Table 2.
Characteristics of case reports and case series describing modified electroconvulsive therapy (mECT) for perinatal depression.
| Reference | Country | Diagnos(es), n cases | Trimester(s) of pregnancy or weeks postpartum | ECT delivery characteristics | Main effective-ness outcomes | Obstetric safety outcomes | Fetal/neonatal or nursing infant safety outcomes |
|---|---|---|---|---|---|---|---|
| Bak et al. (33) | Turkey | Mixed sample, 4 cases total Prenatal depression, n=1 Prenatal BP, n=2 Prenatal “atypical psychosis”, n=1 |
Mean gestational age 23 weeks, individual level data unspecified | ECT electrode placement unspecified; mean of 10 ECT applications (individual level data unspecified) | Not reported. | No maternal complications. | No complications in newborns. Normal development through first 1 month of life. |
| Balki et al. (34) | Canada | Prenatal BP-D, suicidal ideation, n=1 | Second trimester | Acute RUL ECT, three stimuli given during session 1 owing to inadequate seizure activity | Not reported. | SE after third stimulus requiring high-dose BZD, thiopental, propofol, and DPHD, ICU transfer, and prolonged MV | Fetal death followed by spontaneous vaginal delivery |
| Ballone et al. (35)a | Unspecified | PPD, n=1 | 8 weeks postpartum | Acute RUL/UB ECT, 15 treatments, delivered in an ambulatory setting to permit breastfeeding | Conference abstract, outcomes unspecified | Not applicable. | Conference abstract, outcomes unspecified |
| Bergink et al. (36)a | Netherlands | Postpartum BP, n=7 | Postpartum week(s) unspecified | Acute ECT, lead placement and frequency of treatments unspecified | Remission in one patient who received ECT owing to poor response to pharmacotherapy | Not applicable | Conference abstract, outcomes unspecified |
| Bulut et al. (37) | Turkey | Prenatal MDD, n=3 Prenatal MDD, psychotic features, n=3 Prenatal BP, n=5 Other prenatal depression, n=1 |
First trimester, n=6 Second trimester, n=3 Third trimester, n=3 |
Acute BT ECT treatments (all 12 cases), range 3–20 treatments Maintenance BT ECT (2 cases, one with MDD), 3 treatments each |
Mean CGI score for all 12 cases reduced from 6.0 (baseline) to 2.6 (end of ECT sessions). Diagnosis-specific results were not provided. | One pregnancy was terminated early. Remaining pregnancies were un-complicated. Diagnosis-specific results were not provided. | One neonate with pes ekinovarus deformity. The remaining 10 new-borns were described as healthy after delivery. |
| Bhatia et al. (38) | USA | Prenatal MDD, n=1 (Case 1) Other prenatal depression, n=1 (Case 2) |
Third trimester, n=2 | Case 1 – Acute BT ECT, 3x/week, 6 treatments total Case 2 – Acute BT ECT, 5 treatments total |
Case 1 – improvement after 6 treatments, remission at 6-month contact. Case 2 – improvement after 5 treatments, remission at 6-month contact. |
Case 1 – transient mild uterine contractions Case 2 – transient uterine contractions, preterm labor on post-ECT day 7 (31 weeks EGA) |
Case 1 – delivery of healthy infant at 39 weeks EGA. Case 2 – premature delivery of otherwise healthy infant at 35 weeks EGA, unspecified reason for delivery. |
| Bozkurt et al. (39) | Turkey | Prenatal psychotic depression, n=1 | Second trimester, n=1 | Acute BT ECT, 3x/week, 10 treatments Maintenance BT ECT, once monthly, 3 treatments (until 31 weeks EGA) |
Remission, as evidence by reduced (improved) HAM-D score from baseline (33) through the 10th treatment (7). | Pelvic pain after the 8th and 9th treatment. | Delivery of healthy infant at 38 weeks EGA. |
| Brown et al. (40) | USA | Prenatal psychotic depression, n=1 | Second trimester, n=1 | ECT electrode placement unspecified, 8 treatments | Not reported. | Patient required the use of a supraglottic airway owing to difficult ETI, and completed 8 ECT treatments without apparent adverse events. | Not reported. |
| Bulbul et al. (41)b | Turkey | Mixed sample, 33 cases total Prenatal MDD, n=19 Prenatal BDc, n=12 Schizophrenia, n=2 |
Multiple trimesters of pregnancyb | Acute ECT, electrode placement and treatment frequency unspecified | 16 (84.2%) of 19 patients with MDD had a decrease (improvement) in CGI-S scores to ≤ 2 (borderline ill or not ill) 11 (91.7%) of 12 patients with BPc had a decrease in CGI-S scores to ≤ 2 |
Diagnosis-specific information was not available. Three patients had transient uterine contractions during ECT requiring no specific intervention. | Diagnosis-specific information was not available. There was one stillbirth (cause not determined) and once case each of congenital hip dysplasia and SVT after myocarditis. |
