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: kle@nokc.no

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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