ECT in Pregnancy: A Review of the Literature From 1941 to 2007 ERIC L. ANDERSON, MD,

AND

IRVING M. RETI, MBBS

Objective: To review the literature on the use of electroconvulsive therapy (ECT) during pregnancy and to discuss its risks and benefits for treating severe mental illness during pregnancy. Method: PubMed and PsycINFO databases were searched for English or English-translated articles, case reports, letters, chapters, and Web sites providing original contributions and/or summarizing prior data on ECT administration during pregnancy. Results: A total of 339 cases were found. The majority of patients were treated for depression and at least partial remission was reported in 78% of all cases where efficacy data were available. Among the 339 cases reviewed, there were 25 fetal or neonatal complications, but only 11 of these, which included two deaths, were likely related to ECT. There were 20 maternal complications reported and 18 were likely related to ECT. Conclusions: Although there are limited available data in the literature, it seems that ECT is an effective treatment for severe mental illness during pregnancy and that the risks to fetus and mother are low. Key words: ECT, pregnancy, depression, safety, neonatal. ECT ⫽ electroconvulsive therapy; MDD ⫽ major depressive disorder; MVA⫽ motor vehicle accident.

INTRODUCTION he treatment of mental disorders in pregnancy poses a unique clinical challenge because the clinician is treating not just one but at least two patients simultaneously. Accordingly, pharmacological treatment of psychiatric disorders in pregnant women is complicated by potential untoward effects of medication on the fetus, including morphologic and behavioral teratogenicity, toxicity, and withdrawal syndromes (1). All medications carry potential risk, and this is especially the case in the first trimester. However, although nonpharmacologic treatments, such as psychotherapy, may be effective in some patients, in severely ill patients such forms of treatment may take too long to work or may not work at all. Electroconvulsive therapy (ECT) has been demonstrated to be effective in the treatment of major depressive disorder (MDD) and other mental disorders, such as bipolar affective disorder, psychotic depression, and schizophrenia (2); however, reports of its efficacy and possible risks during pregnancy are scarce and scattered through the literature over seven decades, and there have been no controlled, prospective trials evaluating its use in pregnant women. The most common major mental illness during pregnancy is MDD. Lifetime prevalence of MDD is 10% to 25% in women and peak prevalence rates are in the childbearing years from ages 25 through 44 (3,4). It is estimated that 9% of pregnant patients suffer with an episode of major depression (4,5). Moreover, a study of women found to be depressed after delivery revealed approximately 50% were depressed during pregnancy (6). Untreated depression has been linked to both poor maternal and neonatal outcomes including poor weight gain during pregnancy, a higher risk of alcohol or illicit drug use, preterm birth, lower birth weight, preeclampsia, and hindered mother-infant bonding (7,8). MDD is also associated

T

From the Department of Psychiatry and Behavioral Sciences and the Department of Neuroscience, Johns Hopkins University, Baltimore, Maryland. Address correspondence and reprint requests to Eric L. Anderson, Department of Psychiatry and Behavioral Sciences, Johns Hopkins Hospital, 600 N. Wolfe Street, Meyer 131, Baltimore, MD 21287. E-mail: [email protected] Received for publication April 3, 2008; revision received July 1, 2008. Disclosures: Drs. Anderson and Reti report no competing interests. Neither Dr. Anderson nor Dr. Reti reports funding or other support for preparing this manuscript. DOI: 10.1097/PSY.0b013e318190d7ca Psychosomatic Medicine 71:235–242 (2009) 0033-3174/09/7102-0235 Copyright © 2009 by the American Psychosomatic Society