| Bulbul et al. (42)d | Turkey | Mixed sample, 68 cases total Prenatal unipolar depression, n=43 Prenatal BP, n=20 (5 with BP-D, 5 with BP-MX, and 10 with BP-M) |
First trimester, n=17 (unipolar depression), n=5 (BP) Second trimester, n=22 (unipolar depression), n=9 (BP) Third trimester, n=4 (unipolar depression), n=6 (BP) |
ECT electrode placement and treatment frequency unspecified | Remission (HAM-D <7 or CGI-S ≤ 2) in 93% of patients with unipolar depression. Phase-specific information on treatment response was unavailable for patients with BP. |
Outcomes unspecified apart from no cases of preterm delivery among 26 women with unipolar depression for whom birth information was available. | No medical problems reported in 30 infants born to mothers with unipolar depression for whom birth information was available. Of 17 infants born to mothers with BP, 16 were normal and 1 had a cardiac disease that healed with treatment. |
| Chase et al. (43) | USA | Perinatal MDD, psychotic features, n=1 | Postpartum week(s) unspecified | Acute BT ECT, 16 treatments | Partial response after 5 treatments, remission after 16 treatments | Not reported. | Not reported. |
| Choi et al. (44) | S. Korea | Perinatal depression, n=1 | Approximately 12 weeks postpartum | Acute BT ECT, stopped after one treatment | Not reported. | ECT stopped owing to treatment-emergent T6 vertebral fracture.e | Not reported. |
| (45) | UK | PPD, n=1f | Postpartum week(s) unspecified | Acute ECT, electrode placement unspecified, 6 treatments | Full response after 6 treatments | Not applicable. | Not reported. |
| DeAsis et al. (46) | USA | Prenatal BP-D, passive suicidal ideation, n=1 | Second trimester, n=1 | Acute RUL ECT, 10 treatments Continuation RUL ECT, 4 treatments |
Remission | Prolonged seizure after 2nd treatment with no recurrence after switching anesthesia induction agent to propofol. | FHR deceleration after 2nd treatment, but non subsequently. Delivery of healthy full-term infant. |
| DeBattista et al. (47) | USA | Prenatal MDD, n=1 | First trimester, n=1 | Acute BT ECT, 5 treatments | Remission (HAM-D score improved from 31 at baseline to 7 following the 5th treatment) | No significant maternal adverse events. | FHR deceleration after 4th and 5th treatments, each followed by rapid return to baseline. Delivery of healthy infant at 38 weeks EGA. |
| Dorn et al. (103) | USA | Prenatal BP-D, psychotic features, n=1 | First trimester, n=1 | Acute BT ECT, 9 treatments | Remission after 9 treatments | No significant maternal adverse events, though “mildly hypomanic” symptoms were described.g | No significant fetal or neonatal adverse events. |
| Echevarria Moreno et al. (48) | Spain | Psychotic depression, n=1 | First trimester, n=1 | Acute BT ECT, 9 treatments | Remission | Moderate memory loss for the time period around the acute ECT series. “Minimal” vaginal bleeding after the 2nd treatment and “profuse” vaginal bleeding after the 3rd treatment. |
Miscarriage after the 3rd treatment. |
| Erturk et al. (49) | Turkey | Prenatal depression with suicidal ideation, n=1 | Second trimester, n=1 | Acute BF ECT, 2x/week, 10 treatments | Remission | Not reported. | Delivery of healthy infant at 38 weeks EGA by cesarean section. |
| Forray & Ostroff (50) | USA | Mixed sample, 5 cases total PPD, psychotic features, n=2 PPP (bipolar I disorder), n=1 Postpartum BP-MX, n=1 Postpartum mood disorder, NOS, n=1 |
3 weeks to 11 months postpartum | Acute BT ECT, 6 to 9 treatments Continuation BT ECT, 4 to 11 treatments |
Case 1 (postpartum mood disorder NOS) – Significant improvement by 3rd treatment and eventual remission.h
Case 2 (PPP, bipolar I disorder) – “marked response” by 2nd treatment and eventual remission.h Case 3 (PPD with psychotic features) – significant improvement by 5th treatment with eventual remission.h Case 4 (BP-MX) – Significant improvement by 3rd treatment and eventual remission.h Case 5 (PPD with psychotic features) – significant improvement by 2nd treatment with eventual remission.h |
Transient memory disturbance in 3 of 5 cases. | Not reported. |
| Gahr et al. (51) | Germany | Prenatal depression, suicidal ideation, resistant to medication and L-DLPFC TMS, n=1 | First trimester, n=1 | Acute RUL ECT, 13 treatments | Remission (reduction in baseline BDI score [56] before ECT to 4 [1 week after final ECT treatment]) | No apparent maternal complications during the acute ECT series. Unimpaired gestation at 24 weeks EGA (2 months after final ECT treatment). |
No fetal trauma based on sonographic data. |
