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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 10  |  Issue : 2  |  Page : 122-124

Anaesthetic management for electroconvulsive therapy during the second trimester pregnancy


Department of Anaesthesia, Sri Venkateswara Medical College, Tirupati, Andhra Pradesh, India

Date of Submission23-Nov-2019
Date of Acceptance10-Mar-2020
Date of Web Publication17-Jul-2021

Correspondence Address:
K G Sreehari
Department of Anaesthesia, Sri Venkateswara Medical College, Tirupati, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JCSR.JCSR_119_19

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  Abstract 


Electroconvulsive therapy (ECT) is a highly effective treatment for patients with psychotic disorders that do not respond to medication. Usually, many psychotropic drugs have a teratogenic effect on the foetus. ECT seems to be a relatively safe and effective choice of treatment in pregnant patients. Adverse events such as foetal heart rate reduction, uterine contractions and premature labour do occur during ECT. We report our experience with ECT in the treatment of first episode of mania with psychosis in a patient in second trimester of pregnancy.

Keywords: Electroconvulsive therapy, general anaesthesia, Mania, pregnancy


How to cite this article:
Sreehari K G, Babu J, Radha J, Jamuna T, Krishna I V, Reddy V R. Anaesthetic management for electroconvulsive therapy during the second trimester pregnancy. J Clin Sci Res 2021;10:122-4

How to cite this URL:
Sreehari K G, Babu J, Radha J, Jamuna T, Krishna I V, Reddy V R. Anaesthetic management for electroconvulsive therapy during the second trimester pregnancy. J Clin Sci Res [serial online] 2021 [cited 2021 Aug 3];10:122-4. Available from: https://www.jcsr.co.in/text.asp?2021/10/2/122/321694




  Introduction Top


For patients with psychotic disorders that do not respond to pharmacological management, electroconvulsive therapy (ECT) is considered to be a highly effective treatment.[1],[2] As several psychotropic drugs have a teratogenic effect on the foetus, ECT seems to be a relatively safe and effective choice of treatment in pregnant patients. Adverse events such as foetal heart rate reduction, uterine contractions and premature labour are known to occur during ECT. We report our experience with ECT in the treatment of first episode of mania with psychosis in a patient in second trimester of pregnancy.


  Case Report Top


A 24-year-old primigravida with 20 weeks of gestation hailing from the rural background was admitted to the psychiatric department with complaints of decreased interaction, decreased work function, sleep disturbances and decreased appetite from 3 months. The following next 15 days, the patient has muttering behaviour, increased energy levels, excessive talking, reduced sleep, irritability and anger outbursts. The patient was diagnosed to have the 'first episode of mania with psychosis'. Psychiatric evaluation, according to the Young Mania Rating Score,[3] the patient had a score of 40.

The patient was started on tablet diazepam 5 mg and tablet olanzapine 10 mg BD for 10 days. No improvement was noticed after 10 days (the patient's Young Mania Score was 35), so the patient was started on tablet haloperidol 5 mg BD dose and olanzapine was increased to 30 mg. No improvement was seen (the patient's Young Maniac score was 35 after oral psychotic drugs were used). Hence, the patient was posted for electroconvulsive therapy (ECT) therapy under anaesthesia.

A urine pregnancy test confirmed her pregnancy. The obstetrician diagnosed the patient as 18–20-week pregnancy with single live intrauterine gestation using the ultasound. The patient was anaemic with haemoglobin of 7.9 mg/DL, so the patient was also started on iron and folic acid tablets. The thyroid profile was within the normal limits.

ECT was planned for the patient, and written informed consent was obtained from the patient's husband. Pre-anaesthetic checkup was done for the patient and was given tablet ranitidine 150 mg previous night before the ECT was planned. The patient was kept nil by mouthfor 8 h for solid food.