with an elevated risk for suicide and this risk is increased further by psychotic symptoms (9). Accordingly, MDD is a common condition complicating pregnancy with serious adverse effects if left untreated. There are no figures or estimates available for the number of pregnant women receiving ECT annually. Nonetheless, it likely represents a small proportion of women who might benefit from the treatment. To our knowledge, the last comprehensive review of ECT’s use in pregnancy was by Miller in 1994 (10). Accordingly, we felt it was timely to reassess the benefits and risks of this treatment in pregnancy. METHOD English-language and English-language translated articles published since 1941 that included data on ECT in pregnancy were located in bibliographic databases, online sites, journal issues, and secondary sources, such as journal articles and book chapters. PubMed and PsycINFO were searched using the terms “ECT,” “electroshock,” “electroconvulsive” or “electroconvulsive shock,” and “pregnancy.” Due to the paucity of prospective studies of ECT during pregnancy, articles were included if they provided case report data on ECT being used as an exclusive treatment, in combination with medications, or in conjunction with other somatic therapies, such as insulin shock or metrazol shock therapy. Articles describing courses of shock therapy in which convulsions were triggered exclusively by a nonelectroconvulsive means were excluded. The search yielded 57 articles that met the inclusion criteria and dated from 1942 to 2007. A case report in 1941 that has been documented in other articles as the first case report of shock therapy during pregnancy involved the use of insulin and metrazol therapy, not ECT (11).

RESULTS The total number of English or English-translated cases in the literature of pregnant women treated with ECT was 339. We scrutinized each case for data on the number of treatments, the gestational age at which treatments began, treatment efficacy, and adverse outcomes in mother, fetus, or neonate. Nonetheless, many case reports were missing data. Authorship and year of publication are listed for each case in Table 1 (12– 68). Number of Treatments and Gestational Age Of the 339 cases for which we have some data, 59 of them reported an exact number of treatments, the shortest course being just a single treatment and the longest course being 35 treatments. The mean number of treatments was 10.8. Gestational age was reported in 71 cases. Fifteen patients received ECT in the first trimester, 37 received ECT in the second trimester, and 19 in the third trimester. 235

E. L. ANDERSON AND I. M. RETI TABLE 1.

Case Reports of Pregnant Women Treated With ECT. For Each Case, Where Available, Number of Treatments, Gestational Age at Which Treatments Began, Adverse Outcomes in Mother, Fetus, or Neonate and Treatment Efficacy Are Provided

Case Report

Patient Diagnosis

Thorpe, 1942 (12) Rondepierre et al., 1943 (13)

Depression Unknown

Leroux et al., 1944 (14)

Agitated depression

Pacella, 1944 (15)

No. of ECTs

Gestational Age

13 Unknown

4.5 months 4 weeks

3

8.5 months

Unknown Unknown 3 6 10 Unknown

4 months 5 months 7.5 months 3.5 months 7 months Unknown

Kent, 1947 (21)

Unknown Unknown Unknown Bipolar depressed Hysteria and depression Schizophrenia, depression (14 total cases) Psychosis Unknown Unknown Schizophrenia

6 followed by 18 5 8 16

1 month 3 months Unknown Unknown

Moore, 1947 (22) Turner et al., 1947 (23) Block, 1948 (24) Boyd et al., 1948 (25)

Bipolar disorder Schizophrenia Unknown Depression Depression Schizophrenia

30 20 Unknown 17 11⫹ 26

6 months 4 months 3 months 4 months 5 months 4.5 months

Ravina, 1944 (16) Polatin et al., 1945 (17) Feldman et al., 1946 (18) Gralnick, 1946 (19) Sands, 1946 (20)

Mania Doan et al., 1948 (26)

2⫹

7 months

Simon, 1948 (27)

Depression Depression Psychotic depression Schizophrenia? Psychosis Psychosis Psychotic depression Depression

6 10 2 9 18 12 16 6

Porot, 1949 (28)

Anxiety Psychotic depression Unknown

14 11 Unknown

3 months 6 months First trimester

Unknown

Unknown

Second trimester

Cooper, 1952 (29) Forman et al., 1952 (30) Yamamoto et al., 1953 (31) Charatan et al., 1954 (32) Forssman, 1955 (33) Laird, 1955 (34)

Russell et al., 1955 (35) Smith, 1956 (36)