| Gannon et al. (52) | USA | Prenatal BP-D, passive suicidal ideation, n=1 | Third trimester, n=1 | Acute BT ECT, 7 treatments | Remission noted after delivery | Prolonged seizure, transient uterine contractions (first treatment only), nausea, mild headaches, transient urinary retention. Hypomanic symptomsi while receiving ECT and taking sertraline and lurasidone, necessitating discontinuation of sertraline and increasing the dose of lurasidone. |
Delivery of healthy infant at 38 weeks EGA. |
| Gonzales et al. (53) | USA | Depression with catatonia, n=1 | Second trimester and in early postpartum, n=1j | Acute RUL ECT during the second trimester, 10 treatments Acute ECT during the early postpartum, electrode placement unspecified, 12 treatments |
“Notable improvement” in mood and catatonic symptoms after 10 treatments initiated in the second trimester. Improvement in depressive symptoms with residual impoverished speech after 12 treatments (response plateaued after the 10th treatment) given in the postpartum. |
Not reported. | Delivery of healthy infant at 40+1 weeks. |
| Gressier et al. (13) | France | PPD, suicidal ideation, n=1 | Approximately 12 weeks postpartum | Acute BT ECT, 29 treatments total | Remission, with improvement in HAM-D, QIDS-C, and EPDS scores from baseline (32, 28, and 23) to the end of ECT (3, 2, and 3). No depressive relapse at 6 month follow-up. | Not reported. | Not reported. |
| Griffiths et al. (54) | USA | Prenatal MDD, suicidal ideation, n=1 | Second trimester, n=1 | Acute BT ECT, 11 treatments total | Initial series of 6 ECT treatments (given between 23 and 26 weeks EGA) were provided “with good results.” Hospital admission was required at 28 weeks EGA, where 5 additional ECT treatments were provided over 3 weeks. | No abnormalities in VS, SaO2, or uterine activity | No abnormalities in FHR. Delivery of healthy infant at 40 weeks. |
| Grover et al. (55)k | India | Mixed sample, 13 cases total. PPD, n=3 PPD, psychotic features, n=4 Postpartum BP-D, n=1 Postpartum manic episode, n=2 Schizophrenia, n=2 “Acute and transient” psychotic disorder, n=1 |
For PPD and BP-D cases, 2 to 21 weeks postpartum.k | Acute ECT, electrode placement unspecified, 5 to 12 treatments for PPD and BP-D cases. | Remission for all PPD and BP-D cases based on post-ECT HAM-D score ≤ 7. | Body aches, memory disturbances | All babies were breastfed during the postpartum without observed or reported adverse effects. |
| Grover et al. (56)l | India | Mixed sample, 10 cases total. PPD, n=6 Postpartum manic episode, n=1 “Acute and transient” psychotic disorder, n=2 Organic psychosis, n=1 |
Mean duration of episode(s) at the time of ECT con-sideration was 3.8 months. Diagnosis-specific results were not provided. | Acute BT ECT, mean number of effective ECT treatments (all cases) was 6.7 (range 2 to 12). Diagnosis-specific results were not provided. | 9 or 10 patients had at least a partial response to ECT (“overall improvement >50%”). Diagnosis-specific results were not provided. | “No immediate complications” during the ECT procedure. Two patients developed “delayed complications” (delirium, seizures). | Not reported. |
| Grover et al. (57)m | India | Mixed sample, 5 cases total. Prenatal depression, suicidal ideation, n=2 Manic episode, n=1 Schizophrenia, n=2 |
Second trimester, n=2 | Acute BT ECT, 6 treatments were provided in both prenatal depression cases. | Remission in one prenatal depression case (78.6% reduction in HAMD score), partial response in the other prenatal depression case (65.7% reduction in HAMD score). | No ECT-related complications in either prenatal depression case. | Delivery of healthy infant (both prenatal depression cases). One delivery was by cesarean section at 35 weeks owing to PIH. The other was by NSVD at 38 weeks EGA. |
| Guillet et al. (58) | France | Prenatal depression, suicidal ideation, in patient with dopamine-responsive dystonia, n=1 | Unspecified | Acute ECT, electrode placement unspecified, 13 acute treatments followed by consolidation treatments occurring once every 2 months. | “Clear improvement” in mood symptoms, dyskinesia, and dystonia after 13th treatment | Not reported. | Not reported. |
| Gunduz et al. (59)a | Turkey | Prenatal MDD with psychotic features, n=1 | Third trimester, n=1 | ECT electrode placement unspecified, 4 acute treatments. | Not reported. | Transient uterine contractions that increased in intensity after each ECT treatment despite tocolytic therapy. | FHR fluctuations on continuous fetal monitoring (90 bpm to 140 bpm), each lasting about 5 minutes before returning to baseline. No delivery outcomes reported. |
