
pressureandarterialoxygen
saturatio
n.Regular
ultrasound
exam
inationof
fetus
Caesarian
sectionat39
GW
dueto
developm
ento
fpreeclam
psiasymptom
s
Cardiotocographynotu
sed,
sinceauthorsclaim
inform
ationfrom
thisto
belim
itedbefore
24GW
Pesiridou
etal.
(2010)
Case
USA
33years,P3
,GW
30–32
BipolarII,alcoholandcocaine
abuse,borderlin
epersonality
disorder
6ULBrief
pulseECT
Maternalp
osition:lefth
iplateraltilt
Device:Mectaspectrum
5000Q60-H
z15
sseizures
firstthen
etom
idatesubstitution
increasedto
38–45s
Anesthesia:
Methohexital1
70mgand
musclerelaxant
succinylchlorine
100mg
10hafterECTsession6
painfulcontractio
ns,further
interm
ittentcontractio
nsuntil
spontaneousbirth
at37
GW
Babyok
Apgar
9
Serim
etal.
(2010)
Case
Turkey
16.5
years,P1
,GW
29(atadm
ission),GW
31(atE
CTstart)
Major
depression
with
psychotic
features
(HDRSscore32)
10ECTs
(lastin
g30
sor
more)
BL(bitemporal)
Brief
pulsewave
Device:Thyam
tron
System
IV
Anesthesia.Propofol
1mg/kg
andmusclerelaxant
rocuronium
.Mask
oxygenation.
Fetalm
onito
ring:
Ultrasonography
Examinationweeklyduring
pregnancyby
obstetrician
After
5thECTpatient
improved
(HDRS8).
Twoweeks
after10th
ECT
psychotic
anddepressive
symptom
relapse.
Uterine
contractions
afterone
ECTsessionfor2–3min
inneed
oftocolytic
treatm
ent
byobstetrician.
FHRdecreasedto
below
120bpm
in2–3sduring
oneECTsession.
Caesarian
sectionchosen
for
safe
deliv
erydueto
mental
condition
ofpatient
inGW
39
Baby,1and5min
Apgar
10.
Noabnorm
ality
inneonatal
exam
ination
Mothertreatedwith
antip
sychoticsand
antid
epressant
(risperidone
and
paroxetin
e)during
pregnancyandafter
deliv
ery.Po
stpartum
symptom
improvem
ent
(HDRS11)
Molinaetal.
(2010)
Cases
N=2
Spain
Case1:
GW
26Case2:
GW
38Manicdepressive
psychosis
refractory
tomedication
treatm
ent
13ECTs
altogether
for
both
2cases.
Frequency,2ECTs
perweek.
ECTdevice
notspecified
Anesthesianotspecified.
Cardiotocogram
monitoring.
Uterine
contractions
reported
after5ECTs,d
isappearing
after58
min
(not
specified
towhich
case)
FHRdeclineunder6
ECTs
(not
specifiedto
which
case).
Spontaneous
deliv
eryat39
GW
(Case1)
and40
GW
(Case2)
Babiesok,adequateweight.
Apgar9/10
forboth
Congressabstractwith
limitedinform
ation
Electroconvulsive therapy during pregnancy: a systematic review 17
Tab
le8
(contin
ued)
Prim
ary
author
and
year
Studytype:
Case(s)
Num
ber(N
)Country
Background
Age
inyears
Para
pregnancynumber(P),
Gestatio
nweeks
(GW),
Diagnoses,ratingscales
(e.g.,Ham
ilton
Depression
(HDRS)),M
edication,etc.
ECTparameters
Num
berof
ECTs,treatment
frequency,electrode
placem
entb
ilateral(BL)or
unilateral(UL),
Brief
pulseor
sine
wave
current,device,etc.
Anesthesiaandmonito
ring
Anesthesia,
Oxygenatio
n,monito
ring
ofmother(patient)andfetus
(fetalheartrate(FHR)),etc.
Mothercommentsand
adverseevents
Vaginalbleeding,
Uterine
contractions,
Abdom
inalpain,
Prem
aturelabor,
Miscarriage,
Meconium-stained
amnioticfluid,etc.
Fetus,baby/child
comments
andadverseevents
FHRin
beatsperminute
(bpm
),fetalcardiac
arrhythm
ias,andfetal
malform
ations
Stillbirth,neonataldeath,
neonatalrespiratory
distress,etc.
Generalcommentsand
treatm
entefficacy
Postpartum
treatm
ent,
symptom
remission
orrelapse,other
inform
ation,etc.
Kucukgoncu
etal.
(2009)
Case
Turkey
Noage,Por
GW
data.
Schizophrenia
Alsotreatedwith
Clozapine
during
pregnancy
Nodata
Nodata
Noadverseeffectsforthe
patient
Noadverseeffectsforthe
baby
Conferencepaperwith
sparse
data
Ghanizadeh
etal.
(2009)
Case
Iran
30years,P1
,GW
8Bipolar
mooddisorder.
History
ofmentalilln
ess
12years.
Carbamazepine200mg/day
taken5monthspriorto
pregnancy
9ECTs
total
(given
between8to
12GW)
Anesthesia:Thiopental
4mg/kg
andmuscle
relaxant
succinylcholine
1mg/kg
Ultrasonographyexam
ination-
nopathologicalfindings
andgestationalage
12weeks
and2days
Moderatevaginalb
leeding
after3rdECT,
lasting12
h.Given
6moreECTs,
improved
anddischarged.
Nouterinecontractions
orpain.
Relapse
20days
later,
readmitted
manicandgiven
3ECTs
givenin
1week
Nodataaboutfetus,delivery
orbaby
Pregnancy
follo
wed
only
to12
GW+2days
ECTadministeredin
early
pregnancy.
Vaginalbleeding
aftereach
ECTsessionandECT
stopped
Malhotraetal.
(2008)
Cases
N=2
India
Case1:
24years,GW
24Severedepression,suicidal.
Case2:
22years,GW
26Catatonia
Case1:
3ECTs
Case2:
3ECTs
Prem
edication2hpriorto
ECTwith
ranitid
ine,
metoclopram
ideand
isoxsuprine.Preoxygenated
for3min
with
100%
oxygen.
Anesthesia:Thiopentone
and
musclerelaxant
succinylcholine,tracheal
intubatio
n.Monito
ring
fetus:fetalcardiom
etry.
Monitoringpatient:heartrate,
bloodpressure,pulse
oximetry,electrocardiogram
end-tidalCO2.
Nursedinleftlateralposition
inrecovery
room
afterECT
andgivenprofylatctictocolytic
treatm
entw
ithisoxsuprine
10mg8hourly
for48
h
Nodata
Beyond1sttrimestertracheal
intubatio
npreferredto
avoidpulm
onary
aspiratio
n.Mainlyaboutanesthesia,
otherdatavery
sparse
and
lacking
Ceccaldietal.
(2008)
Case
France
28years,P1
,GW
26–30
(2nd
trim
ester)
Bipolar
disorder
with
severe
depressive
episode.
History
ofbipolardisorder
since16
yearsold.
Venlafaxine
andparoxetin
emedicationstoppeddueto
pregnancy
10ECTs
(in26–30GW)
Anesthesia:etom
idate,
propofol
andmuscle
relaxant
suxamethonium
.Monito
ring
ofFH
R
ECTdiscontin
uedafter10th
ECTdueto
prem
ature
deliv
erythreat.
Treated
with
fluoxetin
ein
month
priorto
vaginal
deliv
eryunderepidural
analgesia
Deliveryat36
GW.B
abygirl
healthy,3,120g.
Neurologicalexaminationof
child
revealed
noabnorm
ality
Clinicalim
provem
entfrom
ECTreported
18 K. A. Leiknes et al.
Tab
le8
(contin
ued)
Prim
ary
author
and
year
Studytype:
Case(s)
Num
ber(N
)Country
Background
Age
inyears
Para
pregnancynumber(P),
Gestatio
nweeks
(GW),
Diagnoses,ratingscales
(e.g.,Ham
ilton
Depression
(HDRS)),M
edication,etc.
ECTparameters
Num
berof
ECTs,treatment
frequency,electrode
placem
entb
ilateral(BL)or
unilateral(UL),
Brief
pulseor
sine
wave
current,device,etc.
Anesthesiaandmonito
ring
Anesthesia,
Oxygenatio
n,monito
ring
ofmother(patient)andfetus
(fetalheartrate(FHR)),etc.
Mothercommentsand
adverseevents
Vaginalbleeding,
Uterine
contractions,
Abdom
inalpain,
Prem
aturelabor,
Miscarriage,
Meconium-stained
amnioticfluid,etc.
Fetus,baby/child
comments
andadverseevents
FHRin
beatsperminute
(bpm
),fetalcardiac
arrhythm
ias,andfetal
malform
ations
Stillbirth,neonataldeath,
neonatalrespiratory
distress,etc.
Generalcommentsand
treatm
entefficacy
Postpartum
treatm
ent,
symptom
remission
orrelapse,other
inform
ation,etc.
Bozkurtetal.
(2007)
Case
Turkey
34years,P2
,GW
13Psychotic
depression.
History
of3yearsprior
psychotic
depression,
treatedwith
antid
epressant
andantip
sychotic
medication
13ECTs
(3tim
esweekly)
given
inonemonth
and3ECTs
monthlyform
aintenance
until
32GW
before
birth.
BifrontalECT
Device:MectaSp
ectrum
5000Q
Anesthesia:Thiopental
250mg,100%
oxygenation.Airway
and
cricoidpressureused
(not
intubated).
Nolateraltilt
used.P
atient
monito
redwith
blood
pressure,
electrocardiography
Motherpelvispain
after8th
and9thECT.
Vaginaldeliv
eryat38
GW
FHRreducedto
90bpm
after
13thand16thECT,
rose
tobaselin
eafter2–3s.
Health
ybaby
boyat38
weeks
HDRSscorereducedfrom
33to
7(at1
0thECT)andto
3atreleasefrom
hospital.
Photoof
baby
boyin
article
Kasar
etal.
(2007)
Case
Turkey
32years,P2
,GW
32Major
depressive
disorderwith
psychotic
features
and
suicidalideatio
n(H
DRS
47,IQ71).
Venlafaxinandquetiapine
medicated
Similarcomplaintsin
1st
pregnancy,butn
ottreatedthen
4ECTs
(frequency
3ECTs
perweek)
Bifrontalplacem
ent
Device:Thymatronsystem
IV(Som
atics,LakeBluff,IL)
In4thECTanesthesia:
Propofol
1mg/kg
and
musclerelaxant
succinylcholine.
Fetalm
onito
ring
byobstetric
consultatio
nsand
ultrasonography
1dayafter4thECTuterine
contractions/birth
pains–
prem
aturelaborand
caesariansectionperformed
at34
GW
Babyprem
aturehealthy,
2,600g.
Baby:
‘normal’developm
ent
for6months
After
3rdECT,
improvem
ent
indepression,H
DRS15
Pinette
etal.
(2007)
Case
USA
22years,P1
,GW
20–34
Bipolar
depression
(longhistory).
Priorto
pregnancy
maintenance
ECTtreatm
ent
7ECTs
in20–34GW
BifrontalECTevery2ndweek
inentirepregnancy
Nodata
Preeclampsiadevelopm
ent:
elevated
bloodpressureand
urineproteinlevel.