236

Depression Depression Depression Schizophrenia Schizophrenia Depression (16 cases) Bipolar disorder Psychotic depression Schizoaffective Schizoaffective Bipolar disorder Schizophrenia Schizophrenia Schizoaffective Unknown (10 cases) Depression (12 cases) Schizophrenia (2 cases) Unknown

9 7 9 12 6 1–6 18 35 7 17 4 20 7 25 Unknown 4–7 4–7 Unknown

2 months 4 months 7 months 6 months 3 months 6.5 months 6 months 4 months

8 months 4 months 7 months 6 months 28 weeks Range of 9–21 weeks Unknown 14 weeks 2 months 5 months Unknown 4 months 6 months 4 months 3–8.5 months 1–9 months 1–9 months Unknown

Adverse Eventsa

Efficacy

Nil Miscarriage, but followed an MVA Transient fetal arrhythmia;b normal neonate Nil Nil Nil Nil Nil Nil

R U R R R U R N U

IUFD in 9th month R Nil U Nil U P Preterm labor;b condition of neonate unknown Nil P Nil P Nil U Nil R Nil R Vaginal bleeding;b normal P neonate Preterm labor;b normal R neonate Nil R Nil P Nil P Nil N Nil N Nil R Nil N Term, died 2 days after R delivery Nil P Nil R Hematuria;b normal U neonate Vaginal bleeding;b normal U neonate Nil N Nil R Nil P MR noted at 2-yr follow-up R Nil P Nil U Nil R Preterm labor;b condition R of neonate unknown Nil R Nil R Nil R Nil R Nil R Nil P Nil U Nil U Nil U Nil U (Continued)

Psychosomatic Medicine 71:235–242 (2009)

ECT IN PREGNANCY TABLE 1. Case Report

Patient Diagnosis

Continued

No. of ECTs Unknown

Gestational Age

Sobel, 1960 (37)

Agitation or catatonia (33 cases)

Barten, 1961 (38) Impastato et al., 1964 (39)

Unknown Unknown Unknown Unknown Various unknown (159 cases) Unknown

3rd trimester 3rd trimester Variable

Levine et al., 1975 (40)

Schizophrenia

35 weeks

Loke et al., 1983 (41)

Repke et al., 1984 (42) Dorn, 1985 (43) Wise et al., 1984 (44) Varan et al., 1985 (45)

Schizophreniform Schizophrenia Schizophrenia Depression Depression Psychotic depression Schizophrenia

5 6 6 5 9 12 12

Griffiths et al., 1989 (46) Mynors-Wallis, 1989 (47) LaGrone, 1990 (48)

Psychotic depression Depression Bipolar disorder

6 followed by 5 Unknown 7

Yellowlees et al., 1990 (49) Sherer et al., 1991 (50)

Psychotic depression Psychotic depression

Vanelle et al., 1991 (51) Walker, 1992 (52)

Psychotic depression (10 cases) Depression

Livingston et al., 1994 (53)

Moreno et al., 1998 (54) Bhatia et al., 1999 (55)

Unknown

2nd–3rd trimester

26 weeks 26 weeks 26 weeks 24 weeks 8 weeks 7–8 months 19 weeks 23 weeks 28 weeks 23 weeks

9 7

32 weeks 30 weeks

Unknown

Unknown

13

23 weeks

Depression

8

26 weeks

Psychotic depression Depression

3 6

8 weeks 35 weeks

Depression, Panic d/o

6

29 weeks

Gilot et al., 1999(56)

Psychotic depression

9

23 weeks

Polster et al., 1999 (57)

Schizophrenia, depression

Ishikawa et al., 2001 (58)

Schizophrenia

Iwasaki et al., 2002 (59) DeBattista et al., 2003 (60)

Depression Depression

Fukuchi et al., 2003 (61)

OCD

Psychosomatic Medicine 71:235–242 (2009)