| Herzog et al. (60) | USA | Mixed sample, 13 cases total. PPD, n=5 BP, n=5 Schizophrenia, n=3 |
Unspecified | Acute ECT was provided for three rapid cycling patients diagnosed with BP. ECT electrode placement was unspecified. Four to 8 treatments were provided in these cases. | “Good response” after 4–8 treatments. | Not reported. | Not reported. |
| Howe et al. (61) | UK | Psychotic depression, n=1 | Third trimester, n=1 | Acute BT ECT, 4 treatments | “Rapid and sustained recovery.” Was noted as being well after 2 years of follow up. | Not reported. | Not reported. |
| Isik et al. (62) | Turkey | Psychotic depression, n=1 | Second trimester, n=1 | Acute ECT, electrode placement unspecified, 6 treatments | Not reported. | TMJ dislocation after 2nd treatment in the setting of a prior TMJ dislocation 4 years previously, leading to switch from plastic bite block to cotton bit block and no further complications. | Not reported. |
| Iwasaki et al. (63) | Japan | Prenatal depression, n=1 | Second trimester, n=1 | ECT electrode placement unspecified, 14 treatments | Gradual improvement reported. | Not reported. | Transient FHR decrease with propofol but not thiamylal anesthesia. Delivery of healthy infant. Normal development through first three years of life. |
| Reveles Jensen et al., (64) | Denmark | PPD, psychotic features, n=1 | 24 weeks postpartum | Acute BT ECT, 26 treatments | Improved depressive symptoms between admission (HAMD score 21) and hospital discharge (HAMD score 16). | Objectively documented improvement in red-green color-blindness. No other side-effects from ECT occurred. | Not reported. |
| Kasar et al. (65) | Turkey | Prenatal MDD with psychotic features, n=1 | Third trimester, n=1 | Acute BT ECT, 4 treatments | “Marked improvement” in depressive symptoms (and reduction in HAMD score from 47 to 15) was noted after the 3rd treatment. | Onset of “birth pain” one day after the 4th treatment. | Premature delivery at 34 weeks, with normal newborn development and normal development over the first 6 months of life. |
| Kisa et al. (66) | Turkey | PPD, n=1 | Approximately 8 weeks postpartum | Acute BF ECT, 8 treatments | “Substantial improvement” in depressive symptoms after 8th treatment. | Prolonged seizure terminated with midazolam during the 2nd treatment, thought to be influenced by ciprofloxacin. No prolonged seizures after resuming ECT without ciprofloxacin. | Not reported. |
| Leite et al. (67)a | Portugal | PPD with catatonia, n=1 | 24 weeks postpartum | Acute ECT, electrode placement and treatment frequency unspecified | Remission of catatonic symptoms, “improvement” of depressive symptoms. | Not reported. | Not reported. |
| Levy et al. (68) | Australia | Mixed sample, 3 cases total PPD, suicidal ideation, n=1 BP-D, suicidal ideation, n=2 |
Unspecified | Acute RUL/UB ECT, 3x/week. Case 1–10 treatments. Case 2–20 treatments. Case 3–9 treatments. |
Cases 1 and 2 had clinically significant improvement in depressive symptoms (EPDS scores 21–22 at baseline, 2–4 at discharge). Clinical outcome was unclear for Case 3. | Not reported. | Not reported. |
| Livingston et al. (69) | USA | Prenatal psychotic depression, n=1 | Second trimester of twin pregnancy, n=1 | Acute ECT, electrode placement unspecified, 8 treatments | After delivery, the patient’s psychiatric status deteriorated, requiring “multiple medications and regular ECT.” | Spontaneous preterm labor at 35 weeks EGA. | One episode of transient FHR deceleration during the 3rd treatment. Preterm delivery at 35 weeks EGA. Twin A was diagnosed with transposition of the great vessels; however, died of postoperative complications after successful surgical repair. Twin B was diagnosed with anal atresia, a small sacral defect, and coarctation of the aorta. |
| Maletsky et al. (70) | USA | Mixed sample, 27 cases total. Prenatal MDD, n=7 Prenatal MDD, psychotic features, n=7 Prental MDD, catatonia, n=5 Unspecified catatonia, n=8 |
One pregnancy case was described in detail. Trimesters of pregnancy unspecified. | One pregnancy case was presented in detail and described two acute BT ECT series, the first occurring 3x/week over two weeks (6 treatments). | All four pregnant patients “showed marked improvement.” The case described in detail had a partial acute response and declined continuation ECT. She experienced a relapse at 4 weeks postpartum and “responded fully” to a second series of BT ECT. |
Not described. | Delivery of a healthy infant. |