Inducedlabor,vaginald
elivery
at36
GW
FHRrecorded
aftereach
ECT
with
noabnorm
alities.
Babyboy,2,550g
1and5min
Apgarscores,
4and7.
Baby:
smallleftcerebellum
andbi-hem
isphericdeep
whitemattercortical
infarct
Sparse
ECTdata.
Longterm
motor
control
issues
assumed
forbaby
Espínola-
Nadurille
etal.
(2007)
Case
Mexico
22years,GW
21Schizophreniform
catatonicfeatures.
Haloperidol
5mg
intram
uscularinjection
givenin
emergencyroom
resulting
inmalignant
catatonicsyndromeand
acuterenalfailure
10ECTs
given3tim
esweekly
with
20%
stim
ulus
BL
Device:ThymatronDGx,
Alsotreatedwith
Lorazepam
afterECT
Obstetricultrasonography
monito
ring
offetus
during
pregnancy
Nodata
Noadverseeffectson
fetus
observed
Partialrem
ission
ofsymptom
safterECTand
furthertreatedwith
clozapine
Case
35years,GW
30
Electroconvulsive therapy during pregnancy: a systematic review 19
Tab
le8
(contin
ued)
Prim
ary
author
and
year
Studytype:
Case(s)
Num
ber(N
)Country
Background
Age
inyears
Para
pregnancynumber(P),
Gestatio
nweeks
(GW),
Diagnoses,ratingscales
(e.g.,Ham
ilton
Depression
(HDRS)),M
edication,etc.
ECTparameters
Num
berof
ECTs,treatment
frequency,electrode
placem
entb
ilateral(BL)or
unilateral(UL),
Brief
pulseor
sine
wave
current,device,etc.
Anesthesiaandmonito
ring
Anesthesia,
Oxygenatio
n,monito
ring
ofmother(patient)andfetus
(fetalheartrate(FHR)),etc.
Mothercommentsand
adverseevents
Vaginalbleeding,
Uterine
contractions,
Abdom
inalpain,
Prem
aturelabor,
Miscarriage,
Meconium-stained
amnioticfluid,etc.
Fetus,baby/child
comments
andadverseevents
FHRin
beatsperminute
(bpm
),fetalcardiac
arrhythm
ias,andfetal
malform
ations
Stillbirth,neonataldeath,
neonatalrespiratory
distress,etc.
Generalcommentsand
treatm
entefficacy
Postpartum
treatm
ent,
symptom
remission
orrelapse,other
inform
ation,etc.
Prieto
Martin
etal.
(2006)
Spain
Severedepression
ECTindicatio
n:clinical
condition
worsenedafter
initiationantip
sychoticand
antid
epressantm
edication
(mirtazapine,fluvoxamine,
alprazolam
,quetiapine)
9ECTs
(3tim
esweekly)
begun
at32
GW
Brief
pulsewave
Device:Thymatrone
TM
SomaticsInc
Anesthesia:propofol
and
succinylcholinewith
endotrachealintubatio
nPatient
andfetuswere
monito
red.
Nosignificantv
ariatio
nsin
maternalb
lood
pressure
orheartrate,norFH
R
Tocolytic
treatm
entgiven
when
uterinecontractions
detected
afterECT.
2days
afterlastECTin
35–36
GW
thepatient
wentinto
prem
aturelabor.Vaginal
deliv
ery
After
6thECTFH
Rdeceleratio
nobserved.
Babyboy,2,320g,Apgar
9after1min,A
pgar
10after
5min
Patient
improved
from
ECT
anddischarged
with
only
lorazepam
medication
Balki
etal.
(2006)
Case
Canada
31years,P1
,GW
22Bipolar
disorder,suicidal
Medication:
lithium
,paroxitene,lorazepam
.Lith
ium
discontin
uedand
othermedicationcontinued
during
pregnancy
1ECT(w
ith3successive
electricalcurrentstim
ulations
given).
Right
UL
Anesthesia:Thiopental
250mgandmuscle
relaxant
succinylcholine
100mg.Endotracheal
intubation.40
%oxygenation.
Patient
monito
redwith
electroencephalogram
(EEG).MRIscan
ofbrain
takenshow
ingincreased
signalover
parietalarea
consistent
with
seizure
activ
ity.
FHRmonito
redinterm
ittently
byobstetrician
After
last3rdECTstim
ulus
continuous
grandmal
seizures
occurred.
Inattempttostop
seizuregiven
largedosesthiopental,
diazepam
andpropofolover
2½h.Fo
llowed
bythiopentalandpropofol
infusion.E
EGdemonstrated
seizureactiv
ityfor5h.
Patient
transferredto
intensivecare
unit.
Due
tohypotensiontreatedwith
phenylephrineand
dopamineinfusion.O
n7th
daypatient
regained
consciousnessand
extubated.EEGmild
encephalography
On2nddayfetusdied,labor
ensued
andspontaneous
vaginaldeliveryon
3rdday
PatientsICUcomplicated
with
diabetes
insipidus,
renaland
leftventricular
dysfunction
Maletzky
(2004)
Cases
N=4
USA
Case1:
27years,GW
unknow
n,MDD2months
afterpregnant
2Cases
Major
depressive
disorder
(MDD)
2Cases
MDDwith
psychotic
features
Case1:
6ECTs,B
L,over
2weeks
Case2:
8ECTs
Case3:
5ECTs
Case4:
8ECTs
Device:MectaSp
ectrum
Nodata
Nodata
Case1:
healthyboybaby
Cases
2–4:
nodata
Case1:Po
stpartum
ECTdue
torelapseof
symptom
s4weeks
afterdeliv
ery,
response
toECTgood
atboth
timepoints
Onlyoneouto
f4pregnancy
casesreported
with
more
detail
Brownetal.
(2003)
Case
USA
37years,P1
,GW
20Psychotic
depression
8ECTs
during
3weeks
Preoxygenatio
nNoadverseeventsreported
Nodata
Acase
reportconcernedmore
with
theairw
ay
20 K. A. Leiknes et al.
Tab
le8
(contin
ued)
Prim
ary
author
and
year
Studytype:
Case(s)
Num
ber(N
)Country
Background
Age
inyears
Para
pregnancynumber(P),
Gestatio
nweeks
(GW),
Diagnoses,ratingscales
(e.g.,Ham
ilton
Depression
(HDRS)),M
edication,etc.
ECTparameters
Num
berof
ECTs,treatment
frequency,electrode
placem
entb
ilateral(BL)or
unilateral(UL),
Brief
pulseor
sine
wave
current,device,etc.
Anesthesiaandmonito
ring
Anesthesia,
Oxygenatio
n,monito
ring
ofmother(patient)andfetus
(fetalheartrate(FHR)),etc.
Mothercommentsand
adverseevents
Vaginalbleeding,
Uterine
contractions,
Abdom
inalpain,
Prem
aturelabor,
Miscarriage,
Meconium-stained
amnioticfluid,etc.
Fetus,baby/child
comments
andadverseevents
FHRin
beatsperminute
(bpm
),fetalcardiac
arrhythm
ias,andfetal
malform
ations
Stillbirth,neonataldeath,
neonatalrespiratory
distress,etc.
Generalcommentsand
treatm
entefficacy
Postpartum
treatm
ent,
symptom
remission
orrelapse,other
inform
ation,etc.
Positio
n,leftuterine
displacement
Anesthesia:Thiopental3
mg
andsuccinylcholine
1.6mg/kg.
Intubatio
ndifficultiesin
1st
ECTdueto
mandibular,
teethandpalateanatom
ical
condition.P
roSealTMLMA
chosen
forairw
aymanagem
entd
uringall
furtherECTs
managem
entand
preventionof
aspiratio
n
DeB
attista
etal.
(2003)
Case
USA
41years,P1
,17GW
Major
depression,w
ithdraw
nfrom
daily
nefazodone
medicationatapprox.
4weeks
gestation
5ECTs
BL
Brief
pulsewave
Device:Thymatron.
Devicesetat4
5%
maxim
umforallE
CTs
Anesthesia:
Thiopental(in
first2
ECTs),
etom
idate(inlast3ECTs)
with
musclerelaxant
succinylcholine,100%
oxygenation.
Prem
edicationwith
bicitraper
osandintravenous
metoclopram
ideto
avoid
gastricreflux.
Maternalelectrocardiogram
,bloodpressure
monito
ring
andEEGduring
ECT.
FHRmonito
redwith
Doppler
before
andafterECT.
Lateraltiltn
otused
Maternalh
eartrateandblood
pressure
increase
20%
Vaginaldeliv
eryat38
GW
In4thECTFH
Rdeceleratio
ndownto
100bpm
In5thECTFH
Rdeceleratio
ndownto
60bpm,lastin
g3–5s.
Babyboy,38
weeks,ok
HAM-D
scorereducedfrom
31preECTto7postECT
andpatient
discharged
Fukuchietal.
(2003)
Case
Japan
36years
Obsessive
compulsivedisorder
(OCD)
Pharmacotherapy
ineffective
2ECTs
Anesthesiagivenbuttype
unknow
n.Monito
ring:cardiotocography
throughout
theprocedure
FHRdeclineduring
2ndECT
Uterine
contractions
after2nd
ECT,
tocolytic
treatm
ent
with
ritodrine.
Nodeliv
erydata
Nobaby
data
Onlyabstractdata,due
toJapanese
language
Iwasakietal.
(2002)
Case
Japan
24years(G
W>26,in3rd
semester)
Schizophrenia(10year
history)
treatedwith
oral
antip
sychotics
6ECTs
BL,alternativecurrent
(sinewave)
Anesthesia:
thiamylalandsuxamethonium
100%
oxygenation
At6
thECTgeneralanesthesia
maintainedby
sevoflurane
inoxygen,followed
bysuxamethonium
Monito
ring:M
aternal
hemodynam
icvariables,
arterialoxygen
saturatio
n(Spo2),uterine
contractions
bycardiotocogram
At3
rdECTcontinuous
uterine
contractionrefractory
to
3rdECTfetalb
radycardia
6thECTFH
Runchanged
Onlyabstractdata,due
toJapanese
language
Electroconvulsive therapy during pregnancy: a systematic review 21
Tab
le8
(contin
ued)
Prim
ary
author
and
year
Studytype:
Case(s)
Num
ber(N
)Country
Background
Age
inyears
Para
pregnancynumber(P),
Gestatio
nweeks
(GW),
Diagnoses,ratingscales
(e.g.,Ham
ilton
Depression
(HDRS)),M
edication,etc.
ECTparameters
Num
berof
ECTs,treatment
frequency,electrode
placem
entb
ilateral(BL)or
unilateral(UL),
Brief
pulseor
sine
wave
current,device,etc.
Anesthesiaandmonito
ring
Anesthesia,
Oxygenatio
n,monito
ring
ofmother(patient)andfetus
(fetalheartrate(FHR)),etc.
Mothercommentsand
adverseevents
Vaginalbleeding,
Uterine
contractions,
Abdom
inalpain,
Prem
aturelabor,
Miscarriage,
Meconium-stained
amnioticfluid,etc.
