CASE REPORT
Fetal Spasms After the Administration of Electroconvulsive Therapy in Pregnancy Our Experience Martin Halmo, MD, Barbara Spodniaková, MD, and Petra Nosáľová, MD Objectives: Most psychotropic drugs are not approved for use during pregnancy. Electroconvulsive therapy (ECT) might be an effective and safe treatment option for several psychiatric disorders in pregnant women. This study assessed ECT for treating major psychoses during pregnancy, taking all possible adverse effects into account. Methods: We scrutinized all biomedical reviews on ECT during pregnancy published within the past 10 years, and present our experience with 3 patients in different phases of pregnancy that were treated with ECT between December 2009 and July 2012. Four to 5 ECT sessions were administered to pregnant women (10th to 28th week of pregnancy) with severe psychoses, and fetal heartbeat and movements were monitored during ECT and for 2 hours afterward. Results: Bizarre fetal spasms occurred in pregnant women treated with ECT. The authors are not aware of any similar description in the published reviews on this topic, to date. Still, all 3 women had successful deliveries, and the infants remained healthy during follow-ups ranging from 1 to 3.5 years. These data fill a lacking gap in the literature regarding longterm infant outcomes after ECT administration to pregnant women. This supports the theory that ECT may be an excellent treatment solution for pregnant women with certain severe mental disorders. Conclusions: Electroconvulsive therapy may be an acceptable approach for preventing pharmacotherapy risks or danger arising from injuries associated with mental illnesses in pregnant women. Nonetheless, careful monitoring of both mother and baby is absolutely necessary when considering ECT during pregnancy. Key Words: electroconvulsive therapy (ECT), pregnancy, spasms, fetus (J ECT 2014;30: e24–e26)
E
lectroconvulsive therapy (ECT) use in combined psychiatric/ obstetric patients remains controversial.1 To our knowledge, there are only 2 extensive studies reporting the influence of ECT on pregnant patients to date: Miller (1941–1991)2 and Anderson and Reti (1941–2007).3 Fetal complications mainly included fetal death, transient fetal bradycardia, decelerations, and prematurity. Of the 11 reported fetal deaths, only 1 was believed to be the direct result of ECT, which followed an episode of status epilepticus in the mother secondary to ECT.3 We thoroughly reviewed all cases of ECT during pregnancies that were presented in accessible databases.1–3 No study to date has mentioned the phenomenon of fetal spasms in association with ECT. Here, we present 3 case reports of ECT being administered at different stages of pregnancies, and evaluate the incidence of fetal spasms that occurred despite successful deliveries. The
From the *UNB-Petrzalka, Psychiatric Department, and †UNB-Ruzinov, II. Obsterics - Gynaecology Department, Bratislava, Slovakia. Received for publication September 18, 2013; accepted November 25, 2013. Reprints: Martin Halmo, MD, UNB-Petrzalka, Psychiatric Department, Bratislava, Slovakia (e‐mail: [email protected]). The authors have no conflicts of interest or financial disclosures to report. Copyright © 2014 by Lippincott Williams & Wilkins DOI: 10.1097/YCT.0000000000000101
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case reports presented here are enriched by long-term follow-up (ie, 1–3.5 years) of all 3 children.
METHODS We report 3 cases of pregnant women with psychiatric disorders whose aggravating symptoms required the administration of ECT. Each ECT session was performed in the presence of an anesthesiologist, 2 psychiatrists, and 1 obstetrician. Ultrasound was used to monitor fetal status. Total intravenous anesthesia was performed with thiopental (4 mg/kg) and succinylcholine (1 mg/kg). Several anesthetics drugs can be used during pregnancy (eg, thiopental, methohexital, etomidate, propofol, and sevoflurane).4,5 The 2 most widely used anesthetics in pregnant women are thiopental and propofol. Thiopental crosses the placenta and can be detected in the fetal circulation within 1 minute after IV administration. Propofol does not outbalance the advantages of thiopental.6 According to 1 study, propofol should be used with caution, especially in immature fetuses, emphasizing the risk of fetal bradycardia.7 In light of this knowledge and after consultation with anesthesiologists, thiopental was selected as the most appropriate agent in our study cases. The device used was a Spectrum 4000Q (Mecta Corporation, USA). Stimulus settings were as follows: pulse width, 1 millisecond; frequency, 30 Hz; stimulus duration, 3 seconds; and current, 800 mA. Electrodes were applied bitemporally. Every ECT session, including the ultrasound examination was videotaped and the results were compared with the previously published scientific findings.