Unreported

6

14 5 Unreported

30 weeks

3rd trimester

21 weeks 17 weeks Unknown

Adverse Eventsa

Efficacy

2 deaths (1 anencephaly, 1 congenital pulmonary cysts) Nil Nil Preterm labor ⫻ 3;b abdominal pain ⫻ 1;b 1 club foot; 1 premature, congenital pulmonary cysts, died; 1 congenital blindness Transient fetal arrhythmia;b normal neonate Nil Nil Nil Nil Nil Nil Transient fetal arrhythmia;b normal neonate Nil Nil Preterm labor (8.5 weeks following ECT); normal neonate Nil Abruptio placentae;b normal neonate Nil

U

R R U

U R P R R R R R R R R

R U U

R Twin B decelerations;b twin A died (transposition of great vessels noted preECT), twin B with VATER (noted pre-ECT) Twin A with transposition P of great vessels, twin B with aorta coarctation (both noted pre-ECT); twin A died and twin B survived Miscarriage;b fetal death R Uterine contractions;b R normal neonate R Preterm labor;b normal neonate Vascular meconium R peritonitis and infant death postop Preterm labor;b neonatal N bradycardia; neonate presumed normal Uterine contractions;b U condition of neonate unknown Nil R Fetal HR decelerations;b R normal neonate R Late decelerations;b normal neonate (Continued)

237

E. L. ANDERSON AND I. M. RETI TABLE 1. Case Report

Patient Diagnosis

Maletzky et al., 2004 (62) Balki, 2006 (63) Prieto et al., 2006 (64) Bozkurt et al., 2007 (65)

Depression (4 cases) Bipolar depression Depression Psychotic depression

Espinola et al., 2007 (66) Kasar et al., 2007 (67)

Schizophreniform Psychotic depression

Pinette et al., 2007 (68)

Bipolar depression

Continued

No. of ECTs Unreported 1 9 25⫹

10 4 7⫹

Adverse Eventsa

Gestational Age Unknown 22 weeks 30 weeks 13 weeks

Efficacy

Nil P (all 4) R Status epilepticus;b stillborn Nil R Transient fetal bradycardia;b R maternal pelvic pain; normal neonate Nil N R Preterm labor 1 day after ECT;b normal neonate Neonatal cortical, deep U hemispheric, and cerebellar infarctionsb

21 weeks 34 weeks Conception⫹

ECT ⫽ electroconvulsive therapy; R ⫽ remission of symptoms; P ⫽ partial remission; N ⫽ no remission; U ⫽ unknown; MVA ⫽ motor vehicle accident; IUFD ⫽ intra-uterine fetal demise; MR ⫽ mental retardation; HR ⫽ heart rate. a Does not include common ECT side effects experienced by most patients, such as confusion, memory loss, headache, and muscle soreness. b Indicates ECT-related or ECT-linked adverse event. TABLE 2.

ECT Efficacy for Reported Conditions Available for 68 Cases Diagnosis

Total cases Remission Partial remission No remission Unknown % At least partial response

BPAD

MDD/Depressiona

Schizophreniab

Schizoaffective

Psychosis (Undefined)

7 5 1 0 1 85.7

37 26 5 3 3 83.8

18 6 5 3 4 61.1

3 2 1 0 0 100.0

3 2 0 1 0 66.7

ECT ⫽ electroconvulsive therapy; BPAP ⫽ Bi-polar affective disorder; MDD ⫽ major depressive disorder. With or without psychoses. b Includes schizophreniform disorder. a

Efficacy Efficacy data were available on 68 of 339 cases (Table 2). Of these 68, 37 were diagnosed with either MDD or “depression” (with or without psychosis) and the rate of at least partial response was 84%. Twenty-one pregnant women were treated for schizophrenia or schizophreniform disorder and the rate of at least partial remission was 61%. Adverse Events Fetal Adverse Events Among the 339 cases, there were 25 cases in which fetal or neonatal abnormalities were reported; however, in many of these cases, the abnormality likely arose months after ECT administration. Among the 25 cases, the following occurred: death (n ⫽ 11), transient fetal bradycardia and or decelerations (n ⫽ 8), peritonitis (n ⫽ 1), club foot (n ⫽ 1), prematurity (n ⫽ 1), congenital pulmonary cysts (n ⫽ 2), congenital blindness (n ⫽ 1), great vessel transposition (n ⫽ 2), aorta coarctation (n ⫽ 1), cortical infarcts (n ⫽ 1), anencephaly (n ⫽ 1), VATER syndrome (n ⫽ 1), and mental retardation (n ⫽ 1). Of the 11 reported fetal or neonatal deaths, only one was believed to be the direct result of ECT. In that case, death 238