Fetus,baby/child
comments
andadverseevents
FHRin
beatsperminute
(bpm
),fetalcardiac
arrhythm
ias,andfetal
malform
ations
Stillbirth,neonataldeath,
neonatalrespiratory
distress,etc.
Generalcommentsand
treatm
entefficacy
Postpartum
treatm
ent,
symptom
remission
orrelapse,other
inform
ation,etc.
tocolysisfor6
minresulting
infetalb
radycardia
AT6thECTuterinecontraction
diminished
Monito
ring
ofFH
RIw
asakietal.
(2002)
Case
31years,GW
21(P
unknow
n)Depression
14ECTs
over
65days
Anesthesia:thiamylalor
propofol.P
ropofolchosen
whensevere
nausea
after
thiamylal.
Patientlaidinasupine
positio
nduring
ECT
FHRmonito
ring:significant
decrease
inFH
Rwith
propofol,nonewith
thiamylal
Delivered
healthybaby,
3yearsoldandwell
Patient
gradually
improved
afterECT.
Verybriefreportwith
sparse
data
Polsterand
Wisner
(1999)
Case
USA
29years,P1
,GW
26Paranoid
schizophreniawith
depressive
symptom
sHistory
of2yearstreatm
ent
with
risperidoneand
paroxetin
e.Patient
self
discontin
uedmedication
before
pregnancy.Becam
eincreasingly
psychotic,
treatedwith
risperidonein
23GW
for19
days.
Increasingly
depressed,
suicidal,catatonicandlittle
effectfrom
loxapine,
lorazepam
and
nortriptyline.ECT
indicatio
n“m
edication
resistant”
12ECTs,3
times
weekly(total
course
lasting3½weeks)
8rightsided
ULand4BL,
BLafter8thECT
Prophylacticpreterm
labor
treatm
entw
ithterbutaline
andindomethacinin
2nd
to12th
ECT
Anesthesia:240mgthiopental
andmusclerelaxant
80mg
succinylcholine.Additional
80mgthiopentalgivenin
ordertodiscontinue
seizure.
Obstetricnursemonito
red
FHRbefore,d
uringand
afterECT
After
1stE
CTuterine
contractions
every2–3min.
Prem
aturelabor,tocolytic
treatm
entw
ithindomethacinandritodrine.
Trichom
oniasisinfectionof
urinarytracttreated
with
metronidazoleand
nitrofurantoin.
During12th
ECTtransient,
patient
hadsignificant
bradycardiaandhypoxemia.
ECTstopped
Nodata
ObstetricianadvisedECT
discontin
uedafter
prem
aturelabortreatm
ent
inobstetricunit,
butE
CT
was
decidedcontinuedby
psychiatricunit.
ECTdiscontinueddueto
minim
alim
provem
ent
Gilo
tetal.
(1999)
Case
France
28years,GW
20(at
admission),GW
28atECT
start
Severe
depressive
disorder,
with
agitatio
nand
psychosis
History
of8yearsrecurrent
mooddisorder.
9ECTs
in5weeks
BL
Sinuswave
Leftlateraltilt
Improvem
ento
bserved
after9ECTs
Anesthesia:Propofol,1
00%
oxygenationandoral-
trachealintubatio
nMonito
ring:U
ltrasonography,
recordingof
uterine
contractions
andFH
R
FHRchange
observed
during
anesthesia.F
etus
exam
inationat32
GW
asnorm
al.
At34GW,signs
offetalascitis
onroutineultrasonography.
Emergencycaesariansection
Babyboy,Apgar
score8and
9.Im
mediatesurgical
treatm
entfor
vascular
meconium
peritonitis.
Asciticfluidsterile,no
bacteriaor
virusfound.
Babydied
9days
later,dueto
metabolicpost-surgical
complications.
ECTadministeredin
asurgical-obstetric
environm
ent.
Multid
isciplinarydiscussion
betweenPsychiatrists,
anesthetistsand
obstetriciansforECT
indicatio
n
22 K. A. Leiknes et al.
Tab
le8
(contin
ued)
Prim
ary
author
and
year
Studytype:
Case(s)
Num
ber(N
)Country
Background
Age
inyears
Para
pregnancynumber(P),
Gestatio
nweeks
(GW),
Diagnoses,ratingscales
(e.g.,Ham
ilton
Depression
(HDRS)),M
edication,etc.
ECTparameters
Num
berof
ECTs,treatment
frequency,electrode
placem
entb
ilateral(BL)or
unilateral(UL),
Brief
pulseor
sine
wave
current,device,etc.
Anesthesiaandmonito
ring
Anesthesia,
Oxygenatio
n,monito
ring
ofmother(patient)andfetus
(fetalheartrate(FHR)),etc.
Mothercommentsand
adverseevents
Vaginalbleeding,
Uterine
contractions,
Abdom
inalpain,
Prem
aturelabor,
Miscarriage,
Meconium-stained
amnioticfluid,etc.
Fetus,baby/child
comments
andadverseevents
FHRin
beatsperminute
(bpm
),fetalcardiac
arrhythm
ias,andfetal
malform
ations
Stillbirth,neonataldeath,
neonatalrespiratory
distress,etc.
Generalcommentsand
treatm
entefficacy
Postpartum
treatm
ent,
symptom
remission
orrelapse,other
inform
ation,etc.
Treated
with
clom
ipramineand
phenothiazine.Also
amitriptylin
e,haloperidol,
oxazepam
andnitrazepam
.ECTdecidedafter7weeks
dueto
lack
ofmedication
response
Examinationof
baby
revealed
perforationof
thesigm
oid
colon,andalefttemporal
sub-duralh
ematom
a.Probablecauseof
death
anoxic-ischemicin
nature
Bhatia
etal.
(1999)
Cases
N=2
USA
Case1:
26years,P1
,GW
35(atadm
ission)GW
37(at
ECTstart)
Recurrent
major
depression
(lastepisode
startedat15
GW).Also
dysm
orphophobiaand
OCDthinking
patterns.
Treated
with
desipram
ine,
lorazepam
andloapine
succinateatGW
35for
2weeks
beforeECT.
History
of5years,multip
leadmissionsandim
ipramine
medicationwith
out
sufficient
effect.
Case2:
23years,P4
,GW
27(atadm
ission)GW
28.7(at
ECTstart)
Generalized
anxietywith
panic
attacks.
Treated
with
desipram
ine,
oxazepam
andtryptophan
with
outsufficientresponse.
History
of8yearsgeneralized
anxietywith
panicattacks
Case1:
6ECTs
(from
GW
37to
39)
3tim
esweekly
BL
Case2:
6ECTs
BL
Case1:Anesthesia:Thiam
ylal,
succinylchlorine
and
curare.100
%oxygenation
andintubation.
Monito
ring:p
elvic
exam
ination,
tocodynamom
etry
and
FHR.
Case2:
Anesthesia:Methohexitaland
succinylchlorine.1
00%
oxygenationandintubatio
n.67
sseizureafter1stE
CT.
Monito
ring:A
fter
6thECT
(GW
31)preterm
labor
contractions
Case1:
uterinecontractions
after2ndECT.
After
3rd
ECTtocolytic
treatm
ent.
After
6thECTuterine
contractions
lasting12
hpostECTandtransferredto
maternity
ward.
FHRvariability
during
uterine
contractions
anddecreased
in3rdECT.
Case2:
NoFH
Rvariability
oruterinecontractions
until
after6thECT.
PostE
CT
preterm
labor(at3
1GW)
subsided
with
tocolytic
treatm
ent
Case1:after6thECTabsence
offetalm
ovem
entfor
25min.
Health
ygirlbaby
6lb
4oz
(2,835
g),bornat39
GW
(2days
afterlastECTand
afterbeingdischarged
home)
Case2:healthybaby
boy,7lb
(3,175
g)born
at35
GW
ECTadministeredindeliv
ery
room
.Bothpatientsmentalstatus
reported
improved
after
ECTseries.
Atfollow-up6monthsafter
ECTboth
patients
symptom
free.
Echevarria
etal.
(1998)
Case
Spain
25years,GW
8Reactivedepression
and
delusionaldisorder
3ECTs
(ECTgivenevery
2ndday)
BL
Sine-w
avecurrent
Anesthesia:
Prem
edication0.01
mg/kg
Atropine.Pre-oxygenated
100%
oxygen
for2min.
Thiopental4
mg/kg
and
After
2ndECTvaginal
bleeding.
After
3rdsessionprofuse
vaginalb
leeding.
Miscarriage
4hlater
After
3rdECTmiscarriage
After
miscarriage
Patient
received
6moreECTs
discharged
incomplete
clinicalremission
Electroconvulsive therapy during pregnancy: a systematic review 23
Tab
le8
(contin
ued)
Prim
ary
author
and
year
Studytype:
Case(s)
Num
ber(N
)Country
Background
Age
inyears
Para
pregnancynumber(P),
Gestatio
nweeks
(GW),
Diagnoses,ratingscales
(e.g.,Ham
ilton
Depression
(HDRS)),M
edication,etc.
ECTparameters
Num
berof
ECTs,treatment
frequency,electrode
placem
entb
ilateral(BL)or
unilateral(UL),
Brief
pulseor
sine
wave
current,device,etc.
Anesthesiaandmonito
ring
Anesthesia,
Oxygenatio
n,monito
ring
ofmother(patient)andfetus
(fetalheartrate(FHR)),etc.
Mothercommentsand
adverseevents
Vaginalbleeding,
Uterine
contractions,
Abdom
inalpain,
Prem
aturelabor,
Miscarriage,
Meconium-stained
amnioticfluid,etc.
Fetus,baby/child
comments
andadverseevents
FHRin
beatsperminute
(bpm
),fetalcardiac
arrhythm
ias,andfetal
malform
ations
Stillbirth,neonataldeath,
neonatalrespiratory
distress,etc.
Generalcommentsand
treatm
entefficacy
Postpartum
treatm
ent,
symptom
remission
orrelapse,other
inform
ation,etc.
Device:Siem
ensKonvulsator
2077-S
1stE
CTseizureduratio
n17
s,2nd24
s,3rd22
s
musclerelaxant
succinylcholine1mg/kg.
Monito
ring:
electrocardiogram,b
lood
pressureandpulse
oxim
etry.U
ltrasonograms
before
andafterECT
Livingston
etal.
(1994)
Casetwins
N=2
USA
28years,P1
,GW
26–34
Severedepression.A
tadmission
confused,
suicidal,v
iolent,not
eatin
ganddelusional.
Medicationpriorto
ECT:
nortriptyline,perphenazine,
fluoxetin
e,thiothixene,
benzotropine
mesylate.
History
of3yearsdepression,
treatedwith
lithium
,thiothixene,benztropine
mesylate,fluoxetin
e,nortriptyline–having
received
someof
these
drugsin
earlypregnancy
8ECTsessions
Minim
albipolarsetting
used
for
generatin
g60–90sseizures
Anesthesia:endotracheal
intubatio
nLeftlateraltiltp
osition.
Monito
ring:
electrocardiography,EEG,
pulseoxim
etry.U
terine
activ
ityandFH
Ralso
Spontaneous
preterm
laborat35
GW
FHRdeceleratio
nfor
2.5min
after3rdECT
Twin
A,2,549
gApgar
6and7
Transpositio
nof
greatvessels.