RESULTS Case 1 A 35-year-old secundigravida was transferred in 28th week of gestation from the Gynaecology to the Psychiatric Department with the worsening symptoms of schizoaffective disorder. She reported massive attacks of depression and hatred against the fetus. Because of imminent premature delivery, regular obstetric checkups were provided. Obstetrical assessment on admission revealed normal fetal state, a quiescent condition with oral intake of magnesium and hospital stay was sufficient maintenance therapy. Because of the patient's resistance to standard pharmacotherapy, ECT was proposed as an adjunctive treatment. The first ECT application caused unusual spasms of fetus, starting in the second minute after stimulus application, and disappearing spontaneously within 3 minutes after contraction onset. Fetal tachycardia (170–175 beats per minute) was also present (Table 1). The second and third ECT sessions did not cause any detectable pathological reactions in either fetus or mother. The fourth ECT session resulted in fetal spasms from the first to fourth minute, with normocardia (Table 1). Considering the outstanding patient condition improvement, no additional ECT sessions were deemed necessary. Subsequent therapy consisted of oral venlafaxine 75 mg daily and quetiapine 600 mg daily. The Clinical Global Journal of ECT • Volume 30, Number 3, September 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Journal of ECT • Volume 30, Number 3, September 2014
Fetal Spasms After the Administration of ECT
TABLE 1. Patient in 28th Week of Pregnancy
TABLE 3. Patient in 17th Week of Pregnancy
ECT 1 2 3 4
Fetal Heart Rate
Presence of Fetal Spasms
ECT
Tachycardia Normal Normal Normal
Yes (second–fifth minute) No No Yes (first–fourth minute)
1 2 3 4
Impression score decreased from the previous 7 to 2 points post-ECT and the Positive and Negative Syndrome Scale decreased from the previous 66 to 27. The patient was discharged in the 30th week of pregnancy. Subsequent gynecological hospitalization was highly recommended to monitor her cervical dilatation. The patient refused it because of family issues. She was again admitted in the 33rd week of pregnancy because of regular uterine contractions. She delivered spontaneously with no signs of distress; the child was a healthy male, 2440 g, 45 cm, Apgar score of 6/9, borderline hypotrophic, and his early clinical stage required 4 months of hospitalization in the Neonatal Department. Regarding long-term follow-up, the baby is currently 3.5 years old, experiences no medical conditions, and his psychomotor development is proportionate to age.
Case 2 A 27-year-old primigravida had been admitted in the 10th week of pregnancy because of relapse of the schizoaffective disorder. Because of the low therapeutic effectiveness and risk of the abortion caused by uncontrolled behavior of the patient, we decided to provide ECT. The first ECT application went well. No adverse effects were observed, and fetal normocardia was maintained during the whole session (Table 2). The second ECT application caused spasms of the fetal head, starting in the second minute after ECT initiation and lasting for a total duration of 5 minutes (Table 2). Fetal spasms also occurred during the third ECT application, but the spasms lasted longer and disappeared within 60 minutes. The fourth and fifth ECT sessions followed the same pattern but fetal spasms ended 45 and 30 minutes, respectively, after ECT administration (Table 2). Together with ECT, quetiapine therapy (900 mg daily) was maintained. The patient remained without floridity, and her original mood and affectation symptoms totally resolved. During predischarge evaluation, her Clinical Global Impression score had decreased from 6 to 2 points, and her Positive and Negative Syndrome Scale score had decreased from 62 to 24 points. The patient was discharged in the 14th week of pregnancy. She was admitted to the Department of Obstetrics and Gynaecology because of regular contractions in her 38th week of pregnancy. Assuming cephalopelvic disproportion, she underwent cesarean delivery without any complications. The newborn was a healthy mature female, 3640 g, 50 cm, and
TABLE 2. Patient in 10th Week of Pregnancy ECT 1 2 3 4 5
Fetal Heart Rate
Presence of Fetal Spasms
Normal Normal Normal Normal Normal
No Yes (2nd–7th minute) Yes (2nd–60th minute) Yes (2nd–45th minute) Yes (2nd–30th minute)
© 2014 Lippincott Williams & Wilkins
Fetal Heart Rate
Presence of Fetal Spasms
Normal Normal Normal Normal
Yes (1st–10th minute) Yes (5th–60th minute) No Yes (2nd–max 5th minute)
Apgar score of 10/10. The child is currently 2 years and 5 months old and has exhibited normal development, to date.
