Recurrent mild abruptio placentae occurring immediately after repeated electroconvulsive therapy in pregnancy David M. Sherer, MD," Mary Lou D'Amico, RNC, BSN," David P. Warshal, MD," Robert A. Stern, MD,b Harold F. Grunert, MD,c and Jacques S. Abramowicz, MD" Rochester, New York We present a case in which electroconvulsive therapy was performed repeatedly in pregnancy because of severe depression with psychotic features and failure of chemical treatment. Each electroconvulsive treatment was immediately followed by uterine contractions and active uterine bleeding, possibly representing recurrent abruptio placentae occurring in association with the treatment. Transient acute episodes of maternal hypertension between 180/90 and 190/100 mm Hg, documented within minutes after application of each electroconvulsive treatment, might explain the abruptio placentae manifested by active uterine bleeding and uterine hyperstimulation. (AM J OSSTET GYNECOL 1991 ;165:652·3.)
Key words: Pregnancy, electroconvulsive therapy, abruptio placentae The relative safety of electroconvulsive therapy in the treatment of certain cases of depression, mania, or psychosis in pregnancy has been reported in both obstetric and psychiatric literature. 1.2 To the best of our knowledge, adverse outcomes with the application of this therapy in pregnancy have not been reported. We present a case in which repeated electroconvulsive therapy was performed in pregnancy. After each session of electroconvulsive therapy, mild abruptio placentae was suspected. We discuss the possible underlying mechanisms. Case report A 35-year-old Oriental woman, gravida 2, para 0, with one previous elective termination of pregnancy, was monitored during her second gestation. Her medical history was unremarkable. Gestational dating was based on last menstrual period and 9-week ultrasonography. The patient declined a genetic amniocentesis. At 19 weeks' gestation the patient began experiencing insomnia, anxiety attacks, and occasional suicidal thoughts. Treatment with oral diazepam, 5 mg three times a day, was initiated. Initially the patient responded. Ultrasonographic evaluation at 21 weeks revealed normal fetal anatomy and a low-lying posterior placenta. The patient'S psychiatric condition deteriorated at 25 weeks' gestation with signs of worsening depression. After a suicide attempt at 26 weeks, she
From the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology," and the Department of Psychiatry,' Strong Memorial Hospital, and Highland Hospital,' the University of Rochester School of Medicine and Dentistry. Received for publication March 20, 1991; accepted March 22, 1991. Reprint requests: David M. Sherer, MD, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Strong Memorial Hospital, The University of Rochester School of Medicine and Dentistry, 601 Elmwood Ave., Box 668, Rochester, NY 14642-8668. 611129778
652
was hospitalized at an inpatient psychiatric hospital with a diagnosis of severe depression with psychotic features. Her condition remained unchanged, and antipsychotic therapy consisting of oral haloperidol (Haldol), 10 mg twice a day, was added. At 30 weeks, because of the intensity of delusions, severe anorexia, continued suicidal ideations, and advancing pregnancy, a decision was made to move directly to electroconvulsive therapy with the patient under general anesthesia and with continuous cardiotocographic monitoring. Before the electroconvulsive therapy, intravenous fluids were administered to avoid hypovolemia, and the blood pressure was 106/68 mm Hg. She was given oxygen by mask and intubated after intravenous thiopental sodium, 125 mg, and succinylcholine, 50 mg. Electroconvulsive therapy was performed with standard bilateral temporal electrode placement and a 30% energy setting (pulsed bidirectional square-wave stimulus with a fixed pulse width of I msec and a frequency of 70 Hz; Thymatron Somatics, Inc., Lake Bluff, 111.), resulting in a seizure lasting 50 seconds. Immediately after the seizure, transient hypertension with pressures of 180/90 mm Hg was noted in conjunction with visible, palpable regular uterine contractions every 2 to 3 minutes. The fetal heart rate revealed reduced variability that was attributed to the intravenous thiopental sodium and was otherwise normal (Fig. I). Uterine hyperstimulation (Fig. I) was noted in conjunction with mild, bright red uterine bleeding. Gradually the bleeding and uterine contractions subsided. This regimen was performed on a weekly basis, with the same clinical picture after each session of electroconvulsive therapy. The uterine hyperstimulation noted after the electroconvulsive therapy at 31 weeks necessitated subcutaneous terbutaline, 2.5 mg. At 32 weeks' gestation Doppler velocimetric studies of the uterine and umbilical arteries were performed before, during, immediately after, and 10, IS, 20, and 30 minutes after the electroconvulsive therapy. Only minor changes were demonstrated in the systolic-
Volume 165 Number 3
Abruptio placentae after electroconvulsive therapy
653
ECT sue
Fig. 1. Continuous cardiotocography during electroconvulsive therapy (ECT) at 34 weeks. Note regular uterine contractions and subsequent hypertonic-tetanic contractions. Medications before electroconvulsive therapy (ECT) and blood pressure after therapy are noted (pent, thiopental sodium; sue, succinylcholine) (paper speed, 3 em/min).