DIEDof
postoperative
complications
Twin
B,2,894
gApgar
6and8
Analatresia,smallsacral
defect,coarctatio
nof
aorta
Fetaloutcom
e(death)for
one
twin
infant.B
othinfants
norm
al46XXkaryotypes.
Symptom
relapsepost
partum
,treated
with
ECT
anddiversemedication
Verwieletal.
(1994)
Case
Netherlands
27years,18
GW
Treated
with
clorazepateand
oxazepam
inpregnancy.
ECTindication:
Malignant
neuroleptic
syndrome
(MNS)
afterHaloperidol
treatm
ent,unresponsive
todantrolene
2ECTs,given
at29
GW
and
3days,prior
to9weeks
ofMNS
Anesthesia:
thiopental125mgand
succinylcholine35
mg.
Monito
ring:cardiotocography
during
ECTandultrasound
fetusevery7days
Onday88
vaginally
deliv
ery
with
outcom
plications
after
afeverpeak
of39
°Cwith
leukocytecounto
f23
×10
g/land
5barsin
the
imagedifferentiatio
n
Babygirlhealthy,1,790g
Apgar
score8and9after1
and5min.V
entilationnot
needed
andno
sepsis.
Prophylacticantib
iotics
given,from
2ndday
phototherapy
(high
bilirubin
andnorm
alliv
erfunctio
nvalues)
Transferred
toanother
psychiatricwardand
discharged
afterafew
weeks
inreasonable
condition
together
with
healthydaughter
Vanelleetal.
(1991)
Cases
N=5
France
Case1:
30years,P3
,GW
20(4½months)
Bipolar
IIdisorder
History
ofprevious
depressive
episodes
andhypomania.
Treated
with
Quinuprine
Case1:
10ECTs
Case2:
10ECTs
Case3:
6ECTs
Case4:
9ECTs
Case5:
20ECTs
Anesthesia:Propanidid
(Epontol)andmuscle
relaxant
(atlow
dose
toavoiduterinecontractions)
andoxygenation.
Nofetalm
onito
ring
Case1:
Fullterm
baby
okCase2:
Fullterm
baby
okCase3:
Fullterm
baby
okCase4:
Fullterm
baby
okCase5:
Fetusdeathat11
GW
Case4:
Developed
postpartum
mania
antip
sychotic
(pipothiazine)
medication
andmoodstabilizer
(carbamezapine)
24 K. A. Leiknes et al.
Tab
le8
(contin
ued)
Prim
ary
author
and
year
Studytype:
Case(s)
Num
ber(N
)Country
Background
Age
inyears
Para
pregnancynumber(P),
Gestatio
nweeks
(GW),
Diagnoses,ratingscales
(e.g.,Ham
ilton
Depression
(HDRS)),M
edication,etc.
ECTparameters
Num
berof
ECTs,treatment
frequency,electrode
placem
entb
ilateral(BL)or
unilateral(UL),
Brief
pulseor
sine
wave
current,device,etc.
Anesthesiaandmonito
ring
Anesthesia,
Oxygenatio
n,monito
ring
ofmother(patient)andfetus
(fetalheartrate(FHR)),etc.
Mothercommentsand
adverseevents
Vaginalbleeding,
Uterine
contractions,
Abdom
inalpain,
Prem
aturelabor,
Miscarriage,
Meconium-stained
amnioticfluid,etc.
Fetus,baby/child
comments
andadverseevents
FHRin
beatsperminute
(bpm
),fetalcardiac
arrhythm
ias,andfetal
malform
ations
Stillbirth,neonataldeath,
neonatalrespiratory
distress,etc.
Generalcommentsand
treatm
entefficacy
Postpartum
treatm
ent,
symptom
remission
orrelapse,other
inform
ation,etc.
(tricyclicantid
epressant)
andclom
ipraminein
1st
trim
esterwith
outeffect.
Case2:
32years,P3
,GW
20(4½months)
Unipolardepression
(melancholic)
Case3:
27years,P2
,GW
27(7
months)
Schizoaffectivedisorder
ECTdueto
melancholicand
delusionalstate.
History
ofpostpartum
psychoses
Case4:
27years,P1,GW
14(4
months)
Schizoaffectivedisorder
ECTdueto
psychotic
anxiety
state.
Case5:
28years,P1
,GW
7(1½months)
Psychotic
depression
History
ofmelancholy,
hypomaniaprevious
abortio
n.ECTgivento
avoid
antip
sychoticdrugsin
early
pregnancy
Case5:
used
lithium
and
amitryptylinein
early
pregnancy
Sherer
etal.
(1991)
Case
USA
35years,P2
,GW
30Psychotic
depression
7ECTs
BLtemporallobe
ECTfrequency,1tim
eweekly
Device:ThymatronSo
matics
Inc,LakeBluffIll.30
%stim
ulus
setting
(pulsed
bidirectionalsquare-
wave)
fixedpulse1sandfrequency
70Hz,50
sseizures
Anesthesia:Thiopentalsodium
125mgand
succinylcholine50
mg.
100%
oxygen
Motherandfetusmonitored.At
32GW
Dopplervelocimetric
monitoringbefore,during
andafterECT
Bleedinganduterine
contractions
aftereach
ECT
TransienthypertensionafterE
CT.
At31weeks
tocolytic
treatment
with
terbutaline.
At3
4weeks
observationin
deliv
erysuite
needed
dueto
bleeding.
Spontaneous
labor37
GW
and
caesariansectionperformed
FHRreductionafter1stE
CT
Babyboy,2,704gApgar
3and9
Large
retro-placentalclot
confirmingabruption
placentaediagnoses
Electroconvulsive therapy during pregnancy: a systematic review 25
Tab
le8
(contin
ued)
Prim
ary
author
and
year
Studytype:
Case(s)
Num
ber(N
)Country
Background
Age
inyears
Para
pregnancynumber(P),
Gestatio
nweeks
(GW),
Diagnoses,ratingscales
(e.g.,Ham
ilton
Depression
(HDRS)),M
edication,etc.
ECTparameters
Num
berof
ECTs,treatment
frequency,electrode
placem
entb
ilateral(BL)or
unilateral(UL),
Brief
pulseor
sine
wave
current,device,etc.
Anesthesiaandmonito
ring
Anesthesia,
Oxygenatio
n,monito
ring
ofmother(patient)andfetus
(fetalheartrate(FHR)),etc.
Mothercommentsand
adverseevents
Vaginalbleeding,
Uterine
contractions,
Abdom
inalpain,
Prem
aturelabor,
Miscarriage,
Meconium-stained
amnioticfluid,etc.
Fetus,baby/child
comments
andadverseevents
FHRin
beatsperminute
(bpm
),fetalcardiac
arrhythm
ias,andfetal
malform
ations
Stillbirth,neonataldeath,
neonatalrespiratory
distress,etc.
Generalcommentsand
treatm
entefficacy
Postpartum
treatm
ent,
symptom
remission
orrelapse,other
inform
ation,etc.
Yellowlees
andPage
(1990)
Case
Australia
22years,(P
unknow
n)GW
29(atadm
ission)
GW
32(atE
CTstart)
Diagnoses
somew
hatu
nclear-
catatonicfeatures
and
psychotic
depression
Antipsychoticmedicationwith
Haloperidol
10mgdaily
priortoECTandstoppedat
32GW.A
lsogivenacourse
ofam
ytriptyline
9ECTs
over
3weeks
UL(ECTtype
notedas
low
voltage
andno
otherdata)
ECTadministeredin
surgical
recovery
room
with
obstetrician
present
Anesthesia:generalanesthesia
with
endotracheal
intubation100%
oxygen
Fetalm
onito
ring
bycardiotocographand
ultrasound.M
aternal
oxygenationby
oxim
etry.
Maternalo
xygenatio
nbetween99-100
%saturatio
n
FHRnorm
alBabygirlborn
at37
GW,
3,050g
Apgar
8and9.
Child
exam
ined
at3months
follo
w-up:
“no
developm
ental
abnorm
alities”
Postpartum
diagnosis:
Schizoaffectivepsychosis,
IQ63
At3months
follow
-up
“well”
andtaking
flup
hena
zine
decan
oate
(25mg
every3weeks)an
dam
itryptyline
(100mg
atnigh
t)
LaG
rone
(1990)
Case
USA
23years,
GW
22–2
3Acutemania(agitated,
psychotic)andsicklecell
anem
ia.H
istory
ofcholecystectom
yat
19years.Previous
psychiatricadmission
and
antip
sychoticmedication
(thioridazine)
7ECTs
BL
Device:Thymatron,
LakeBuff,Illin
ois
(Brief-pulse
current)
1stseizureindu
cedwith
50%
energy,du
ration
prolon
ged26
0sand
abortedwithintravenou
sdiazepam
.Rem
aining
ECTsat
30%
energy
and
duration
s62
–126
s
Anesthesia:Glycopyrrolate,
methohexitaland
succinylcholinewith
100%
oxygenation.
Intubatedeach
time.
Externalm
onito
ring
avfetus
17days
afterlastECTrelapse
ofsymptom
s,readmission
andmedicated
with
haloperidol.
Prematurelaborat34
GW.
Deliveryby
Caesarian
sectionduetogenital
herpes
infection
Babyboy1,445grequired
intubatio
nApgar
4and6
Infant
grow
thretardation
Postpartum
symptom
relapse,
treatedwith6
ECTsan
dha
lope
rido
l,then
maintainedon
litium
and
flup
hena
zine
Griffith
setal.
(1989)
Case
USA
30years,P2
,GW
22(at
admission)GW
23(atE
CT
start).E
astIndianwom
an.
Majoraffectivedisorder(m
ajor
depression
psychotic
type)
History
ofhy
pothyroidism
treatedwith
levo
thyrox
ine
11ECTs
total:6ECTs
in23–26
GWsand5ECTs
in28–31
GW
3tim
esaweeks
Bifrontem
poral
ECTshock1.00-1.25sand
current6
0Hzwith
1.6-msec
pulsewidth.
Seizureduratio
n30–50s
observed
inoneextrem
ityby
arterialtourniquetmethod
Anesthesia:Pre-
medication
with
glycopyrrolate.
Thiam
ylalsodium
andmuscle
relaxant
succinylcholine.
Monito
ring:M
aternalb
lood
oxygen
saturatio
n,blood
pressure,electrocardiogram
anduterineactiv
ity.F
HR
monito
ring
Normalparametersfor
maternaland
fetal
monito
ring.
Spontaneous
deliv
eryat40
GW
Babyboy2,900g
Apgar
9and9at1and5min
Dischargedwith
thioridazine
medication
at31
GW
Mynors-
Wallis
(1989)
Case
UK
28years,GW
28Ghanian
wom
anDepression
ECTcourse
(num
berof
ECTs
notstated)
Nodata
Nodata
Nofetus/child
data
Letterto
editor.Sparse
data.
Responseto
ECTreported
asgood
26 K. A. Leiknes et al.
Tab
le8
(contin
ued)
Prim
ary
author
and
year
Studytype:
Case(s)
Num
ber(N
)Country
Background
Age
inyears
Para
pregnancynumber(P),
Gestatio
nweeks
(GW),
Diagnoses,ratingscales
(e.g.,Ham
ilton
Depression
(HDRS)),M
edication,etc.