Case 3 A 30-year-old patient in the 17th week of pregnancy came to the hospital with worsening symptoms of schizophrenia. After the first ECT sequence, craniocervical spasms began during the first minute and lasted for a total duration of 9 minutes (Table 3). Second ECT administration caused regular repetitive fetal spasms that began during the fifth minute after ECT initiation and were present for 55 minutes, with the fetus pushing its head against the trunk (Table 2). Afterward, the fetus showed normal motional activity, the heart rate was within reference range, and no more spasms were observed. The third ECT ran normally (Table 3). The final fourth ECT session began well; however, within 2 minutes, the fetus began to be spastic, and 3 clearly distinguishable spasms were observed in the thoracolumbar region (Table 3). The movements of the mother while awakening were too strong to keep the ultrasound probe accurately placed to get a clear display image. After calming the patient for 3 minutes, pathological fetal reactions were no longer present. The patient was discharged in the 20th week of pregnancy in good condition. She continued with quetiapine 900 mg daily. She was readmitted in the 34th week of pregnancy because of decompensated preeclampsia. A cesarean delivery was performed because of eclamptic seizures and with acute intrauterine hypoxia being imminent. An immature male newborn was delivered, 1830 g, 45 cm, and Apgar score of 5/6. The baby was transported to the intensive care unit. In 3 weeks, the newborn’s condition was satisfactory, and physical examination showed no remarkable aberrations. The infant is currently 1 year old, and the only abnormality present is right testicular retention. Otherwise, psychomotor development has occurred at the normal rate.
SUMMARY We reported fetal alterations in heart rate tachycardia and pathologic fetal movements involving spasms. Although the intrauterine spasms in literature are associated with neurological disorders, we did not observe this in our 3 cases.8 The case of premature delivery and its relation to ECT does not seem to be related to ECT itself. The occurrence of eclamptic seizures on a preeclamptic background likely was not directly related to ECT either. All the babies were born healthy, and the testicular retention observed in 1 case was definitely not caused by ECT.