The patient was monitored with pulse oximetry, non-invasive blood pressure and five-lead ECG monitor, during the procedure. Baseline vitals were within normal limits. Injection glycopyrrolate 0.2 mg intravenous (IV) and injection ondansetron 4 mg IV were given. The patient was pre-oxygenated with 100% oxygen for 3 min using Bain's circuit. The patient was induced with 60 mg propofol IV and muscle relaxation by 50 mg of succinylcholine IV. The patient was ventilated manually with 100% oxygen using a tight-fitting facemask and Bain's circuit. After 60 s of succinylcholine administration, the mouth gag was inserted to prevent the tongue bite. Electric stimulation was provided with a charge of 120 mC, and seizure duration was 30–70 s was noted. After ECT was given, bag-mask ventilation was resumed until the patient had adequate spontaneous respirations. During the procedure, the patient had transient hypertension (140-160-/90-100 mmHg), and tachycardia (120–130) recovery was uneventful.

The patient had undergone another six sessions of ECT in 2 weeks, the electrical stimulus in all her six ECT was 120 mC. After six sessions, psychiatric symptoms were improved markedly, a psychiatric evaluation of patients. Young Mania Scoring rate improved to 12. Post-treatment obstetric consultation and ultrasound were done 18–20-week single live uterine gestation, and no abnormalities were found. Two weeks later, the patient was discharged with oral olanzapine 7.5 mg once-a-day.


  Discussion Top


Psychotropic medications are the first-line choice in the treatment of mood disorders with psychotic features occurring in pregnant women but are known to have an adverse effect when used during pregnancy and lactation.[1] ECT is a non-pharmacological treatment, which is a highly effective option, especially in depression and also for the psychotic manifestation of schizophrenia.[1] To optimize the anaesthetic management of a patient undergoing ECT, it is important to understand the physiological response to electrical stimulus, the effect of anaesthetic drugs on the ECT response and the pharmacological effect of the drug used to attenuate the side effects related to ECT.[4]

Haemodynamic responses that occur during ECT consist of generalised autonomic nervous system stimulation, as electrical current is delivered, the parasympathetic nervous system is stimulated and resulting in bradycardia/rarely asystole. Shortly after that the sympathetic nervous system is stimulated, which causes tachycardia, hypertension lasting for 5 min or longer and may lead to arrhythmias.[4],[5] Increased catecholamine levels in the blood can affect the uterine blood flow. Vasoconstriction from catecholamine action decreases blood flow to the uterus and placenta with potential hypoxaemia of the foetus. Usually, transient hypoxaemia is tolerable. However, foetal bradycardia can occur if there are pre-existing conditions such as chronic hypertension or diabetics, which tend to compromise uteroplacental circulation.[6] The efficacy of ECT in alleviating acute depression is dependent on the duration of the induced seizures. EEG seizure activity lasting for 25–50 s is alleged to produce the optimal response. Patients experiencing seizure duration of shorter than 15 s or longer than 120 s achieve a less favourable response. Since many of the anaesthetic drugs used have anticonvulsive property, they would be expected to decrease the duration of ECT-induced seizures activity in a dose-dependent manner.[4]

Methohexital is considered as the gold standard in anaesthetizing for ECT. It does not affect ECT seizures' duration.[4],[5] Thiopental sodium can also be an alternative barbiturate although it decreases seizure duration. Propofol has been used in many reports because systemic cerebrovascular and haemodynamic changes under propofol anaesthesia are more stable than under barbiturates.[5] In this case, anaesthesia was induced with propofol and succinylcholine, EEG, seizures duration lasted for 20–75 s and the psychotic symptoms improved.