ECTparameters
Num
berof
ECTs,treatment
frequency,electrode
placem
entb
ilateral(BL)or
unilateral(UL),
Brief
pulseor
sine
wave
current,device,etc.
Anesthesiaandmonito
ring
Anesthesia,
Oxygenatio
n,monito
ring
ofmother(patient)andfetus
(fetalheartrate(FHR)),etc.
Mothercommentsand
adverseevents
Vaginalbleeding,
Uterine
contractions,
Abdom
inalpain,
Prem
aturelabor,
Miscarriage,
Meconium-stained
amnioticfluid,etc.
Fetus,baby/child
comments
andadverseevents
FHRin
beatsperminute
(bpm
),fetalcardiac
arrhythm
ias,andfetal
malform
ations
Stillbirth,neonataldeath,
neonatalrespiratory
distress,etc.
Generalcommentsand
treatm
entefficacy
Postpartum
treatm
ent,
symptom
remission
orrelapse,other
inform
ation,etc.
Varan
etal.
(1985)
Case
Canada
33years,P1
,GW
18–20
Paranoid
schizophrenia
Long-standing
historyof
psychiatricillness.
Chlorprom
azinemedicationin
earlypregnancyandbefore
entering
hospital.
Chlorprom
azinemedication
during
pregnancyuntil
discharge
12ECTs
totalo
ver24
days.
BLfirst3
days,then
rightU
L,3
times
weekly.
Device:MECTA
with
minim
umeffectivesettings
Anesthesia:
Methohexital(Brietal),muscle
relaxant
succinylcholine
and100%
oxygenation
Monito
ring:E
EG,
electrocardiogram
(EKG)
andof
mother.FH
Rby
Doppler.
Transient
FHRbradycardia
notedin
tonicphaseof
treatm
ent.
At38
GW
mildpre
eclampsia
toxaem
iadiagno
sed.
Labou
rindu
cedat
term
,no
rmal
vaginaldelivery.
Sligh
tam
nesia,minim
alan
terogrademem
ory
impa
irmen
t,slow
ingof
motor
speed-
normal
after3weeks
Babyboy4,270g.Apger9/9.
Nofetalabnormalities
atbirth
and8days
follo
w-up
Discharged8days
afterb
irth.
Psychiatrically
post
partum
stable
Dorn(1985)
Case
USA
27years,GW
8Bipolar
affectivedisorder
Psychotic
depression
atadmission.
History
ofpsychiatric
hospitalizations
sinceage
20years.Mild
cerebral
palsydiagnoses.Bilateral
hearingloss
sinceage5.
Smallatelectasisof
right
lowerlung
lobe
butn
oactivepulm
onarydisease.
Haloperidol,benztropine,
doxepinmedicationinearly
pregnancy–discontin
ued
whendiscovered
pregnant
9ECTs
BL
Device:MedcraftB
-24
AlternatingCurrent
170Vfor
1s(sinewavetype)
Anesthesia:
Glycopyrrolateprem
edication.
Methohexitalsodium
80mgandmusclerelaxant
succinylcholine80
mg.
Ventilationby
oxygen
mask
(noendotracheal
intubation).M
onitoring:
Maternalb
lood
gases
before
andafterECT.
FHR
byeitherDoppler
orultrasonography.
Electroenchephalogram
(EEG)takenafter5th,7th
and9thECT
Maternalbloo
dpressure
and
pulseincreasedslightly
immediately
afterECT
butno
maternalor
fetal
heartarrhythm
ias.
FHR140bpm
after4thECT
Nobirthdata
Nodata
Symptom
sim
proved
after6th
ECT.
After
9thECT
mild
lyhypomanic.
Dischargedwith
outpatient
planned
maintenance
ECT.
Obstetricianand
anesthesiologistpresent
alongsidepsychiatricstaff
during
ECT.
ECTduring
pregnancy
regarded
assafe
Wiseetal.
(1984)
Case
USA
24years,P2
,GW
28Psychotic
depression
Antipsychoticmedication
taken8monthsbefore
pregnancy
12ECTs
UL(non-dom
inanth
emisphere)
NoECTtype
dataexcept
“low
voltage”.
Generalanesthesiaand
endotrachealintubatio
n.Monito
ring:C
ufftechnique
andEEGrecordings.
Uterine
muscletone
by
PostE
CTpatient
hadbrief
episodeof
supraventricular
tachycardia.Nouterine
contractions
notedafter
ECT.
Baby7lb,6
ozApgar8and9,at1and3min
Rem
ission
ofdepressive
symptom
safter8ECTs
butthenrelapserequiring
4additio
nalE
CTs
Electroconvulsive therapy during pregnancy: a systematic review 27
Tab
le8
(contin
ued)
Prim
ary
author
and
year
Studytype:
Case(s)
Num
ber(N
)Country
Background
Age
inyears
Para
pregnancynumber(P),
Gestatio
nweeks
(GW),
Diagnoses,ratingscales
(e.g.,Ham
ilton
Depression
(HDRS)),M
edication,etc.
ECTparameters
Num
berof
ECTs,treatment
frequency,electrode
placem
entb
ilateral(BL)or
unilateral(UL),
Brief
pulseor
sine
wave
current,device,etc.
Anesthesiaandmonito
ring
Anesthesia,
Oxygenatio
n,monito
ring
ofmother(patient)andfetus
(fetalheartrate(FHR)),etc.
Mothercommentsand
adverseevents
Vaginalbleeding,
Uterine
contractions,
Abdom
inalpain,
Prem
aturelabor,
Miscarriage,
Meconium-stained
amnioticfluid,etc.
Fetus,baby/child
comments
andadverseevents
FHRin
beatsperminute
(bpm
),fetalcardiac
arrhythm
ias,andfetal
malform
ations
Stillbirth,neonataldeath,
neonatalrespiratory
distress,etc.
Generalcommentsand
treatm
entefficacy
Postpartum
treatm
ent,
symptom
remission
orrelapse,other
inform
ation,etc.
Nortriptylin
emedication
during
pregnancy
ECTadministeredinlaborand
deliverysuite.O
bstetrician
present
tocodynamom
eter.F
HR
byDoppler
Noabnorm
alFH
R.
Oxytocininducedvaginallabor
at37
GW
dueto
sustained
hypertension
Repke
and
Berger
(1984)
Case
USA
33years,P2
,GW
19.5(at
admission)
Severedepression,suicidal.
History
of4years,treatedwith
imiprimineand
desimipramin.M
edication
discontin
uedwhen
discovered
pregnant
but
startedagaindueto
severe
condition,given
desimipraminup
to200mg
peros
twicedaily
for
30days
with
minim
alim
provem
ent,then
ECT
2-5ECTcourses
(nootherECTtype
data)
Anesthesia:Atropine
prem
edication.
Methohexitalsodium,
pancuronium
brom
ide,and
succinylcholinechloride.
Markeddrop
inbloodpressure
afterfirstE
CT
FHRtransientelevatio
nBaby3,024g
Apgar
8–9,norm
aldeliv
ery
Babytransient
hyperbilirubinemia
Babyborn
3monthsafter
discharge3
Neurologicalexaminationof
baby
at1month,reported
with
innorm
allim
its
52days
hospitalstay
Lokeand
Salleh
(1983)
Cases
N=3
Malaysia
Case1:21
years,P1,26+GW
atadmission
Case2:25
years,P2,26+GW
atadmission
Case3:22
years,P1,26+GW
atadmission
Diagnoses:A
llschizophrenia,
DSM
-III
Medication:
Case1:oralChlorprom
azine
200mgandHaloperidol6mg
Case2:
oralChlorprom
azine
50mgandHaloperidol
4.5mg
Case3:
oralChlorprom
azine
100mgand100mg
intram
uscularinjection
whenneeded
Case1:
5ECTs
Case2:
6ECTs
Case3:
6ECTs
Nodata
Case1:
Spontaneousvaginal
deliv
eryafterECT
Case2:
Breechpresentatio
n,deliv
ered
atterm
Case3:
Nodataaboutd
elivery
Case1:
Baby3.2kg
Apgar
9–10
Case2:
Baby3.3kg,
Apgar
6–10
Nofetalabnormality
reported
in2of
cases
Nodataaboutcase3baby
Case2:
Postpartum
relapse
andgiven8ECTs
Case3:
11yearspsychiatric
historyof
chronic
schizophrenia
28 K. A. Leiknes et al.
Tab
le8
(contin
ued)
Prim
ary
author
and
year
Studytype:
Case(s)
Num
ber(N
)Country
Background
Age
inyears
Para
pregnancynumber(P),
Gestatio
nweeks
(GW),
Diagnoses,ratingscales
(e.g.,Ham
ilton
Depression
(HDRS)),M
edication,etc.
ECTparameters
Num
berof
ECTs,treatment
frequency,electrode
placem
entb
ilateral(BL)or
unilateral(UL),
Brief
pulseor
sine
wave
current,device,etc.
Anesthesiaandmonito
ring
Anesthesia,
Oxygenatio
n,monito
ring
ofmother(patient)andfetus
(fetalheartrate(FHR)),etc.
Mothercommentsand
adverseevents
Vaginalbleeding,
Uterine
contractions,
Abdom
inalpain,
Prem
aturelabor,
Miscarriage,
Meconium-stained
amnioticfluid,etc.
Fetus,baby/child
comments
andadverseevents
FHRin
beatsperminute
(bpm
),fetalcardiac
arrhythm
ias,andfetal
malform
ations
Stillbirth,neonataldeath,
neonatalrespiratory
distress,etc.
Generalcommentsand
treatm
entefficacy
Postpartum
treatm
ent,
symptom
remission
orrelapse,other
inform
ation,etc.
Impastato
etal.
(1964)
Case
USA
Noage,16
GW
(atE
CTstart)
Nodiagnosis
7ECTs
Nodata
Abdom
inalpain
after3rdECT
andafterlastECT
Babyborn
fullterm
,normal
Containssummaryof
previous
reportsby
others
ofECTgivenunder
pregnancy,unclearly
presented.Onlyonenew
case
bytheauthors
presentedin
table.
Incompletereferencelist,
impossibleto
tracemany
references
Evrard(1961)
Case
Netherlands
27years,P2
,GW
31–35
(8monthspregnant)
Manicdepressive
psychosis
Previous
historyof
depression
6ECTs
over
3weeks
and
discharged
Nodata
Normaldeliv
ery
Babyboyborn
fullterm
,norm
al,health
yfollo
wed
for6years
Postpartum
relapse,
readmitted
andgiven12
ECTs
with
antip
sychotic
medication(Tofranil),
improved
anddischarged
Barten(1961)
Cases
N=2
Netherlands
Case1:
36years,P4
,GW
32–36
Endogenousdepression
with
psychotic
features
Case2:
33years,P2
,GW
31–34
Obsessive
compulsivedisorder
Case1:
10ECTs
Case2:
8ECTs
Case1:
Anesthesia:Pentothal
andmusclerelaxant
(succinylcholin
echloride).
FHRmonito
ring,frequency
changesduring
ECT
Case2:
Anesthesiatype
unknow
n,succinylcholine
noted.
FHRmonito
ring
Case1:In
7–8ECT,
at34
GW,
uterus
also
inconstant
contraction.