DISCUSSION Treating serious mental illnesses in pregnant women requires special considerations.9–11 In our cases, premature delivery was observed in 1 patient, and it seems unlikely that ECT was the cause. This patient was hospitalized with an important cervical dilatation before ECT administration. There was no progression of cervical score present subsequent to the 4 ECT applications. Eclamptic seizures reported in case 3 also cannot be expressly referred to ECT. No data are available in the literature www.ectjournal.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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Journal of ECT • Volume 30, Number 3, September 2014
Halmo et al
regarding the occurrence of eclampsia after ECT. Nonetheless, a possible contribution of ECT-induced convulsions on placental tissue perfusion (a possible pathogenic focus of the disease) cannot be excluded. The fetus of case 1 presented tachycardia (175 beats per minute) after the first ECT application. Fetal arrhythmias, in particular bradyarrhythmias, are very frequent complications of ECT, according to Anderson and Reti,3 who blames it on localized hypoxia. Despite thorough scrutiny of the medical databases, we did not find any reference to fetal spasms after ECT. To our knowledge, the cases presented in this study are the first reports of ECT-induced fetal spasms. Fetal motility is a direct expression of neural activity and an excellent means of assessing dysfunctions of the fetal nervous system. Therefore, a few cases of intrauterine spasms reported in literature were mostly associated with neural malformations or severe brain lesions.8 We observed the “spastic” phenomenon in all 3 cases yet with no neurological harm to the fetuses. Here, the pathophysiology of the spasms remains unclear. We considered several hypotheses explaining the origin of fetal spasms: administration of succinylcholine; use of thiopental, and the influence of maternal convulsions and movements while awakening. Succinylcholine is the muscle relaxant used to induce paralysis for ECT.12–14 Patient responses to this drug were of the expected magnitude and time course; thus, the hypothesis explaining fetal spasms caused by using myorelaxant seems to be unreasonable because little succinylcholine enters the fetal circulation and its potential adverse effects do not include convulsions. Thiopental doses less than 4 mg/kg were presented to be safe for the fetus. At these doses, peak barbiturate concentrations in the fetal brain barely reach the border level for inducing neurological symptoms.6 Maternal convulsions and movements do not present an adequate explanation for the generation of fetal spasms because some fetal spasms occurred even before maternal movements started. The general opinion of ECT has dramatically changed during the last 20 years, with ECT status converted from being a redoutable to a practical and effective alternative for treating serious psychiatric disorders in pregnant women. Here, we have presented a new phenomenon observed during ECT sessions involving pregnant women, that is, the occurrence of fetal spasms. Nevertheless, ECT was an effective therapy for treating psychoses in
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all 3 pregnant women, and to date, after 1 to 3.5 years of follow-up, has had no adverse impact on infant development.
REFERENCES 1. Saatcioglu O, Tomruk NB. The use of electroconvulsive therapy in pregnancy: a review. Isr J Psychiatry Relat Sci. 2011;48:6–11. 2. Miller L. Use of electroconvulsive therapy during pregnancy. Hosp Community Psychiatry. 1994;45:444–450. 3. Anderson EL, Reti IM. ECT in pregnancy: a review of the literature from 1941-2007. Psychosom Med. 2009;71:235–242. 4. Yang HS, Seo HJ, Lee YK. Anesthetic care for electroconvulsive therapy during pregnancy—a case report. Korean J Anesthesiol. 2011;60:217–220. 5. Pesiridou A, Baquero G, Cristancho P. A case of delayed onset of threatened premature labor in association with electroconvulsive therapy in the third trimester of pregnancy. J ECT. 2010;26:228–230. 6. Chestnut DH, Polley LS, Tsen LC, et al. Obstetrics Anesthesia: Principles and Practice. 3rd ed. Mosby, PA: 2004:435. 7. Iwasaki K, Sakamoto A, Hoshino T. Electroconvulsive therapy with thiamylal or propofol during pregnancy. Can J Anesth. 2002;3:324–325. 8. Usta I, Adra A, Nassar A. Ultrasonographic diagnosis of fetal seizures: a case report and review of the literature. BJOG. 2007;114:1031–1033. 9. White C, Craig DF. The successful use of ECT for the treatment of depression during pregnancy. MUMJ. 2010;7:33–35. 10. Lovas A, Álmos P, Peto Z. Anesthesia for electroconvulsive therapy in early pregnancy. J ECT. 2011;27:328–330. 11. Asis SJ, Helgeson L, Ostroff R. The use of propofol to prevent fetal deceleration during electroconvulsive therapy treatment. J ECT. 2013;29:57–58. 12. Lentz SK. Brattleboro Retreat Psychiatric Review. June 1996 at: http://www.healthyplace.com/depression/articles/ electroconvulsive-therapy-during pregnancy/. 13. Moya F, Kvisselgaard N. The placental transmission of succinylcholine. Anesthesiology. 1961;22:1–6. 14. Ferrill MJ, Kehoe WA, Jacisin JJ. ECT during pregnancy. Convuls Ther. 1992;8:186–200.