It seems that ECT is an effective treatment for several mental illnesses during pregnancy, and the risk of foetus and mother are low.[7] However, there were 20 maternal complications reported, and 18 were likely related to ECT such as vaginal bleeding was reported more often during the first trimester, whereas uterine contraction and preterm labour and caesarean section occurred during the second and third trimester, miscarriage, status epilepticus, haematuria, abdominal pain and placental abruption. Foetal adverse events also reported 25 cases, which include foetal death, transient foetal bradycardia and decelerations, clubfoot prematurity, congenital blindness, aorta coarctation, cortical infarct, VATER syndrome and mental retardation.[8]

Volatile anaesthetics such as sevoflurane can also be used in ECT. However, its time-consuming induction, depression of seizure duration and the requirement of an anaesthesia machine make this technique impractical, except for women requiring ECT in the late stages of pregnancy, when it may reduce the post-ECT uterine contractions.[4] The use of tocolytic treatment after ECT to avoid preterm labour was noted by several as well as prophylactic tocolytic medication before the ECT. Uterine contraction usually can be controlled by ritodrine or magnesium sulphate.[8] Foetal bradyarrhythmias can be avoided by adequate pre-oxygenation and proper position of the mother to minimize aortocaval compression by elevating the right hip and displacing the uterus.[8] Another anaesthetic consideration in ECT for pregnancy is on regurgitation of gastric acid resulting from an upwards displacement of the stomach and intestines by the enlarged uterus.[6],[9] The simple method to prevent aspiration is to apply constant manual pressure to cricoids cartilage (Sellick's manoeuvre). Patients in their third trimester should be considered for endotracheal intubation with ECT.[10] Tocodynamometry during ECT can be helpful for monitoring uterine activity and early detection of uterine contraction.[11] Our patient was kept nil oral for ≥8 h, and Sellick's manoeuvre was applied during ECT.

ECT under general anaesthesia is a reasonably safe and effective treatment alternative for the management of many psychiatric disorders in pregnant patients. Establishment of the multidisciplinary approach is fundamental for the safety of pregnant women undergoing ECT.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Baghai TC, Möller HJ. Electroconvulsive therapy and its different indications. Dialogues Clin Neurosci 2008;10:105-17.  Back to cited text no. 1
    
2.
Miller LJ. Use of electroconvulsive therapy during pregnancy. Hosp Community Psychiatry 1994;45:444-50.  Back to cited text no. 2
    
3.
Lukasiewicz M, Gerard S, Besnard A, Falissard B, Perrin E, Sapin H, et al. Young Mania Rating Scale: How to interpret the numbers? Determination of a severity threshold and of the minimal clinically significant difference in the EMBLEM cohort. Int J Methods Psychiatr Res 2013;22:46-58.  Back to cited text no. 3
    
4.
Ding Z, White PF. Anesthesia for electroconvulsive therapy. Anesth Analg. 2002;94:1351-64.  Back to cited text no. 4
    
5.
Mayo C, Kaye AD, Conrad E, Baluch A, Frost E. Update on anesthesia considerations for electroconvulsive therapy. Middle East J Anaesthesiol 2010;20:493-8.  Back to cited text no. 5
    
6.
Walker R, Swartz CM. Electroconvulsive therapy during high-risk pregnancy. Gen Hosp Psychiatry 1994;16:348-53.  Back to cited text no. 6
    
7.
Benabarre A, Bernardo M, Arrufat F, Salvà J. Management and treatment of severe mental disorders in pregnancy. Actas Esp Psiquiatr 2000;28:45-58.  Back to cited text no. 7
    
8.
Anderson EL, Reti IM. ECT in pregnancy: A review of the literature from 1941 to 2007. Psychosom Med 2009;71:235-42.  Back to cited text no. 8
    
9.
Saito S. Anesthesia management for electroconvulsive therapy: Hemodynamic and respiratory management. J Anesth 2005;19:142-9.  Back to cited text no. 9
    
10.
10 Yang HS, Seo HJ, Lee YK. Anesthetic care for electroconvulsive therapy during pregnancy – A case report. Korean J Anesthesiol 2011;60:217-20.  Back to cited text no. 10
    
11.
Kasar M, Saatcioglu O, Kutlar T. Electroconvulsive therapy use in pregnancy. J ECT 2007;23:183-4.  Back to cited text no. 11
    




 

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