Electroconvulsive Therapy (ECT) for Major Depressive Disorder during Pregnancy
Abstract Number: S-69
Abstract Type: Case Report/Case Series
Introduction: Major depressive disorder is a psychiatric illness affecting women with twice the lifelong prevalence as men.(1) Pregnancy poses many challenges to therapy.(2) The American Psychiatric Association (APA) affirms that ECT is relatively low risk and highly effective in the management of psychiatric disorders throughout pregnancy.(3) The literature lacks extensive guidelines regarding the anesthetic management of these patients.(4) We present a case of a primigravida undergoing serial ECT during third trimester pregnancy for depression.
Case Report: A 33 year-old primigravida at 30 4/7 weeks gestation presented to the emergency department with suicidal ideation following a two month period of depression. Ultrasound revealed a healthy, viable fetus. Despite pharmacologic treatment, the patient continued to suffer from suicidal thoughts, thus ECT was considered the safest treatment option. Prior to each session the patient was made NPO and given sodium citrate. Left uterine displacement was maintained throughout each anesthetic. RSI using propofol or etomidate, and succinylcholine, was administered followed by successful intubation. Etomidate was used exclusively for six sessions due to its decrease in seizure threshold, while propofol was used for two sessions at the discretion of the anesthesiologist. Neither significant hemodynamic differences, nor differences in therapeutic seizure were noted with either drug. Non-stress tests were performed prior to and immediately after all sessions with no adverse findings. Ten days following the final ECT session (37 3/7 weeks gestation), a healthy neonate was delivered vaginally under epidural anesthesia. Unfortunately, a week after delivery, our patient tried to harm her infant and is again undergoing ECT treatments.
Discussion: Guidelines for the use of ECT in pregnancy are based entirely on published case reports since randomized prospective trials pose an ethical dilemma.(2,5) We feel it is important to add to this base with the description of our case. It is also unique in that two induction agents were used during the course of treatment with equal benefit. Currently, there is no recommended induction agent for ECT during pregnancy.(2,6) Simply, not enough data exists; therefore, we feel this is a possible area for future research.
1. Am J Psychiatry 2002; 159:1667.
2. Obstet Gynecol 2007; 110:465.
3. American Psychiatric Press Inc, 2001.
4. Psychosom Med 2009; 71: 235-42.
5. Obstetric Anesthesia, 3rd ed. Mosby Inc, 2004.
6. Clinical Anesthesia, 5th ed. Lippincott, 2006.