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Anesthetic Management for ECT during Different Stages of Pregnancy
Abstract Number: F 71
Abstract Type: Case Report/Case Series
The most common major mental illness during pregnancy is major depressive disorder. Untreated depression has been associated with poor maternal and neonatal outcome including poor prenantal care, inadequate weight gain, premature delivery, substance abuse, disengaged parenting behaviors, and suicide. Pharmacological therapy is complicated; many psychotropic medications are teratogens and there is a risk of neonatal toxicity (O'Reardon et al). Electroconvulsive therapy (ECT) is therefore an attractive treatment option and sometimes a first line therapy (Maletzky et al). Literature on ECT in pregnancy suggests that it is effective with low risk to the woman and fetus. Of 329 cases reviewed, there were 20 maternal complications, 18 related to ECT, and 25 fetal complications (Anderson et al). We report on four cases from first trimester to postpartum in which anesthesia was safely delivered.
Case #1 is a 22yo at 7.5 weeks and case #2 is a 31yo at 14 weeks. For the first and second trimester, we preoxygenated and induced with propofol and succinylcholine. The patient was masked until spontaneous ventilation returned. Methohexital and propofol are commonly used anesthetics for ECT because of rapid onset, short duration, and while they cross the placenta, are not teratogenic. Succinylcholine is the most commonly used muscle relaxant and is metabolized by pseudocholinesterases and although these levels decrease with pregnancy, it is not clinically significant.
Case #3 is a 35yo at 35.5 weeks and case #4 is a 33yo 9 days postpartum. For the third trimester and postpartum, we gave sodium citrate, preoxygenated, and induced with propofol and succinylcholine with cricoid pressure. An endotracheal tube was placed, patient ventilated on manual spontaneous mode, and extubated at the end. Pregnant women are predisposed to aspiration due to increased intragastric pressure and decreased lower esophageal sphincter tone and case reports have described intubation for ECT during the third trimester. Anticholinergic agents are commonly used in ECT to prevent bradycardia due to parasympathetic stimulation.
We have described the anesthetic management of 4 cases throughout various stages of pregnancy. Pharmacologic management, full stomach precautions, and hemodynamic changes in ECT were each considered and the anesthetic plan was tailored to the particular risks of the fetus and mother. With care, anesthesia for ECT may safely and effectively be administered during pregnancy.
Anderson, et al. ECT in pregnancy: a review of the literature from 1941 to 2007. Psychosom Med. 2009 Feb;71(2):235-42.
Maletzky, et al. The first-line use of electroconvulsive therapy in major affective disorders. J ECT. 2004 Jun;20(2):112-7.
O’Reardon, et al. Acute and maintenance electroconvulsive therapy for treatment of severe major depression during the second and third trimesters of pregnancy with infant follow-up to 18 months. J ECT. 2011 Mar;27(1):e23-6.