| Malhotra et al. (71) | India | Mixed sample, 2 cases total. Prenatal depression, suicidal ideation, n=1 Unspecified catatonia, n=1 |
Second trimester, n=2 | Acute ECT, electrode placements and treatment frequencies unspecified. | Not reported. | No apparent complications. | Normal real-time US findings (pre- and post-procedure). |
| Martinez-Sosa et al. (72) | USA | Prenatal depression with catatonia, n=1 | First trimester, n=1 | Acute BT ECT, 7 treatments | Significant improvement after 4th treatment and eventual resolution of mood and catatonic symptoms. | Premature labor/PPROM at 31 weeks | Normal spontaneous premature delivery at 31 weeks. Infant diagnosed remained hospitalized for first 50 days of life with hyaline membrane disease and prematurity associated apnea, retinopathy, and anemia. |
| May et al. (73) | USA | PPD, suicidal ideation, n=1 | ECT offered during third hospitalization within the 1 year after delivery. | ECT electrode placement unspecified, 7 acute treatments followed by maintenance ECT. | Acute remission based on improvement in MADRS score from 45 to 9. Clinical response sustained while receiving maintenance treatments. | None described during acute ECT. Severe unilateral myalgias after one maintenance ECT treatment, “possibly due to insufficient paralysis.” | Not reported. |
| Morris et al. (74)n | Puerto Rico | PPD, suicidal ideation, n=1 | Unspecified | Acute ECT, electrode placement and treatment frequency unspecified. | Full response achieved after several exacerbations of depressive symptoms | Headache | Not reported. |
| Mynors-Wallis et al. (75) | UK | Prenatal depression, catatonia, n=1 | Third trimester, n=1 | Acute ECT, electrode placement and treatment frequency unspecified. | “Good response.” | Not reported. | Not reported. |
| O’Reardon et al. (76) | USA | Prenatal MDD, suicidal ideation, n=1 | Second trimester, n=1 | Acute BT-BF ECT, 18 treatments, followed by 13 continuation ECT treatments over 6 months. | Positive response based on 50% improvement in HAM-D scores after 3rd acute treatment. Depressive symptoms eventually remitted. Continuation treatments extended into the postpartum were effective. | Not reported. | Delivery of a healthy infant at 37 weeks by scheduled cesarean section. Normal development through 18th month of life. |
| Ozgul et al. (77) | Turkey | Prenatal depression, suicidal ideation, n=1 | First trimester, n=1 | Acute BT ECT, 3x/week, 10 treatments | Not reported. | No significant hemodynamic changes. | Condition of the fetus was evaluated by obstetrician after each treatment, but outcomes were not reported. |
| Patel et al. (78) | USA | Prenatal MDD, suicidal ideation, n=1 | Third trimester, n=1 | Acute BT ECT, 3x/week, 8 treatments | Remission. | Transient asymptomatic contractions relieved with IV fluids. | Transient decreases in FHR. |
| Pesiridou et al. (79) | USA | Prenatal BP-D, borderline personality disorder, PTSD, SUDs, suicidal ideation, n=1 | Third trimester, n=1 | Acute RUL ECT, 6 treatments, followed by continuation ECT | Acute remission of suicidal ideations, “significant decreases” in depressive and anxious symptoms. | Disorientation, confusion, and memory disturbances after increasing stimulus strength owing to short seizures.° Painful contractions at 32 weeks EGA following 6th treatment, responsive to tocolytics. Experienced periodic contractions until 37 weeks EGA. |
Delivery of healthy newborn at 37 weeks EGA. |
| Pierre et al. (80) | France | Prenatal BP-MX, suicidal ideation, n=1 | Second trimester, n=1 | Acute BT ECT, 5 treatments | Depression scores (HAMD 25) “entirely improved” after ECT. YMRS scores improved from 26 to 3. | Uterine contractions after 1st treatment. | Normal fetal development on ultrasound scanning. No development of fetal bradycardia. |
| Pinette et al. (81) | USA | Prenatal MDD, n=1 | ECT administered throughout pregnancy | Maintenance ECT was continued into and throughout pregnancy | Good response to maintenance ECT was documented. | Induction of labor owing to pre-eclampsia at 37+1 weeks. | Small left cerebellar, bihemispheric deep white matter, and cortical infarcts on CT/MRI. |
| Rabie et al. (82) | USA | Mixed sample, 5 cases total. Prenatal depression, n=3 (1 with suicidal ideation) Prenatal BP/BP-D, n=2 (1 with suicidal ideation) |