followed an episode of status epilepticus in the mother secondary to ECT (63). Another death was the result of a miscarriage when the mother was 8 weeks pregnant and followed 24 hours after her third ECT treatment. ECT was believed unlikely as the cause of death, but it could not be absolutely ruled out (54). Nine of the deaths were believed to be unrelated to ECT: one neonate suffered from peritonitis and died after postoperative complications over 8 weeks after the last ECT (56); two died due to transposition of the great vessels noted on ultrasound before ECT (52,53); one died 2 days after birth which was several months after the last ECT (27); one died as a result of a motor vehicle accident (MVA) (13); and three died from congenital anomalies— congenital pulmonary cysts (37,39) and anencephaly (37)—which were believed to be unrelated to ECT because ECT was administered in the second through third trimesters rather than during organogenesis in the first trimester. The final death, after the use of combination ECT and insulin coma therapy, was believed to be unrelated to ECT as it occurred several months after the last ECT (19). Among the nonfatal abnormalities, the eight reported cases of transient fetal arrhythmias were believed to be related to ECT occurring around the time of its administration Psychosomatic Medicine 71:235–242 (2009)

ECT IN PREGNANCY (14,40,45,52,57,60,61,65). Pinette and colleagues (68) recently reported on an infant whose mother underwent multiple rounds of ECT, the first being around the time of conception. The child was born with multiple interhemispheric infarctions and ECT was considered as a possible cause. Other nonfatal fetal or neonatal abnormalities— congenital blindness (39), club foot (39), aorta coarctation (53), and VATER syndrome (52)—were believed to have developed independently of ECT because they were either present before ECT or because ECT was conducted in the second or third trimester. Also, Gilot and colleagues (56) reported on a case of vascular meconium peritonitis that followed 2 months after the last ECT and was believed unrelated to the treatment. In the one reported case of mental retardation noted at 2-year follow-up, the pregnant mother received ECT at almost the third trimester (31), suggesting ECT was unlikely to be the cause. Accordingly, when likely non-ECT-related complications are excluded, the total number of fetal or neonatal abnormalities possibly related to ECT is 11, being eight cases of transient fetal arrhythmias, one fetal death secondary to status epilepticus, one miscarriage in the first trimester 24 hours post ECT, and one case of multiple cortical and deep white matter infarctions after multiple ECT courses in the pregnant mother. Maternal Adverse Effects Of 339 cases, there were 20 women whose pregnancies were complicated. The complications included status epilepticus (63), hematuria (28), miscarriage (13,54), uterine contractions and/or preterm labor (21,25,34,39,48,55,57,58,67), vaginal bleeding (25,28), abdominal pain (39), and placental abruption (50). Both miscarriages were believed to be unrelated to ECT: one was a miscarriage after an MVA (13), and the other was preterm labor 8.5 weeks after the last ECT treatment (54). The other 18 complications, however, were believed to be at least possibly due to ECT. The 11 neonatal or fetal and 18 maternal cases describing complications likely related to ECT include four cases that each have both a neonatal and maternal complication (54,57,63,65). DISCUSSION Pregnancy does not convey protection against mental illness. However, medications for treating mental illness during pregnancy are associated with a range of potential adverse effects on the fetus. Accordingly, ECT has been viewed as an alternate treatment. Available data on ECT efficacy and risks are scant, but our review suggests ECT administered during pregnancy is effective and that the risks to the woman and child are low. Efficacy Despite missing data, it seems pregnant women administered ECT underwent courses of treatment comparable in length to nonpregnant patients with a mean treatment number of 10.7 treatments (2). Women treated for depression with ECT had a partial response to treatment in 84% of cases, and Psychosomatic Medicine 71:235–242 (2009)

