Electroconvulsive therapy in pregnancy

An estimated 15-29% of pregnant women suffer from psychiatric illnesses.[1] Treatment of psychiatric illnesses during pregnancy is a particular challenge. A delicate balance must be struck between the risks and benefits of any modality of psychiatric treatment. Although the prognosis of a pregnancy in which a psychiatric illness is not treated is significantly worse than one which is treated, electroconvulsive therapy (ECT) offers an added advantage of not having any of the pregnancy-related adverse effects of psychotropic medications.[2,3] The most common fetal complication of ECT is cardiac arrhythmia (1.6%), bradycardia, irregular fetal heart rate, and reduced variability. The incidence of miscarriage in ECT is not higher than the general population. Preterm labor (1.3%) and still-birth (<1%) are also reported, but are usually unrelated to ECT. The most common maternal complication is vaginal bleeding (1.6%); some others are: abruptio placentae, uterine contractions, and severe abdominal pain.[1]

A 20-year-old lady was hospitalized with the complaints of suspecting everyone to be viewing a nude selfie of hers which had gone viral on social media. She believed that her relatives and neighbors thought she was a promiscuous girl and was worried the police were searching for her to imprison her for wrong deeds that she hadn’t even done. She would hear hallucinatory voices of her relatives abusing her and would often be seen crying to self inconsolably. Symptoms began 15 days ago after a trivial altercation with her mother-in-law. Patient had suffered from a similar episode two years ago, after she clicked a nude selfie on her brand-new smartphone. She felt that her selfie had leaked to all social media portals and was visible to everyone. She was hearing hallucinatory voices convincing her of the same, as well as rebuking her of being an immoral girl. With a diagnosis of Paranoid Schizophrenia, she was treated with antipsychotics and six cycles of modified ECT, with resolution of symptoms. She maintained well on regular treatment, until six months before presentation, when she went off-treatment due to marriage. Patient’s LMP was 54 days ago. A urine pregnancy test confirmed pregnancy. Period of gestation was confirmed by USG. Mental status examination revealed poor personal hygiene, persecutory, and referential delusions, second person auditory hallucinations in a clear sensorium with impaired insight. Being in the first trimester of pregnancy antipsychotics was withheld. After 6 cycles of modified ECT her delusions and hallucinations resolved, there were no ECT-related complications. She was then discharged but not started on any antipsychotic and asked to maintain close follow-ups. After 6 weeks, she had a relapse of symptoms. Being in the second trimester of her pregnancy, she was started on 20 mg of Olanzapine at bedtime after which she once again showed resolution of symptoms. She maintained well until delivery and the post-partum period. She is currently maintaining well at 20 mg of olanzapine and is breast-feeding her child, who is also healthy.

The first trimester being the period of blastogenesis and organogenesis is the least favorable duration of pregnancy for fetal exposure to drugs. Hence, we avoided administering any antipsychotic to the patient, but put her on ECTs which are an approved modality of treatment of psychotic illnesses in pregnancy.[1,4] Olanzapine is considered to be the safest antipsychotic for use during pregnancy.[5] The notable side effects of olanzapine are gestational diabetes mellitus and increased birth weight did not occur in our case. Congenital malformations associated with olanzapine use have been reported but almost always in presence of another drug with olanzapine. Olanzapine has well-proven safety for use during lactation, as well.[5,6]

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