© 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Fetal Spasms After the Administration of Electroconvulsive Therapy in Pregnancy Our Experience Martin Halmo, MD, Barbara Spodniaková, MD, and Petra Nosáľová, MD Objectives: Most psychotropic drugs are not approved for use during pregnancy. Electroconvulsive therapy (ECT) might be an effective and safe treatment option for several psychiatric disorders in pregnant women. This study assessed ECT for treating major psychoses during pregnancy, taking all possible adverse effects into account. Methods: We scrutinized all biomedical reviews on ECT during pregnancy published within the past 10 years, and present our experience with 3 patients in different phases of pregnancy that were treated with ECT between December 2009 and July 2012. Four to 5 ECT sessions were administered to pregnant women (10th to 28th week of pregnancy) with severe psychoses, and fetal heartbeat and movements were monitored during ECT and for 2 hours afterward. Results: Bizarre fetal spasms occurred in pregnant women treated with ECT. The authors are not aware of any similar description in the published reviews on this topic, to date. Still, all 3 women had successful deliveries, and the infants remained healthy during follow-ups ranging from 1 to 3.5 years. These data fill a lacking gap in the literature regarding longterm infant outcomes after ECT administration to pregnant women. This supports the theory that ECT may be an excellent treatment solution for pregnant women with certain severe mental disorders. Conclusions: Electroconvulsive therapy may be an acceptable approach for preventing pharmacotherapy risks or danger arising from injuries associated with mental illnesses in pregnant women. Nonetheless, careful monitoring of both mother and baby is absolutely necessary when considering ECT during pregnancy. Key Words: electroconvulsive therapy (ECT), pregnancy, spasms, fetus (J ECT 2014;30: e24–e26)
E
lectroconvulsive therapy (ECT) use in combined psychiatric/ obstetric patients remains controversial.1 To our knowledge, there are only 2 extensive studies reporting the influence of ECT on pregnant patients to date: Miller (1941–1991)2 and Anderson and Reti (1941–2007).3 Fetal complications mainly included fetal death, transient fetal bradycardia, decelerations, and prematurity. Of the 11 reported fetal deaths, only 1 was believed to be the direct result of ECT, which followed an episode of status epilepticus in the mother secondary to ECT.3 We thoroughly reviewed all cases of ECT during pregnancies that were presented in accessible databases.1–3 No study to date has mentioned the phenomenon of fetal spasms in association with ECT. Here, we present 3 case reports of ECT being administered at different stages of pregnancies, and evaluate the incidence of fetal spasms that occurred despite successful deliveries. The
From the *UNB-Petrzalka, Psychiatric Department, and †UNB-Ruzinov, II. Obsterics - Gynaecology Department, Bratislava, Slovakia. Received for publication September 18, 2013; accepted November 25, 2013. Reprints: Martin Halmo, MD, UNB-Petrzalka, Psychiatric Department, Bratislava, Slovakia (e‐mail: [email protected]). The authors have no conflicts of interest or financial disclosures to report. Copyright © 2014 by Lippincott Williams & Wilkins DOI: 10.1097/YCT.0000000000000101
e24
www.ectjournal.com
case reports presented here are enriched by long-term follow-up (ie, 1–3.5 years) of all 3 children.
METHODS We report 3 cases of pregnant women with psychiatric disorders whose aggravating symptoms required the administration of ECT. Each ECT session was performed in the presence of an anesthesiologist, 2 psychiatrists, and 1 obstetrician. Ultrasound was used to monitor fetal status. Total intravenous anesthesia was performed with thiopental (4 mg/kg) and succinylcholine (1 mg/kg). Several anesthetics drugs can be used during pregnancy (eg, thiopental, methohexital, etomidate, propofol, and sevoflurane).4,5 The 2 most widely used anesthetics in pregnant women are thiopental and propofol. Thiopental crosses the placenta and can be detected in the fetal circulation within 1 minute after IV administration. Propofol does not outbalance the advantages of thiopental.6 According to 1 study, propofol should be used with caution, especially in immature fetuses, emphasizing the risk of fetal bradycardia.7 In light of this knowledge and after consultation with anesthesiologists, thiopental was selected as the most appropriate agent in our study cases. The device used was a Spectrum 4000Q (Mecta Corporation, USA). Stimulus settings were as follows: pulse width, 1 millisecond; frequency, 30 Hz; stimulus duration, 3 seconds; and current, 800 mA. Electrodes were applied bitemporally. Every ECT session, including the ultrasound examination was videotaped and the results were compared with the previously published scientific findings.