among women treated for schizophrenia and schizophreniform disorders, the rate was 61%. These response rates are comparable to response rates in nonpregnant samples of depressed and schizophrenic patients (69 –71). These rates also compare very favorably to response rates to medications (70,72). In addition, ECT acts more rapidly than antidepressants (72). Risks General Adverse Effects of ECT Confusion, memory loss, muscle soreness, and headache can occur post ECT administered to any patient and were noted among pregnant patients to worsen with continuing treatment (33,36,39). Fetal Bradyarrhythmias Fetal bradyarrhythmias are the most common complication in the fetus resulting from ECT (73), and among the cases we reviewed, they occurred at the rate of 2.7%. Transient fetal heart rate decreases are believed to result primarily from hypoxia (74). In most of the case reports, preoxygenation was not addressed, so it is not possible to comment on the adequacy of the ventilation before ECT treatment. Whereas adequate preoxygenation is necessary to prevent declines in fetal heart rate, hyperventilation to lower seizure threshold should be avoided in pregnancy, as respiratory alkalosis can hinder oxygen unloading from maternal to fetal hemoglobin (10). Positioning a woman during the latter stages of pregnancy to minimize aortocaval compression by elevating the right hip and displacing the uterus will also improve placental perfusion and minimize the risk of hypoxia in the fetus (10,75). Premature Contractions and Labor Induction of premature labor seems to be the most frequent adverse maternal event in ECT. In 3.5% of the cases reviewed, uterine contractions and/or preterm labor were reported. Because the electroconvulsive current does not pass through the uterus (76,77), other physiologic and pathophysiologic factors must be considered. After electroconvulsive stimulation, levels of several hormones change. Among these is oxytocin, which reaches a peak a few minutes post seizure and may induce labor by stimulating uterine contractions (46,75). As well, infection, dehydration, and hypoxia are all risk factors for premature labor. Tocodynamometry during ECT administration can be used for monitoring uterine activity. In the event of uterine contractions, tocolysis with ␤2-adrenergic agonists like ritodrine can be administered (75). Anesthetic Agents The most frequently used anesthetic agent for ECT in the United States is methohexital sodium, although propofol is also used (78). Both propofol and methohexital are shortacting general anesthetics that readily cross the placental barrier (79,80) and their levels in the fetus and newborn vary with maternal serum levels (81,82). The pharmacodynamic prop239

E. L. ANDERSON AND I. M. RETI erties of propofol and methohexital are relatively constant throughout pregnancy and neither drug is associated with teratogenicity. However, maternal administration of methohexital or propofol immediately before delivery can lead to fetal heart rate slowing (59) and temporary sedation in the newborn. These side effects can be minimized by administering low doses of anesthetic, i.e., 0.5 to 1 mg/kg of methohexital or 0.75 to 1.5 mg/kg of propofol (2,81). Given the potential for general anesthesia to sedate the fetus, obstetric fetal monitoring is necessary during ECT (83). During ECT, motor activity is limited by the administration of succinylcholine. Succinylcholine is the muscle relaxant preferred for ECT and is typically given at a dose of 0.5 to 1.5 mg/kg (78). Although succinylcholine does pass the placental barrier, it does so in negligible quantities (84,85). It has no known teratogenic effects. Seizure Induction and Length ECT does not generate current through the uterus. Moreover, cardioversion, which delivers charge comparable in strength to ECT, is associated with a low risk of adverse fetal effects (77). Case reports also exist of pregnant women suffering accidental electric shock with no adverse effects on the fetus (76), most likely because the current did not pass through the abdomen. The mother’s motor activity during ECT per se is not detrimental to the fetus. However, physical injury to or hypoxia of the mother could be detrimental to the fetus. Physical injury is prevented by close monitoring and the administration of muscle relaxants as well as by limiting seizure duration if it is prolonged. The one reported case of status epilepticus resulting in fetal demise post ECT was notable for three stimuli being provided in succession, resulting in a grand mal seizure which was allowed to progress for 200 seconds. Even though seizure activity spontaneously remitted, it resumed again after several minutes and was resistant to attempts at termination (63). Aspiration It has been suggested that pregnant patients receiving ECT are at higher risk of pulmonary aspiration. However, our review demonstrates no cases of aspiration pneumonia. Nonetheless, increasing the gastric pH, for example by administering 30 ml of 0.3 M sodium citrate 15 to 20 minutes before ECT, may minimize the risk of aspiration pneumonia (10,75). Also, anticholinergics sometimes administered before ECT to prevent excessive bradycardia, can lower esophageal sphincter tone, thereby increasing aspiration risk, and consequently should be avoided if possible. Other Adverse Events It has been suggested that ECT in pregnant patients increases the risk of fetal and maternal cerebral hemorrhage, and that ECT also increases the risk of bronchospasm and cardiac events during pregnancy (65,86). Most of these concerns have been refuted by the available evidence (87). In the current 240