to-diastolic ratio, the pulsability index, and the resistance index of these vessels with higher values immediately after the electroconvulsive therapy. The electroconvulsive therapy at 34 weeks was followed by uterine bleeding to the extent that the patient required observation in the labor and delivery suite for 48 hours. Laboratory test results were normal, and a KleihauerBetke test gave negative findings. The bleeding subsided, and she was returned to the psychiatric hospital. A total of seven antepartum electroconvulsive treatments were performed. At 37 weeks the patient presented in spontaneous labor. At admission the cervix. was dilated to I em, with the fetal vertex presenting at the spine - I station. During labor, because of active uterine bleeding of approximately 800 ml, a transverse, low-segment cesarean section was performed with the patient under spinal anesthesia. A male infant weighing 2704 gm with Apgar scores of 3 and 9 at I and 5 minutes, respectively, was delivered. A large retroplacental clot was noted, confirming the diagnosis of abruptio placentae. The patient's postoperative course was unremarkable.
Comment Previous reports have addressed the apparent safety and efficacy of electroconvulsive therapy for the treatment of depression in pregnancy. These reports failed to demonstrate any complications of labor and delivery or subsequent childhood growth and development. I. 2 Eclamptic seizures are associated with major maternal and fetal morbidity and mortality. Although a tonicclonic, grand mal-like seizure is caused by electroconvulsive therapy, it differs from eclampsia in that it is controlled: It is of shorter duration (seconds vs. minutes
or longer), the patient is intubated and thus well oxygenated, and the fetus is continuously monitored. A transient increase in blood pressure is known to occur after electroconvulsive therapy. A previous report noting transient maternal hypotension after electroconvulsive therapy in pregnancy was thought to have been due to decreased intravascular volume. I The association of Cl.bruptio placentae and hypertensive crises in pregnancy is well documented. We believe the uterine bleeding and uterine hyperstimulation, both manifestations of abruptio placentae, could possibly have been caused by the observed transient marked hypertension. These pathophysiologic events would be similar to those of abruptio placentae noted with acute hypertensive crises and cocaine abuse. Doppler velocimetric studies of the uterine and umbilical arteries might point to a slightly increased impedance to flow in the placental vasculature during electroconvulsive therapy. However, these changes cannot be attributed directly to electroconvulsive therapy itself and may well have been caused by the uterine contractions associated with the electroconvulsive therapy. In any event, although fetal distress did not occur, abruptio placentae in association with transient hypertension noted with electroconvulsive therapy emphasizes the importance of continuous fetal monitoring during this procedure. REFERENCES 1. Repke JT, Berger NG. Electroconvulsive therapy in pregnancy. Obstet Gynecol 1984;63:39S-40S. 2. Remick RA, Maurice WL. ECT in pregnancy. Am J Psychiatry 1978; 135:761-6.
Key words: Pregnancy, electroconvulsive therapy, abruptio placentae The relative safety of electroconvulsive therapy in the treatment of certain cases of depression, mania, or psychosis in pregnancy has been reported in both obstetric and psychiatric literature. 1.2 To the best of our knowledge, adverse outcomes with the application of this therapy in pregnancy have not been reported. We present a case in which repeated electroconvulsive therapy was performed in pregnancy. After each session of electroconvulsive therapy, mild abruptio placentae was suspected. We discuss the possible underlying mechanisms. Case report A 35-year-old Oriental woman, gravida 2, para 0, with one previous elective termination of pregnancy, was monitored during her second gestation. Her medical history was unremarkable. Gestational dating was based on last menstrual period and 9-week ultrasonography. The patient declined a genetic amniocentesis. At 19 weeks' gestation the patient began experiencing insomnia, anxiety attacks, and occasional suicidal thoughts. Treatment with oral diazepam, 5 mg three times a day, was initiated. Initially the patient responded. Ultrasonographic evaluation at 21 weeks revealed normal fetal anatomy and a low-lying posterior placenta. The patient'S psychiatric condition deteriorated at 25 weeks' gestation with signs of worsening depression. After a suicide attempt at 26 weeks, she
From the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology," and the Department of Psychiatry,' Strong Memorial Hospital, and Highland Hospital,' the University of Rochester School of Medicine and Dentistry. Received for publication March 20, 1991; accepted March 22, 1991. Reprint requests: David M. Sherer, MD, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Strong Memorial Hospital, The University of Rochester School of Medicine and Dentistry, 601 Elmwood Ave., Box 668, Rochester, NY 14642-8668. 611129778
652