Trimesters at ECT initiation unspecified. | Acute RUL ECT administered with continuous FHR monitoring, range 2 to 23 treatments | All patients reported improvement, one with “limited improvement” and another rehospitalized due to depressive relapse. | Headaches, muscle soreness, nausea, fatigue, memory disturbances, transient uterine contractions. | Reassuring FHR tracings before and during ECT (data on 32 of 34 treatments that included continuous FHR monitoring). Transient decelerations noted for 4 treatments, none requiring intervention or additional monitoring. Healthy term deliveries in all 5 cases. |
| Ratan et al. (83) | UK | Perinatal depression with psychotic features, n=1 | Postpartum week(s) unspecified | Acute ECT, electrode placement and frequency of treatment unspecified. | Remission | Not reported. | Not reported. |
| Ray-Griffith et al. (84) | USA | Mixed sample, 8 cases total Prenatal depression, n=3 Prenatal depression, suicidal ideation, n=2 Prenatal BP-D, n=1 Prenatal BP-MX with suicidal ideation, n=1 Unspecified prenatal mood disorder with suicidal ideation, n=1 |
Second trimester, n=5 Third trimester, n=3 |
Acute RUL ECT, 30 treatments total, ranging from 1 to 7 treatments individually. | Remission of suicidality in 5 patients who presented with acute suicidal ideation. “Clinical improvement” of depression for 6 of 8 patients. |
Case 5 - ECT discontinued due to treatment-emergent hypomanic symptoms after the 1st treatment at 21+2 weeks. PPROM/preterm labor at 30+1 weeks. Case 8 – ECT stopped after asymptomatic episode of complete heart block requiring atropine and intensive care observation, deemed secondary to anesthesia with methohexital. |
Uncomplicated term deliveries except for Cases 3 and 8 (did not deliver at investigators’ institution) and Case 7 (below). Case 7 – infant born with right club foot and right 5th toe displacement, detected on ultrasound before ECT. |
| Repke et al. (85) | USA | Prenatal depression with psychotic features, n=1 | Second trimester, n=1 | Acute ECT, electrode placement unspecified, 5 treatments | Positive response | Reduction in blood pressure, though secondary to low intravascular volume, prevented with pre-hydration during treatments 2-5. | Delivery of healthy infant. |
| Richardson et al. (86)a | UK | Prenatal BP-MX, n=1 | Third trimester, n=1 | ECT electrode placement unspecified, 8 treatments. ECT resumed on a Q 2 week basis following delivery, then extended to monthly maintenance ECT. | Positive acute response and positive maintenance response at 6 months postpartum. | No maternal complications. | No fetal complications. Delivery at 38 weeks EGA by elective cesarean section. |
| Rineh et al. (87) | Iran | Prenatal MDD, n=1 | Third trimester, n=1 | Acute ECT, electrode placement unspecified, 3x/week, 6 treatments. | Significant improvement in depression after 3rd treatment and remission after the 6th treatment. | Intermittent uterine contractions, eventually requiring prophylactic magnesium sulfate | Single transient FHR reduction after 2nd treatment. |
| Sahan et al. (88) | Turkey | Prenatal depression with psychotic features, catatonia, and urinary bladder overdistension, n=1 | First trimester, n=1 | Acute ECT, electrode placement unspecified, 3x/week, 7 treatments | Patient was able to urinate after 3rd treatment. Negativism resolved. Discharged from the hospital with full recovery. Experienced relapse during third trimester, managed with pharmacotherapy. |
Not reported. | Delivery of healthy infant, with normal development through first year of life. |
| Salzbrenner et al. (89) | USA | Prenatal BP-D with history of IVF and pre-eclampsia, suicidal ideation, n=1 | Third trimester, n=1 | Acute BT ECT, electrode placement unspecified, 3x/week, 9 treatments | Positive response, improvement in MADRS score from 32 at baseline to 12 after 8th treatment. Psychiatrically stable at 9 month follow-up. |
Hypertensive responses to ECT controlled with IV labetalol initially (switched to remifentanil). ECT had to be stopped owing to cognitive side effects (MMSE 19/30 after 9th treatment; 30/30 at baseline). MMSE scores steadily improved to 30/30 over the following 4 months. |
No fetal complications. Delivery of healthy infant at 38 weeks EGA by cesarean section. Normal development through first 9 months of life. |
| Sandal et al. (90) | Turkey | Prenatal depression, n=1 | Second trimester, n=1 | ECT electrode placement unspecified, 6 treatments | Not reported. | Not reported. | Infant diagnosed with Mobius syndrome, not believed to be caused by ECT. |