review, no occurrences of maternal cardiac events were reported. There is one report of cerebral hemorrhage temporally related to ECT although it was believed to not be causative; the mother suffered from preeclampsia and had to be induced at 36 weeks, 2 weeks after the last ECT treatment (68). Limitations According to a power analysis by Miller, 760 subjects would be required for a controlled prospective trial to test for statistically significant differences in the rate of complications between ECT- and non-ECT-treated pregnant patients with depression (10). However, no randomized, controlled trial has yet been conducted evaluating ECT efficacy for treating major mental illness during pregnancy. An obvious limitation to this current review is reporting bias. Adverse or unusual outcomes post treatment with ECT are much more likely to be reported than normal or uneventful outcomes. For example, at Johns Hopkins, we routinely perform ECT on pregnant patients, but none of these cases have been reported in the general literature as there have been no adverse events. This review also did not focus on the long-term sequelae of ECT as they relate to the neonate, although we found three studies which looked for long-term effects in children born to mothers who received ECT during pregnancy. Forssman evaluated 16 children aged 16 months to 6 years whose mothers had undergone ECT during pregnancy. No children were noted to have defects (33). Smith looked at 15 children aged 11 months to 5 years whose mothers had undergone ECT during pregnancy. Again, no children were noted to have defects (36). Impastato and colleagues (39) reported follow-up on eight children aged 2 weeks to 19 years whose mothers had undergone ECT during pregnancy. They were all normal physically but two were described as “mentally deficient.” The mothers of these two children had received ECT in either the second or third trimesters. CONCLUSIONS Generally speaking, there is support among psychiatrists for the use of ECT in pregnancy (2,88). Based on our review, we find that ECT does seem to be effective for treating major mental illness during pregnancy and the risks of adverse events are low. Accordingly, we would suggest it should be strongly considered in pregnant women with severe symptoms of mental illness, such as psychotic symptoms, catatonia, or strong suicidal urges. REFERENCES 1. Rabheru K. The use of electroconvulsive therapy in special patient populations. Can J Psychiatry October 2001;46:710 –9. 2. American Psychiatric Association Task Force. The Practice of ECT: Recommendations for Treatment, Training, and Privileging. 2nd ed. Washington, DC: American Psychiatric Publishing, Inc.; 2001. 3. Burke KC, Burke JD Jr, Rae DS, Regier DA. Comparing age at onset of major depression and other psychiatric disorders by birth cohorts in five U S community populations. Arch Gen Psychiatry 1991;48:789 –95. 4. Wisner KL, Gelenberg AJ, Leonard H, Zarin D, Frank E. Pharmacologic treatment of depression during pregnancy. JAMA 1999;282:1264 –9. 5. O’Hara MW, Neunaber DJ, Zekoski EM. Prospective study of postparPsychosomatic Medicine 71:235–242 (2009)

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