RESULTS Case 1 A 35-year-old secundigravida was transferred in 28th week of gestation from the Gynaecology to the Psychiatric Department with the worsening symptoms of schizoaffective disorder. She reported massive attacks of depression and hatred against the fetus. Because of imminent premature delivery, regular obstetric checkups were provided. Obstetrical assessment on admission revealed normal fetal state, a quiescent condition with oral intake of magnesium and hospital stay was sufficient maintenance therapy. Because of the patient's resistance to standard pharmacotherapy, ECT was proposed as an adjunctive treatment. The first ECT application caused unusual spasms of fetus, starting in the second minute after stimulus application, and disappearing spontaneously within 3 minutes after contraction onset. Fetal tachycardia (170–175 beats per minute) was also present (Table 1). The second and third ECT sessions did not cause any detectable pathological reactions in either fetus or mother. The fourth ECT session resulted in fetal spasms from the first to fourth minute, with normocardia (Table 1). Considering the outstanding patient condition improvement, no additional ECT sessions were deemed necessary. Subsequent therapy consisted of oral venlafaxine 75 mg daily and quetiapine 600 mg daily. The Clinical Global Journal of ECT • Volume 30, Number 3, September 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Journal of ECT • Volume 30, Number 3, September 2014
Fetal Spasms After the Administration of ECT
TABLE 1. Patient in 28th Week of Pregnancy
TABLE 3. Patient in 17th Week of Pregnancy
ECT 1 2 3 4
Fetal Heart Rate
Presence of Fetal Spasms
ECT
Tachycardia Normal Normal Normal
Yes (second–fifth minute) No No Yes (first–fourth minute)
1 2 3 4
Impression score decreased from the previous 7 to 2 points post-ECT and the Positive and Negative Syndrome Scale decreased from the previous 66 to 27. The patient was discharged in the 30th week of pregnancy. Subsequent gynecological hospitalization was highly recommended to monitor her cervical dilatation. The patient refused it because of family issues. She was again admitted in the 33rd week of pregnancy because of regular uterine contractions. She delivered spontaneously with no signs of distress; the child was a healthy male, 2440 g, 45 cm, Apgar score of 6/9, borderline hypotrophic, and his early clinical stage required 4 months of hospitalization in the Neonatal Department. Regarding long-term follow-up, the baby is currently 3.5 years old, experiences no medical conditions, and his psychomotor development is proportionate to age.
Case 2 A 27-year-old primigravida had been admitted in the 10th week of pregnancy because of relapse of the schizoaffective disorder. Because of the low therapeutic effectiveness and risk of the abortion caused by uncontrolled behavior of the patient, we decided to provide ECT. The first ECT application went well. No adverse effects were observed, and fetal normocardia was maintained during the whole session (Table 2). The second ECT application caused spasms of the fetal head, starting in the second minute after ECT initiation and lasting for a total duration of 5 minutes (Table 2). Fetal spasms also occurred during the third ECT application, but the spasms lasted longer and disappeared within 60 minutes. The fourth and fifth ECT sessions followed the same pattern but fetal spasms ended 45 and 30 minutes, respectively, after ECT administration (Table 2). Together with ECT, quetiapine therapy (900 mg daily) was maintained. The patient remained without floridity, and her original mood and affectation symptoms totally resolved. During predischarge evaluation, her Clinical Global Impression score had decreased from 6 to 2 points, and her Positive and Negative Syndrome Scale score had decreased from 62 to 24 points. The patient was discharged in the 14th week of pregnancy. She was admitted to the Department of Obstetrics and Gynaecology because of regular contractions in her 38th week of pregnancy. Assuming cephalopelvic disproportion, she underwent cesarean delivery without any complications. The newborn was a healthy mature female, 3640 g, 50 cm, and
TABLE 2. Patient in 10th Week of Pregnancy ECT 1 2 3 4 5
Fetal Heart Rate
Presence of Fetal Spasms
Normal Normal Normal Normal Normal
No Yes (2nd–7th minute) Yes (2nd–60th minute) Yes (2nd–45th minute) Yes (2nd–30th minute)
© 2014 Lippincott Williams & Wilkins
Fetal Heart Rate
Presence of Fetal Spasms
Normal Normal Normal Normal
Yes (1st–10th minute) Yes (5th–60th minute) No Yes (2nd–max 5th minute)
Apgar score of 10/10. The child is currently 2 years and 5 months old and has exhibited normal development, to date.