| Sarma et al. (91) | Australia | PPD with suicidal ideation and type 1 Chiari malformation, n=1 | 8 weeks postpartum | Acute BF ECT, 3x/week, reduced in frequency to 2x/week after 2 weeks, totaling 12 treatments | Remission of suicidal ideation and significant improvement in depressive symptoms (MADRS and EPDS 32 and 23 at baseline, 11 and 4 after ECT). Mild reduction in MoCA scores (from 29 to 25). | Mild headaches, concentration and memory disturbances. | Not reported. |
| Serim et al. (92) | Turkey | Prenatal depression with psychotic features, n=1 | Third trimester, n=1 | Acute BT ECT, 3x/week, 10 treatments | “Significant” improvement after 5th treatment. Relapse occurred 2 weeks after 10th acute treatment, eventually responsive to medication only. | Brief uterine contractions after one treatment that was responsive to tocolytic therapy. | Brief (2–3 second) FHR deceleration during one treatment. Delivery of healthy infant at 39 weeks by cesarean section. |
| Shea et al. (93) | USA | PPD with psychotic features in patient with Turner syndrome, n=1 | 4 weeks postpartum | Acute BT, 6 treatments | Resolution of infanticidal thoughts, “steady” improvement of depressive/neurovegetative symptoms. | Not reported. | Not reported. |
| Sherer et al. (94) | USA | Prenatal depression with psychotic features, n=1 | Third trimester, n=1 | Acute BT, 7 treatments | Not reported. | Transient uterine contractions (eventually requiring tocolytic therapy), vaginal bleeding, abruptio placentae diagnosed after delivery with unremarkable postoperative course. | Delivery of healthy infant at 37 weeks by cesarean section. |
| Strain et al. (95) | USA | Diagnosed postpartum depression presenting acutely with psychotic features and catatonia, n=1 | 5 months postpartum | Acute ECT, electrode placement unspecified, 6 treatments | Positive response to ECT, with early improvement noted after the 1st treatment. Stable at 18 month follow up. | Not reported. | Not reported. |
| Takubo et al. (96) | Japan | PPD, suicidal ideation, n=1 | Postpartum week(s) unspecified | ECT electrode placement and frequency of treatment unspecified. | Partial response. | Not reported. | Not reported. |
| Walker et al. (97) | USA | Prenatal depression with psychotic features, n=1 | Second trimester of twin pregnancy, n=1 | Acute BT ECT, 6 treatments initially, 7 treatments after relapse. Two continuation treatments given once-weekly. |
Remission of presenting symptoms after initial acute series, followed by relapse 3 weeks later. This was followed by 7 additional treatments that resulted in remission. Two weekly continuation treatments were given. | Occasional uterine contractions on tocodynamometry | Twin B – nonreactive NST after 2nd treatment with normal contraction stress test and normal subsequent NSTs. Delivery at 35 weeks EGA. Twin A - transposition of the great vessels, death 2 weeks after surgery. Twin B- born with imperforate anus, hemivertebra of the sacral vertebra, atrial septal defect, and coarctation of the aorta. |
| Watanabe et al. (98) | Japan | Prenatal MDD, suicidal ideation, n=1 | Third trimester, n=1 | Acute BT ECT, 2x/week, 6 treatments | Partial response (improvement in HAM-D score from 36 to 26) with resolution of suicidal ideation and restoration of appetite. | Uterine contractions from the 3rd treatment onward | Persistent fetal tachycardia (180–200 bpm >30 minutes), presumed secondary to maternal apnea during ECT, with no recurrence after the reinitiation of oxygenation just after electrical stimulus delivery. Delivery of healthy infant at 38 weeks EGA. |
| Wise et al. (99) | USA | Prenatal depression with psychotic features, n=1 | Third trimester, n=1 | Acute RUL ECT, 8 treatments | Remission after the initial acute series, with good response to 4 additional treatments to address return of depressive symptoms that occurred twice before delivery. | One brief episode of SVT that required no intervention. | Oxytocin-induced vaginal delivery of healthy infant at 37 weeks EGA, with normal development through first 10 months of life. |
| Yamada et al. (100)a | Japan | Prenatal BP-D, n=1 | Third trimester, n=1 | ECT electrode placement unspecified, 2-3x/week, 10 treatments | Unspecified improvement in depressive symptoms. | FGR diagnosed by ultrasound, with fetal growth delay starting at 29 weeks EGA, possibly caused by thrombosis of the umbilical vein. | FGR-delivery by emergent cesarean section at 32 weeks. |
| Yang et al. (101) | S. Korea | Prenatal BP-D with psychotic features, n=1 | Third trimester, n=1 | Acute ECT, electrode placement unspecified, 7 treatments | Positive response to initial acute series followed by relapse 3 weeks after hospital discharge. | Transient uterine contractions/possible preterm labor, responsive to tocolytic therapy, with no apparent reoccurrence. | FGR fetus diagnosed before ECT initiation. Premature delivery at 35+4 by emergency cesarean section. Infant was diagnosed with hyaline membrane disease and congenital hypertrophic pyloric stenosis. |