On10th
shockno
uterine
contraction.
Spontaneous
deliv
ery5weeks
afterlastECTand1week
afterduedate
Meconium-stained
amniotic
fluid.
Case2:
FHRdeceleratio
n.Patient
hadslight
visible
cyanosislasting30
safter
ECT.
Patientwentintolabor1
2days
before
date
Case1:
Babyboy,3,450g
healthy.
Som
edegree
offetalo
xygen
deficiency
during
shocks
dueto
FHRchangesand
meconium-stained
amnioticfluid
Case2:
Babygirl,3,000
g“normalim
pression.”
Amnioticfluidclear
Case1:
6weeks
afterbirth
patientinreasonablygood
psychologicalstate,
discharged
Ferrari(1960)
Cases
N=8
Italy
Case1:
19years,P1
,GW
18(5
months)
Depression,delusionsof
guilt
(conditio
nseveraly
ears
prior,symptom
worsening
during
pregnancy)
Case2:
28years,P3
,GW
31(8
months)
Case1:7ECTs
(3tim
esweekly)
Case2:
9ECTs
Case3:
10ECTs
Case4:
9ECTs
Case5:
7+3ECTs
Case6:
10ECTs
Case7:
2+6ECTs
Case8:
7ECTs
Nodata
Case1:
modestimprovem
ent.
Normalpregnancyandbirth
at8½
months
Case2:
improvem
ent,deliv
ery
10days
afterlastECT
treatm
ent
Case3:
moderate
improvem
ent.Deliveryat
7baby
childrenreported
ok–no
abnorm
alities.
Case8:
baby
ingood
condition
Case7:
1Neonatald
eath
at8days
dueto
bronchopneum
onia
Allcase
datasparse,w
ithmodestsym
ptom
improvem
ent
Case1:
20days
postpartum
relapseof
symptom
sand
another8ECTs.
Case7:
postpartum
treated
with
additio
nal1
0ECTs
Electroconvulsive therapy during pregnancy: a systematic review 29
Tab
le8
(contin
ued)
Prim
ary
author
and
year
Studytype:
Case(s)
Num
ber(N
)Country
Background
Age
inyears
Para
pregnancynumber(P),
Gestatio
nweeks
(GW),
Diagnoses,ratingscales
(e.g.,Ham
ilton
Depression
(HDRS)),M
edication,etc.
ECTparameters
Num
berof
ECTs,treatment
frequency,electrode
placem
entb
ilateral(BL)or
unilateral(UL),
Brief
pulseor
sine
wave
current,device,etc.
Anesthesiaandmonito
ring
Anesthesia,
Oxygenatio
n,monito
ring
ofmother(patient)andfetus
(fetalheartrate(FHR)),etc.
Mothercommentsand
adverseevents
Vaginalbleeding,
Uterine
contractions,
Abdom
inalpain,
Prem
aturelabor,
Miscarriage,
Meconium-stained
amnioticfluid,etc.
Fetus,baby/child
comments
andadverseevents
FHRin
beatsperminute
(bpm
),fetalcardiac
arrhythm
ias,andfetal
malform
ations
Stillbirth,neonataldeath,
neonatalrespiratory
distress,etc.
Generalcommentsand
treatm
entefficacy
Postpartum
treatm
ent,
symptom
remission
orrelapse,other
inform
ation,etc.
Unstablemood(about
2years
priorto
pregnancy)
Case3:
32years,P2
,GW
18(5
months)
Severe
depression
(after
sudden
unexpected
neonatalchild
loss
5days
old,in1stpregnancy
1year
prior)
Case4:
22years,P2
,GW
22(6
months)
Severe
depression
Case5:
21years,P1
,GW
18(5
months)
Major
depression
(with
suicide
attempts)
Case6:
35years,P2
,GW
22(6
months)
Severe
depression
(Accidental
contactp
regnancy)
Case7:
25years,P2
,GW
9(3
months)
Severedepression,anxious
meloncholia(Spontaneous
abortio
nin
1stp
regnancy)
Case8:
27years,P2
,GW
31(8
months)
Severe
depression
(prior
tosymptom
s,deathof
6year
oldsonduring
currentp
regnancy)
8½months.Po
stpartum
symptom
recovery.
Case7:Vaginalbleeding
after2
ECTs.A
fter
15daypause,
another6ECTs
given.
Case8:
3days
afterlastECT
spontaneousbirth
Recom
mends
ECTin
pregnancy
Sobel(1960)
Cases
N=33
USA
Noagedataexceptfor2infant
deaths,tomothersa)
42yearsandb)
37years
ECTindication:
Statesof
severe
agitatio
nand/or
catatonia.ECT
administeredas
an
Nodataon
type
oram
ount
ofECTgivento
each
case.
Nopregnancyterm
orGW
data,except
for2cases
withpo
stECT
abdo
minal
pain
in31
–35GW
(8mon
thspregnancy)
2casesof
severe
recurrent
abdominalpain
directly
followingECTin
31–35GW
One
breech
presentatio
ndeliv
ery
Spontaneous
orinduced
abortio
ns,reportedas
none
31Babies.Allwith
birth
weighto
ver2,500g(no
prem
aturebabies).
Fetaldamageam
ongECT
treatedisreported
as6%
-buttypeof
damagenot
specified.
Overallsparse
dataand
unclear.
Fetalabnormality
6%
iscommentedas
surprisingly
high
–and
dataotherw
iselacking.
30 K. A. Leiknes et al.
Tab
le8
(contin
ued)
Prim
ary
author
and
year
Studytype:
Case(s)
Num
ber(N
)Country
Background
Age
inyears
Para
pregnancynumber(P),
Gestatio
nweeks
(GW),
Diagnoses,ratingscales
(e.g.,Ham
ilton
Depression
(HDRS)),M
edication,etc.
ECTparameters
Num
berof
ECTs,treatment
frequency,electrode
placem
entb
ilateral(BL)or
unilateral(UL),
Brief
pulseor
sine
wave
current,device,etc.
Anesthesiaandmonito
ring
Anesthesia,
Oxygenatio
n,monito
ring
ofmother(patient)andfetus
(fetalheartrate(FHR)),etc.
Mothercommentsand
adverseevents
Vaginalbleeding,
Uterine
contractions,
Abdom
inalpain,
Prem
aturelabor,
Miscarriage,
Meconium-stained
amnioticfluid,etc.
Fetus,baby/child
comments
andadverseevents
FHRin
beatsperminute
(bpm
),fetalcardiac
arrhythm
ias,andfetal
malform
ations
Stillbirth,neonataldeath,
neonatalrespiratory
distress,etc.
Generalcommentsand
treatm
entefficacy
Postpartum
treatm
ent,
symptom
remission
orrelapse,other
inform
ation,etc.
emergencyform
oftreatm
ent
Retrospectiv
ehospitalchart
studyof
ECTtreated
patientswhilepregnant
who
deliv
ered
in8New
Yorkstatehospitalsfrom
1949
to1958
2infant
deaths:
1anencephali(born
tomother
a);1
congenitalcystsand
bronchopneum
onia(born
tomotherbandoneof
twins)
Follo
w-upon
babies
from
2weeks
to5months
reported
having
noabnorm
alities
Schachter
(1960)
Case
France
34years,GW
8(2nd
month
pregnant)
Depression
24ECTs
Nodata
Nodata
Babygirl2,000g,prem
ature,
cyanoticin
need
ofresuscitatio
n,34
GW.
Severementalretardatio
n,congenitalg
laucom
a,left-
sidedcleftp
alate
Mainlycase
reportabout
child
seen
at4to
7years
old.Som
e,butsparsedata
aboutm
other
Smith
(1956)
Cases
N=15
UK
Age
range:18–35years
Age
mean:
27years
Case1:
P1,G
W16
Case2:
P1,G
W30
Case3:
P2,G
W28
Case4:
P2,G
W12
Case5:
P2,G
W8
Case6:
P1,G
W16
Case7:
P3,G
W30
Case8:
P3,G
W20
Case9:
P4,G
W20
Case10:P
3,GW
40Case11:P
1,GW
30Case12:P
1,GW
24Case13:P
1,GW
33Case14:P
6,GW
16Case15:P
1,GW
4Case7:
twoprevious
miscarriages
Case9Rhesusnegativ
eDiagnoses:
12endogenous
depression,1
acuteschizophrenic
Case1:
6ECTs
Case2:
6ECTs
Case3:
7(m
)ECTs
Case4:
6ECTs
Case5:
6ECTs
Case6:
5(m
)ECTs
Case7:
4ECTs
Case8:
5(m
)ECTs
Case9:
4(m
)ECTs
Case10:5
ECTs
Case11:6
(m)ECTs
Case12:5
(m)ECTs
Case13:5
ECTs
Case14:6
ECTs
Case15:6
ECTs
(m)=modifiedECT
Anesthesia,i.e.m
odified
(m)ECT,
givenin
5cases,all
with
thiopentoneandmuscle
relaxant
suxemethonium
All7othercasesunmodified
ECT,
i.e.,with
out
anesthesia
Noinducedlabour
and
miscarriagesreported
asnone,exceptu
ncertainty
for
case
7andin
case
2prolongedlabor
Allchild
renfollo
wed
upbetween11
months
5years.Tw
ochild
renwith
neurotictraits.Intellectual
deficiencies
andphysical
abnorm
alities
reported
asnone
Case9(Rhesusnegative)
noreportof
any
complications
Electroconvulsive therapy during pregnancy: a systematic review 31
Tab
le8
(contin
ued)
Prim
ary
author
and
year
Studytype:
Case(s)
Num
ber(N
)Country
Background
Age
inyears
Para
pregnancynumber(P),
Gestatio
nweeks
(GW),
Diagnoses,ratingscales
(e.g.,Ham
ilton
Depression
(HDRS)),M
edication,etc.
ECTparameters
Num
berof
ECTs,treatment
frequency,electrode
placem
entb
ilateral(BL)or
unilateral(UL),
Brief
pulseor
sine
wave
current,device,etc.
Anesthesiaandmonito
ring
Anesthesia,
Oxygenatio
n,monito
ring
ofmother(patient)andfetus
(fetalheartrate(FHR)),etc.
Mothercommentsand
adverseevents
Vaginalbleeding,
Uterine
contractions,
Abdom
inalpain,
Prem
aturelabor,
Miscarriage,
Meconium-stained
amnioticfluid,etc.
Fetus,baby/child
comments
andadverseevents
FHRin
beatsperminute
(bpm
),fetalcardiac
arrhythm
ias,andfetal
malform
ations
Stillbirth,neonataldeath,
neonatalrespiratory
distress,etc.
Generalcommentsand
treatm
entefficacy
Postpartum
treatm
ent,
symptom
remission
orrelapse,other
inform
ation,etc.
reactio
n,1paranoid
schizophrenicsyndrome
Monod
(1955)
Cases
N=4
France
Case1:
28years,P2
,GW
20Depression.Alsotreatedwith
Largactilmedication
Case2:
34years,P1
,GW
12Depression
Case3:
19years,P1
,GW
20Confusion
state
Case4:
25years,P1
,GW
4Confusion
state
Case1:
2ECTs
Case2:
4ECTs
Case3:
3ECTs
Case4:
9ECTs
ECTfrequency1×
weekly
Case4:
Pentothalanesthesia
andcurare.Improvem
entof
symptom
safter3rdECT.