Case 3 A 30-year-old patient in the 17th week of pregnancy came to the hospital with worsening symptoms of schizophrenia. After the first ECT sequence, craniocervical spasms began during the first minute and lasted for a total duration of 9 minutes (Table 3). Second ECT administration caused regular repetitive fetal spasms that began during the fifth minute after ECT initiation and were present for 55 minutes, with the fetus pushing its head against the trunk (Table 2). Afterward, the fetus showed normal motional activity, the heart rate was within reference range, and no more spasms were observed. The third ECT ran normally (Table 3). The final fourth ECT session began well; however, within 2 minutes, the fetus began to be spastic, and 3 clearly distinguishable spasms were observed in the thoracolumbar region (Table 3). The movements of the mother while awakening were too strong to keep the ultrasound probe accurately placed to get a clear display image. After calming the patient for 3 minutes, pathological fetal reactions were no longer present. The patient was discharged in the 20th week of pregnancy in good condition. She continued with quetiapine 900 mg daily. She was readmitted in the 34th week of pregnancy because of decompensated preeclampsia. A cesarean delivery was performed because of eclamptic seizures and with acute intrauterine hypoxia being imminent. An immature male newborn was delivered, 1830 g, 45 cm, and Apgar score of 5/6. The baby was transported to the intensive care unit. In 3 weeks, the newborn’s condition was satisfactory, and physical examination showed no remarkable aberrations. The infant is currently 1 year old, and the only abnormality present is right testicular retention. Otherwise, psychomotor development has occurred at the normal rate.
SUMMARY We reported fetal alterations in heart rate tachycardia and pathologic fetal movements involving spasms. Although the intrauterine spasms in literature are associated with neurological disorders, we did not observe this in our 3 cases.8 The case of premature delivery and its relation to ECT does not seem to be related to ECT itself. The occurrence of eclamptic seizures on a preeclamptic background likely was not directly related to ECT either. All the babies were born healthy, and the testicular retention observed in 1 case was definitely not caused by ECT.