was hospitalized at an inpatient psychiatric hospital with a diagnosis of severe depression with psychotic features. Her condition remained unchanged, and antipsychotic therapy consisting of oral haloperidol (Haldol), 10 mg twice a day, was added. At 30 weeks, because of the intensity of delusions, severe anorexia, continued suicidal ideations, and advancing pregnancy, a decision was made to move directly to electroconvulsive therapy with the patient under general anesthesia and with continuous cardiotocographic monitoring. Before the electroconvulsive therapy, intravenous fluids were administered to avoid hypovolemia, and the blood pressure was 106/68 mm Hg. She was given oxygen by mask and intubated after intravenous thiopental sodium, 125 mg, and succinylcholine, 50 mg. Electroconvulsive therapy was performed with standard bilateral temporal electrode placement and a 30% energy setting (pulsed bidirectional square-wave stimulus with a fixed pulse width of I msec and a frequency of 70 Hz; Thymatron Somatics, Inc., Lake Bluff, 111.), resulting in a seizure lasting 50 seconds. Immediately after the seizure, transient hypertension with pressures of 180/90 mm Hg was noted in conjunction with visible, palpable regular uterine contractions every 2 to 3 minutes. The fetal heart rate revealed reduced variability that was attributed to the intravenous thiopental sodium and was otherwise normal (Fig. I). Uterine hyperstimulation (Fig. I) was noted in conjunction with mild, bright red uterine bleeding. Gradually the bleeding and uterine contractions subsided. This regimen was performed on a weekly basis, with the same clinical picture after each session of electroconvulsive therapy. The uterine hyperstimulation noted after the electroconvulsive therapy at 31 weeks necessitated subcutaneous terbutaline, 2.5 mg. At 32 weeks' gestation Doppler velocimetric studies of the uterine and umbilical arteries were performed before, during, immediately after, and 10, IS, 20, and 30 minutes after the electroconvulsive therapy. Only minor changes were demonstrated in the systolic-
Volume 165 Number 3
Abruptio placentae after electroconvulsive therapy
653
ECT sue
Fig. 1. Continuous cardiotocography during electroconvulsive therapy (ECT) at 34 weeks. Note regular uterine contractions and subsequent hypertonic-tetanic contractions. Medications before electroconvulsive therapy (ECT) and blood pressure after therapy are noted (pent, thiopental sodium; sue, succinylcholine) (paper speed, 3 em/min).
to-diastolic ratio, the pulsability index, and the resistance index of these vessels with higher values immediately after the electroconvulsive therapy. The electroconvulsive therapy at 34 weeks was followed by uterine bleeding to the extent that the patient required observation in the labor and delivery suite for 48 hours. Laboratory test results were normal, and a KleihauerBetke test gave negative findings. The bleeding subsided, and she was returned to the psychiatric hospital. A total of seven antepartum electroconvulsive treatments were performed. At 37 weeks the patient presented in spontaneous labor. At admission the cervix. was dilated to I em, with the fetal vertex presenting at the spine - I station. During labor, because of active uterine bleeding of approximately 800 ml, a transverse, low-segment cesarean section was performed with the patient under spinal anesthesia. A male infant weighing 2704 gm with Apgar scores of 3 and 9 at I and 5 minutes, respectively, was delivered. A large retroplacental clot was noted, confirming the diagnosis of abruptio placentae. The patient's postoperative course was unremarkable.
Comment Previous reports have addressed the apparent safety and efficacy of electroconvulsive therapy for the treatment of depression in pregnancy. These reports failed to demonstrate any complications of labor and delivery or subsequent childhood growth and development. I. 2 Eclamptic seizures are associated with major maternal and fetal morbidity and mortality. Although a tonicclonic, grand mal-like seizure is caused by electroconvulsive therapy, it differs from eclampsia in that it is controlled: It is of shorter duration (seconds vs. minutes
or longer), the patient is intubated and thus well oxygenated, and the fetus is continuously monitored. A transient increase in blood pressure is known to occur after electroconvulsive therapy. A previous report noting transient maternal hypotension after electroconvulsive therapy in pregnancy was thought to have been due to decreased intravascular volume. I The association of Cl.bruptio placentae and hypertensive crises in pregnancy is well documented. We believe the uterine bleeding and uterine hyperstimulation, both manifestations of abruptio placentae, could possibly have been caused by the observed transient marked hypertension. These pathophysiologic events would be similar to those of abruptio placentae noted with acute hypertensive crises and cocaine abuse. Doppler velocimetric studies of the uterine and umbilical arteries might point to a slightly increased impedance to flow in the placental vasculature during electroconvulsive therapy. However, these changes cannot be attributed directly to electroconvulsive therapy itself and may well have been caused by the uterine contractions associated with the electroconvulsive therapy. In any event, although fetal distress did not occur, abruptio placentae in association with transient hypertension noted with electroconvulsive therapy emphasizes the importance of continuous fetal monitoring during this procedure. REFERENCES 1. Repke JT, Berger NG. Electroconvulsive therapy in pregnancy. Obstet Gynecol 1984;63:39S-40S. 2. Remick RA, Maurice WL. ECT in pregnancy. Am J Psychiatry 1978; 135:761-6.
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