| Ying et al. (102)a | Unspecified | Prenatal depression, suicidal ideation, n=1 | Third trimester, n=1 | Acute ECT, electrode placement and frequency of treatments unspecified. | Resolution of depression. | Prolonged neuromuscular blockade that delayed extubation, due to pseudocholinesterase deficiency owing to pregnancy. Rocuronium replacement of succinylcholine allowed completion of ECT series. | Prolonged transient FHR deceleration after 1st treatment. |
Key: BP, bipolar spectrum disorder; BP-D, bipolar depression; BP-M, bipolar mania; BP-MX, bipolar mixed episode; BF, bifrontal ECT; BT, bitemporal ECT; BZD, benzodiazepine; CGI, Clinical Global Impression scale; CGI-S, Clinical Global Impression severity subscale; CT, computed tomography scan; DPHD, diphenylhydantoin; EGA, estimated gestational age; EPDS, Edinburgh Postnatal Depression Scale; GFR, fetal growth restriction; FHR, fetal heart rate; IV, intravenous; IVF, in vitro fertilization; L-DLPFC, left dorsolateral prefrontal cortex; MADRS, Montgomery Asberg Depression Rating Scale; MDD, major depressive disorder; MMSE, Folstein Mini-Mental Status Examination; MoCA, Montreal Cognitive Assessment; MRI, magnetic resonance imaging scan; MV, mechanical ventilation; NST, non-stress test; NSVD, normal spontaneous vaginal delivery; PIH, pregnancy induced hypertension; PPD, postpartum depression; PPROM, preterm premature rupture of membranes; PTSD, posttraumatic stress disorder; QIDS-C, clinician-rated Quick Inventory of Depressive Symptomatology scale; RUL, right unilateral ECT; RUL/UB, right unilateral ultrabrief pulse ECT; SE, status epilepticus; SUD, substance use disorder; SVT, supraventricular tachycardia; TMS, transcranial magnetic stimulation; UK, United Kingdom; USA, United States of America.
aCitation is from a published conference abstract. bCase series described ECT in 33 pregnant patients, 19 with MDD, 12 with BP, and 2 with schizophrenia. Among all 33 cases, ECT was performed starting in the first, second, and third trimesters for 13, 15, and 5 patients, respectively. cMood polarity was unspecified. dA total of 68 cases were presented, including 43 patients with “unipolar depression,” 20 with a bipolar spectrum disorder, 3 with obsessive-compulsive disorder, and 2 with schizophrenia. eThis 29-year-old patient was subsequently found to have osteoporosis based on a dual-energy X-ray absorptiometry (DEXA) scan z-score of -2.5. fThis was a single case report of ECT for PPD in a patient who attended a day center program for individuals with learning disabilities. g“Mildly hypomanic” symptoms were observed for 1 week after the final (9th) ECT treatment that included being “talkative, with elevated mood.” Maintenance ECT was planned. hAll 5 cases were described as achieving remission of acute symptoms with no subsequent relapses in 4 subjects who received continuation ECT treatments. iHypomanic symptoms included increased energy, increased goal-directed behavior, and “slight” decreased need for sleep after the 4th treatment. There was “mild mood elevation” noted after hospital discharge. Euthymia was documented within 2 weeks following delivery. jThis patient received an acute inpatient series of RUL ECT for depression with catatonic features while pregnant; however, 2 months after discharge, she was hospitalized with a relapse of depressive and catatonic symptoms. Labor was induced at 40+1 weeks. ECT was resumed during the early postpartum. kA total of 13 postpartum ECT cases are described consisting of a mixed sample of patients with PPD (7 cases), BP (3 cases total, 1 with BP-D), schizophrenia (2 cases), and “transient psychotic disorder” (1 case). The mean total duration of psychiatric symptoms during the postpartum period in the entire case series was 57.8 days, or 8.3 weeks. lTen postpartum ECT cases are summarized, composing a mixed sample of patients with PPD (6 cases), acute mania (1 case), PPP without underlying diagnosis specified (2 cases), and “organic psychosis” (1 case). mMixed sample included 2 cases of recurrent prenatal depression, 1 case with BP-M, and 2 cases with schizophrenia. nThis was a first-person account of having undergone ECT for PPD. ° Switching anesthesia induction agent from methohexital to etomidate resulted in enhanced seizure durations.