DISCUSSION Treating serious mental illnesses in pregnant women requires special considerations.9–11 In our cases, premature delivery was observed in 1 patient, and it seems unlikely that ECT was the cause. This patient was hospitalized with an important cervical dilatation before ECT administration. There was no progression of cervical score present subsequent to the 4 ECT applications. Eclamptic seizures reported in case 3 also cannot be expressly referred to ECT. No data are available in the literature www.ectjournal.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
e25
Journal of ECT • Volume 30, Number 3, September 2014
Halmo et al
regarding the occurrence of eclampsia after ECT. Nonetheless, a possible contribution of ECT-induced convulsions on placental tissue perfusion (a possible pathogenic focus of the disease) cannot be excluded. The fetus of case 1 presented tachycardia (175 beats per minute) after the first ECT application. Fetal arrhythmias, in particular bradyarrhythmias, are very frequent complications of ECT, according to Anderson and Reti,3 who blames it on localized hypoxia. Despite thorough scrutiny of the medical databases, we did not find any reference to fetal spasms after ECT. To our knowledge, the cases presented in this study are the first reports of ECT-induced fetal spasms. Fetal motility is a direct expression of neural activity and an excellent means of assessing dysfunctions of the fetal nervous system. Therefore, a few cases of intrauterine spasms reported in literature were mostly associated with neural malformations or severe brain lesions.8 We observed the “spastic” phenomenon in all 3 cases yet with no neurological harm to the fetuses. Here, the pathophysiology of the spasms remains unclear. We considered several hypotheses explaining the origin of fetal spasms: administration of succinylcholine; use of thiopental, and the influence of maternal convulsions and movements while awakening. Succinylcholine is the muscle relaxant used to induce paralysis for ECT.12–14 Patient responses to this drug were of the expected magnitude and time course; thus, the hypothesis explaining fetal spasms caused by using myorelaxant seems to be unreasonable because little succinylcholine enters the fetal circulation and its potential adverse effects do not include convulsions. Thiopental doses less than 4 mg/kg were presented to be safe for the fetus. At these doses, peak barbiturate concentrations in the fetal brain barely reach the border level for inducing neurological symptoms.6 Maternal convulsions and movements do not present an adequate explanation for the generation of fetal spasms because some fetal spasms occurred even before maternal movements started. The general opinion of ECT has dramatically changed during the last 20 years, with ECT status converted from being a redoutable to a practical and effective alternative for treating serious psychiatric disorders in pregnant women. Here, we have presented a new phenomenon observed during ECT sessions involving pregnant women, that is, the occurrence of fetal spasms. Nevertheless, ECT was an effective therapy for treating psychoses in
e26
www.ectjournal.com
all 3 pregnant women, and to date, after 1 to 3.5 years of follow-up, has had no adverse impact on infant development.
REFERENCES 1. Saatcioglu O, Tomruk NB. The use of electroconvulsive therapy in pregnancy: a review. Isr J Psychiatry Relat Sci. 2011;48:6–11. 2. Miller L. Use of electroconvulsive therapy during pregnancy. Hosp Community Psychiatry. 1994;45:444–450. 3. Anderson EL, Reti IM. ECT in pregnancy: a review of the literature from 1941-2007. Psychosom Med. 2009;71:235–242. 4. Yang HS, Seo HJ, Lee YK. Anesthetic care for electroconvulsive therapy during pregnancy—a case report. Korean J Anesthesiol. 2011;60:217–220. 5. Pesiridou A, Baquero G, Cristancho P. A case of delayed onset of threatened premature labor in association with electroconvulsive therapy in the third trimester of pregnancy. J ECT. 2010;26:228–230. 6. Chestnut DH, Polley LS, Tsen LC, et al. Obstetrics Anesthesia: Principles and Practice. 3rd ed. Mosby, PA: 2004:435. 7. Iwasaki K, Sakamoto A, Hoshino T. Electroconvulsive therapy with thiamylal or propofol during pregnancy. Can J Anesth. 2002;3:324–325. 8. Usta I, Adra A, Nassar A. Ultrasonographic diagnosis of fetal seizures: a case report and review of the literature. BJOG. 2007;114:1031–1033. 9. White C, Craig DF. The successful use of ECT for the treatment of depression during pregnancy. MUMJ. 2010;7:33–35. 10. Lovas A, Álmos P, Peto Z. Anesthesia for electroconvulsive therapy in early pregnancy. J ECT. 2011;27:328–330. 11. Asis SJ, Helgeson L, Ostroff R. The use of propofol to prevent fetal deceleration during electroconvulsive therapy treatment. J ECT. 2013;29:57–58. 12. Lentz SK. Brattleboro Retreat Psychiatric Review. June 1996 at: http://www.healthyplace.com/depression/articles/ electroconvulsive-therapy-during pregnancy/. 13. Moya F, Kvisselgaard N. The placental transmission of succinylcholine. Anesthesiology. 1961;22:1–6. 14. Ferrill MJ, Kehoe WA, Jacisin JJ. ECT during pregnancy. Convuls Ther. 1992;8:186–200.
© 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