Along
apneaafter6thECT
Case1:
Normalterm
deliv
ery
Case2:
Deliverywith
aidof
forcepsdueto
changesin
heartsound
Case3:
Normalbirth
Case4:
Nodata
Case1:
Birth
ofdaughter.
Case2:Babyboy,3,250g.At
9monthsoldhealthy
Case3:
Health
ybaby
boy
Case4:
Nobaby
data
Case2:Po
stpartum
symptom
relapserequiring
treatm
ent
Laird
(1955)
Cases
and
review
N=8
USA
Case1:
24years,P3
,GW
8–39
Hebephrenic
schizophrenia
Case2:
37years,P1
,GW20-28
Psychotic
depression
Case3:
39years,P2
,GW
0–8
Schizoaffective
Case4:
29years,P1
,GW
20–40
Schizoaffective
Case5:
35years,P4
,GW
38.
Manic-depressivedisorder,
depressed
Case6:
28years,P3
,GW
16–
24Paranoid
schizophrenia
Case7:
19years,P1
,GW
26–
34.C
atatonicschizophrenia
Case8:
20years,P1
,GW
16–
28Schizoaffective
Case1:
18ECTs
Case2:
28ECTs
between18–30
GW
+7ECTs
afterGW31
Case3:
7ECTs
Case4:
17ECTs
Case5:
4ECTs
Case6:
20ECTs
Case7:
7ECTs
Case8:
25ECTs
AllunmodifiedECT
(with
outanesthesia)
Case1:Delivery1monthafter
lastECT
Case2:
Delivery2days
after
lastECTatGW
34Case4:
Delivery7days
after
lastECT
Case5:
LastE
CT2weeks
before
deliv
ery
Case6:
Delivery4months
afterlastECT
Case7:
Caesarian
sectiondue
toplatypelloid
pelvicand
leftshoulderpresentatio
n,at
8½months(36GW),
14days
afterlastECT
Case8:
Delivery2months
afterlastECT
Case1:
Fullterm
baby,(no
weight)
Case2:
Babygirl,preterm
(GW34),2,100g,norm
aldevelopm
ent
Case3:
Fullterm
baby,
3,000g
Case4:
Fullterm
baby,
3,500g
Case5:
Fullterm
baby,
2,900g
Case6:
Fullterm
baby,
3,700g
Case7:
Babygirl,3,400
gCase8:
Fullterm
baby,(no
weight)
Case1:
Pregnancysuspected
butexamination
impossiblein
first
2monthsdueto
mental
condition
ECTduring
pregnancy
view
edas
safe
Russelland
Page
(1955)
Cases
N=10
UK
14-35GW
(3to
8½months
pregnant)
ECTgivenbetween14–35GW
(3to
8½months)
Nodata
Nodata
Nodata
Com
mentary,letterto
edito
rwith
very
sparse
data.N
oadverseeffectsreported
Charatanand
Oldham
(1954)
Case(and
review
of12
cases)
29years,GW
16(at
admission)GW
28(atE
CT
start)—31GW
6ECTs
(between28–31GW)
2tim
esweekly
Anesthesia:Pentothaland
suxethonium
Labor
uneventful
Babyfullterm
,3,500
gMentalstatetemporarily
improved
32 K. A. Leiknes et al.
Tab
le8
(contin
ued)
Prim
ary
author
and
year
Studytype:
Case(s)
Num
ber(N
)Country
Background
Age
inyears
Para
pregnancynumber(P),
Gestatio
nweeks
(GW),
Diagnoses,ratingscales
(e.g.,Ham
ilton
Depression
(HDRS)),M
edication,etc.
ECTparameters
Num
berof
ECTs,treatment
frequency,electrode
placem
entb
ilateral(BL)or
unilateral(UL),
Brief
pulseor
sine
wave
current,device,etc.
Anesthesiaandmonito
ring
Anesthesia,
Oxygenatio
n,monito
ring
ofmother(patient)andfetus
(fetalheartrate(FHR)),etc.
Mothercommentsand
adverseevents
Vaginalbleeding,
Uterine
contractions,
Abdom
inalpain,
Prem
aturelabor,
Miscarriage,
Meconium-stained
amnioticfluid,etc.
Fetus,baby/child
comments
andadverseevents
FHRin
beatsperminute
(bpm
),fetalcardiac
arrhythm
ias,andfetal
malform
ations
Stillbirth,neonataldeath,
neonatalrespiratory
distress,etc.
Generalcommentsand
treatm
entefficacy
Postpartum
treatm
ent,
symptom
remission
orrelapse,other
inform
ation,etc.
UK
Catatonicschizophrenia
Device:Strauss-McPhail
(TheratronicsLtd.)
Wickes(1954)
Case
UK
Noage,P8,approx
20GW
whenECTtreated
Schizophrenia
2ECTs
35insulin
comas
in1stand
2nd
trim
ester.ECTs
given
1month
afterinsulin
coma
Nodata
Nodata
Babyborn
4weeks
before
estim
ated
term
Child
exam
ined
at3years,
severe
mentald
eficiency,
blindin
lefteye,unableto
feed
himself,talkor
stand,
incontinent
Only2ECTs,m
ainlyinsulin
comatreatm
ent.Fetus
exposedto
insulin
coma
treatm
entinfirsttrimester,
pregnancyunknow
nuntil
thirdtrim
ester
Yam
amoto
etal.
(1953)
Case
USA
25years,P2
,GW
18–21
(5monthspregnant)
Schizophrenicreactio
nFirstb
ornchild
died
1year
earlier
12ECTs
Dismissedfrom
hospital
2monthsafterlastECT
Nodata
Labor
anddeliv
erynorm
al,
3weeks
afterlefthospital
Babygirlexam
ined
at32
months.
Child
slow
insitting
up,
walking
late(15–
18months),verbally
one
wordsyllables,tem
perfits,
activ
e,chew
ing
fingernails,sleeping
difficulties,little
interestin
pictures
andotherchildren,
eyestrabism
us,and
concludedmentally
retarded
Patientsprogress
afterECT
describedsatisfactoryand
clearmentally
Form
anetal.
(1952)
Cases
N=2
USA
Case1:
22years,P2
,GW
20Depression(Retrograde
amnesiaaccident
depression)
Case2:
43years,P1
,GW
24–32
Reactivedepression
Case1:
7ECT
Case2:
9ECTs
8major
convulsions,3petit
mal
Nodata
Case1:
Deliveryatfull–term
withoutd
epression
Case2:
Greatim
provem
ent,
then
worseagain.At38GW
caesariansection.
Phlibitu
sdeep
vein
thrombosis
inleftleg
Case1:
Baby,6lb
2oz
Case2:
Baby,5lb
4oz
Case2:
Severalp
ostpartum
ECTs
Cooper(1952)
Case
SouthAfrica
28years
Psychotic
depression
(suicidal
event,auditory
hallu
cinatio
ns)
(caseadmitted
in1951)
9ECTs
administeredin
3rd
semester
3tim
esweekly
9hafterlastECTnorm
allabor
occurred
Baby7lb
Health
yinfant
Mentalstatusnotimproved
Porot(1949)
Cases
N=3
Alger
Case1:
ECTgivenearlyin
pregnancy.Retarded
condition.
Case1:
10ECTs
Case2:
3ECTs
Case3:
12ECTs
and23
insulin
-com
as
Case2:
Vaginalbleeding
after
3rdECT.
Phlebitis
inpatientsleg,ECT
discontin
ued
Case2:
Normaldeliv
ery
Case1:
Babyfullterm
Case2:
Babyhealthy
Case3:
Babyfullterm
Sparse
data.A
uthorrefersto
anotherknow
ncase
given
7ECTs
during
3rd
Electroconvulsive therapy during pregnancy: a systematic review 33
Tab
le8
(contin
ued)
Prim
ary
author
and
year
Studytype:
Case(s)
Num
ber(N
)Country
Background
Age
inyears
Para
pregnancynumber(P),
Gestatio
nweeks
(GW),
Diagnoses,ratingscales
(e.g.,Ham
ilton
Depression
(HDRS)),M
edication,etc.
ECTparameters
Num
berof
ECTs,treatment
frequency,electrode
placem
entb
ilateral(BL)or
unilateral(UL),
Brief
pulseor
sine
wave
current,device,etc.
Anesthesiaandmonito
ring
Anesthesia,
Oxygenatio
n,monito
ring
ofmother(patient)andfetus
(fetalheartrate(FHR)),etc.
Mothercommentsand
adverseevents
Vaginalbleeding,
Uterine
contractions,
Abdom
inalpain,
Prem
aturelabor,
Miscarriage,
Meconium-stained
amnioticfluid,etc.
Fetus,baby/child
comments
andadverseevents
FHRin
beatsperminute
(bpm
),fetalcardiac
arrhythm
ias,andfetal
malform
ations
Stillbirth,neonataldeath,
neonatalrespiratory
distress,etc.
Generalcommentsand
treatm
entefficacy
Postpartum
treatm
ent,
symptom
remission
orrelapse,other
inform
ation,etc.
Case2:
GW
28(7
months
pregnant)Agitated
condition.
Case3:
Melancholicstate
Case3:
Vaginalbleeding
after1stE
CT
pregnancymonth,
term
inatingin
anabortio
n
Plenter(1948)
Cases
N=3
Netherlands
Case1:32
years,P5
,GW
8(at
admission)GW
14(atE
CT
start).
Schizophrenia,melancholic
syndrome(Psychoticwith
strong
anxiety)
Last4
thchild
born
recently.
Case2:
32years,GW
10(at
admission)GW
14(atE
CT
start).
Mania,psychotic
Case3:
26years,P1
,GW
24–
38Psychosis,suicidal
Case1:
6ECTs
in2ndtrim
ester
(+7ECTs
aftermiscarriage)
Case2:18
ECTs
in2ndtrim
ester
Case3:
23ECTs
(2tim
esweekly)
Case1:
Strong
vaginal
bleeding
andmiscarriage
inthenightafter
6thECT.
Placentahadto
beremoved
manually
Case2:
Normaldeliv
ery
Case3:
Abdom
inal,belly
pain
after1stE
CT
Case2:
Babyboy,
born
fullterm
.Case3:
Babygirl
Case1:
Worsening
ofsymptom
safter
miscarriage,given
further
7ECTs
andthen
dism
issed
Simon
(1948)
Cases
N=3
USA
Case1:
36years,14–17GW
Agitateddepression
Case2:
25years,18–34GW
Anxiety
attacks
Case3:
25years,GW
22–26
(6th
monthspregnant)
Agitateddepression
with
somaticdelusions
Case1:
6ECTs,5
grandmal
seizures
(attim
eof
firstE
CT
almost4
thmonth
pregnant)
Case2:
10ECTs
between18–34
GW
and4ECTs
laterdueto
relapse.
Case3:
11ECTs
(alto
gether
13convulsions,includinginsulin
therapy)
Nodata
Case1:
Pregnancydescribed
“storm
yandtoxic”.L
ast
ECTgiven7monthsbefore
deliv
ery
Case2:
Delivery10
days
after
lastECT
Case3:
Delivery29
days
after
lastECT
Case1:
Child
died
2days
afterbirth,causeunknow
nCase2:
Babyboydescribed
consistently
healthy
Case3:
Babygirlhealthy
Case1:
Not
seen
againafter
5monthspregnant
but
repliedto
questio
nnaire
1yearand5monthslater.
Case2:Fu
rther12
ECTs
post
partum
andim
proved
Case3:
Given
Sub-shock
insulin
treatm
entearly
inpregnancy
Doanand
Huston
(1948)
Cases
N=7
USA
Case1:
32years,P5
,GW
12–
16(2
monthspregnant)
Depression
Case2:
35years,P7
,GW
16Recurrent
depression
Case3:
27years,P4
,GW
28Psychotic.
Blood
andspinalfluid
exam
inationwith
Wasserm
anns
testpositiv
e
Case1:
6ECTs
Case2:
10ECTs
Case3:
2ECTs
Case4:
9ECTs
Case5:
18ECTs
Case6:
12ECTs
Case7:
16ECTs
ECTfrequency2–3tim
esweekly
Noanestheticagent,but
musclerelaxant
curare
givenbefore
each
treatm
ent.
ECTvoltage
setat120
and60-
cyclecurrent(sine
wave)
appliedfor0.1-0.2s.
Eachtreatm
entp
roduceda
major
convulsion
Case1:
Normaldeliv
eryat36
GW
Case2:
Normaldeliv
eryat36
GW
Case3:
Deliverynorm
alCase7:
Labor
inducedat36
GW,normaldeliv
ery
Case1:
Babyok.
Case2:
Babyexam
ined
2monthslater,
developm
entreported
norm
alCase3:
Normalinfant
Case4:Normalinfant,follow-
upat18mnths,no
developm
ental
abnorm
alities
Case1:
motherim
proved
Case2:
motherim
proved
Case3:
Antilu
etic(anti-
syphilis)treatm
entafter
deliv
ery
Case4:
ECTgave
nosymptom
improvem
ent
Case5:
moderatesymptom
improvem
entfrom
ECT,
34 K. A. Leiknes et al.
Tab
le8
(contin
ued)
Prim
ary
author
and
year
Studytype:
Case(s)
Num
ber(N
)Country
Background
Age
inyears
Para
pregnancynumber(P),
Gestatio
nweeks
(GW),
Diagnoses,ratingscales
(e.g.,Ham
ilton
Depression
(HDRS)),M
edication,etc.
ECTparameters
Num
berof
ECTs,treatment
frequency,electrode
placem
entb
ilateral(BL)or
unilateral(UL),
Brief
pulseor
sine
wave
current,device,etc.
Anesthesiaandmonito
ring
Anesthesia,
Oxygenatio
n,monito
ring
ofmother(patient)andfetus
(fetalheartrate(FHR)),etc.
Mothercommentsand
adverseevents
Vaginalbleeding,
Uterine
contractions,
Abdom
inalpain,
Prem
aturelabor,
Miscarriage,
Meconium-stained
amnioticfluid,etc.
Fetus,baby/child
comments
andadverseevents
FHRin
beatsperminute
(bpm
),fetalcardiac
arrhythm
ias,andfetal
malform
ations
Stillbirth,neonataldeath,
neonatalrespiratory
distress,etc.
Generalcommentsand
treatm
entefficacy
Postpartum
treatm
ent,
symptom
remission
orrelapse,other
inform
ation,etc.
(possibleinfection/
syphilis).G
iven
penicillin
treatm
entw
ithout
improvem
ent,thereafter
ECT
Case4:
24years,P2
,GW
24(6th
month
pregnant)
Psychosis
Case5:
31years,P2
,GW
12Delusional
Case6:
24years,P1
,GW
27Psychosis
Case7:
40years,P5
,GW
27Psychosis
Case5:
Normalinfant,
9monthslaterfollo
wed
up,doing
well
Case6:
Normalchild
Case7:
Normalinfant,
follo
wed
upat7months,
baby
reported
norm
al
at9monthspostpartum
still
mentally
ill.
Case6:
symptom
sim
proved
afterE
CT,butat8
months
postpartum
still
mentally
ill.
Case7:
very
slight
symptom
improvem
entfrom
ECT
Boydand
Brown
(1948)
Cases
N=2
USA
Case1:
17years,P2
,GW
17–
18(4½monthspregnant)
Schizophreniawith
hebephrenicandcatatonic,
features.
Case2:
20years,P1
,GW
27–
30(7
monthspregnant)
Manic-depressivepsychosis
(bipolar)
Case1:
26ECTs
with
curare
medication
Case2:
2ECTs
with
outcurare
andgrand-malinduced
seizure
Case1:After2ndECTvaginal
bleeding.N
ovaginal
bleeding
after3rdECT.
Case2:
After
1stE
CT,
tonic
contractionof
uterus,
lasting10
min
andvaginal
bleeding.A
fter
2ndECT
vaginalbleedingwith
blood
clotsandsustaineduterus
contraction15
min
Case1:
Obstetricexam
ination
norm
alprogress
ofpregnancy.Nodeliv
ery
data.
Case2:
FHRincrease
during
2ndECT,
inaudible.
Prem
aturelabor4
days
after
2ndECT
Case1:
Nochild
data.
Case2:
Babyboy5¼
lb,
prem
atureandnothing
unusualn
oted
Case1:
ECTfailedto
give
completerecovery.
Case2:
14moreECTs
given
inpostpartum
period
due
torelapseof
symptom
s.Recoverymadeand
thereafter
discharged
Block
(1948)
Case
USA
30years,P1
,18–21
GW
(ECT
startw
hen5months
pregnant)
Depressed,psychotic
26ECTs,started
at3tim
esweeklyfirst2
weeks,
then
2tim
esweekly.
Recovered
foraperiod
of2monthsthen
relapsed,E
CT
treatm
entresum
eduntil
6days
before
deliv
ery
Nodata
Nodata
Babyborn,nootherdata
4ECTs
inpostpartum
period
(Given
atotalamount
of30
ECTs)
Kent(1947)
Cases
N=3
New
York,
USA
Case1:
35years,P4
,GW
unknow
n.Dem
entia
praecox,
paranoid
type
Case2:
31years,GW
18–21
(5monthspregnant)at
admission
andGW
22–26
Case1:16ECTs
and50
days
ofinsulin
comatreatm
ent
ECT3tim
esweeklyanddaily
insulin
-com
aCase2:30
ECTs,3
times
weekly
(26grand-maland4petit
mal
seizures).
Nodata
Case1:
Noinfo
Case2:Caesarian
sectionat8½
monthspregnancy
Case3:
Spontaneous
labor,vaginald
elivery
2monthsafterended
ECTandcomatreatm
ent
Case1:M
iscarriage
(abortion),fetus
6in.
Case2:
Normalchild
,6lb
(3,000
g)Case3:
Baby7½
lb
Case1:
Treatmentsuspended
for10
days
afterabortio
n.Case2:
7ECTs
postpartum
Electroconvulsive therapy during pregnancy: a systematic review 35
Tab
le8
(contin
ued)
Prim
ary
author
and
year
Studytype:
Case(s)
Num
ber(N
)Country
Background
Age
inyears
Para
pregnancynumber(P),
Gestatio
nweeks
(GW),
Diagnoses,ratingscales
(e.g.,Ham
ilton
Depression
(HDRS)),M
edication,etc.
ECTparameters
Num
berof
ECTs,treatment
frequency,electrode
placem
entb
ilateral(BL)or
unilateral(UL),
Brief
pulseor
sine
wave
current,device,etc.
Anesthesiaandmonito
ring
Anesthesia,
Oxygenatio
n,monito
ring
ofmother(patient)andfetus
(fetalheartrate(FHR)),etc.
Mothercommentsand
adverseevents
Vaginalbleeding,
Uterine
contractions,
Abdom
inalpain,
Prem
aturelabor,
Miscarriage,
Meconium-stained
amnioticfluid,etc.
Fetus,baby/child
comments
andadverseevents
FHRin
beatsperminute
(bpm
),fetalcardiac
arrhythm
ias,andfetal
malform
ations
Stillbirth,neonataldeath,
neonatalrespiratory
distress,etc.
Generalcommentsand
treatm
entefficacy
Postpartum
treatm
ent,
symptom
remission
orrelapse,other
inform
ation,etc.
(6monthspregnant)
atECTstart.
Manic-depressive
psychosis,manictype
Case3:
33years,P4
,GW
14–17GW
(4monthspregnant).
Dem
entia
praecox,
paranoid
type
Case3:20
ECTs,3
times
weekly,
insulin
-com
aatGW
14–17,
and90
insulin
-com
atreatm
entswith
80comas
Gralnick
(1946)
Case
(1ECTand1
insulin
comacase)
USA
Case1:
31years,P5
,GW
1–13
Catatonic,m
uterefusing
toeat.
History
ofprevious
19insulin
shocktreatm
ents.
[Case2,insulin
shock:
32years,P5
.Audito
ryhallu
cinatio
ns,
6weeks
afteradmission
pregnancyconfirmed.
History
ofpersonality
changespast6years]
Case1:
6+ECTs
(unclear
pregnancylength,E
CTgiven
in1sttrimester)
Also18
insulin
treatm
entswith
8comas
Nodata
Case1:
In3rdtrim
ester,
deliv
erynotedas
spontaneousof
macerated
fetus
Case1:
Macerated
fetus
weight7
lb10
oz.
(delivered
in3rdtrim
ester)
Reporto
f2cases,buto
nly1
with
ECTandinsulin
coma
[Case2:
25Insulin
coma
treatm
ents,begun
in1st
trim
ester—
14moderate
deep
comas
(30–60
min),
hypoglycem
icperiods
(4–5
h)with
Fetusdeath.]
Polatin
and
Hoch
(1945)
Cases
N=2
USA
Case1:
28years,P2
,GW
15Manicdepressive
disorder,
depressed
(Uncooperativ
efor
psychotherapytreatm
ent
before
ECT)
Case2:27
years,P(unknow
n),
GW
29(atE
CTstart),G
W20
(atadm
ission)
Psychoneurosis,conversion
hysteriawith
depression.
Psychotherapytreatm
ent
before
ECT
Case1:
6ECTs
(5convulsions)
Case2:
10ECTs
(started
at7monthspregnant)
Nodata
Case1:
Spontaneous
deliv
eryafter9hof
labor.
Case2:
Spontaneous
deliv
eryafter21
hof
labor
Nomiscarriages,no
prem
aturelabor,no
evidence
ofasphyxia
ofchild
ren
Case1:
Babyboy,3,270g.
Noabnorm
alities
detected.
Babyprogress
norm
al.
Case2:
Normalboyinfant,
3,470g.Noabnorm
alities
detected.B
abyprogress
norm
al
Thorpe(1942)
Case
UK
23years,P3
(2nd
pregnancy
spontaneousabortio
n)17–18GW
atadmission
Acuteagitatedmelancholia
13ECTs
givenover
6weeks,
treatm
entstarted
5weeks
afteradmission
(atapprox.
23GW)
Nodata
Nodeliv
erydata
Nobaby
dataexcept
patient
discharged
with
ahealthy
7monthsoldbaby
36 K. A. Leiknes et al.
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