Introduction

Electroconvulsive therapy (ECT) is a type of treatment used for severe symptoms of some mental health problems. It involves the use of small electric currents being passed through the brain. ECT still causes some side effects but the updated use of electric currents and ECT given in a controlled healthcare setting helps to achieve the safest usage and the reduction of possible side effects.

It is estimated that about 1 in 5 women are diagnosed with mental health conditions during pregnancy. Untreated maternal health is associated with unfavourable pregnancy outcomes including premature birth, low birth weight, and foetal (baby) growth restriction.

ECT is considered generally safe but may be underutilised due to the stigma and lack of access for these women due to the perceived increased risk to the mother and the baby. However, studies have shown that serious side effects associated with ECT use in pregnancy are rare.

This article aims to explore the safety and considerations of ECT in pregnancy and provide guidance on the role and use of ECT during pregnancy.

ECT basics

Explanation of electroconvulsive therapy

Electroconvulsive therapy (ECT) is a treatment procedure, used for severe mental health symptoms. However, according to the National Institute for Health and Care Excellence (NICE), doctors are only recommended to use ECT for a few conditions due to the intensity of the treatment involved.

Procedure overview

ECT is a procedure in which small electric currents are passed through the brain to trigger a brief seizure and is usually done under general anaesthesia.¹

Early treatments with ECT involved the use of high doses of electric currents being administered without anaesthesia which can lead to memory loss, fractured bones, and other serious side effects. But today, ECT is now done in a much safer way with the use of anaesthesia and more knowledge about the procedure to prevent fewer side effects.¹

Common uses and indications

Some of the common uses for ECT recommended by NICE guidelines include:

• Treating severe depression 

As a short-term treatment for:

• A severe or long-lasting episode of mania
• Catatonia - a condition when you're frozen in one position or making repetitive or restless movements

Certain criteria need to be met before your doctor can recommend ECT for you, these are:

• If you have a preference for ECT based on your experience of having it in the past 
• If you need urgent treatment and your life is at risk because you're not eating or drinking 
• If other treatments such as medication and talking therapies haven’t worked 

It is important to note that NICE only recommends that you have the ECT procedure again for mania and catatonia if you've previously responded well to the treatment or if all other treatment options have already been considered.

The NICE guidelines don't recommend ECT for ongoing management of schizophrenia or routine treatment in mild depression. In addition, ECT is often used when other treatments at a full course completion have been unsuccessful, but it is important to note that it may not work for everyone.

How ECT works in treating mental health conditions

Some healthcare professionals suggest that ECT works by seeming to cause changes in the brain chemistry which can quickly reverse the symptoms of certain mental health conditions.

ECT is commonly performed in a dedicated suite in a hospital, most frequently in an outpatient setting. Patients with severe mental illness may be admitted to the hospital at first and then transferred to an outpatient unit as needed. You will be expected to have fasted for the procedure, which includes no light meal for six hours, no full-fat meal for eight hours, and no clear liquids for two hours before anaesthesia.¹ You can read about the full ECT procedure here.

Mental health during pregnancy

Overview of mental health challenges during pregnancy

There are many types of mental health problems that you can experience during pregnancy, and they can happen at any time, even if you have been pregnant before. Some of the most common mental health conditions that have been reported are: 

• anxiety (if you have sudden fear or panic) 
• depression (if you feel sad all the time) 
• tokophobia (if you have an intense fear of giving birth)
• post-traumatic stress disorder (PTSD) which can happen if you have had an intensely distressing experience in the past

According to the World Health Organisation (WHO) in 2022, almost 1 in 5 women will experience a mental health problem during pregnancy or within a year after giving birth, with suicide being the leading cause of maternal deaths in the UK within a year after giving birth. 

Impact of untreated mental health conditions on both mother and baby

The welfare of both mother and baby is of equal importance as untreated mental health conditions could impact them both. Various researchers have shown that children born to mothers who suffer from mental health ailments such as depression have low-birth-weight babies with developmental issues, and subsequent mental and social problems as young adults.²

Aside from the effect on the baby, mental health issues during pregnancy have also been linked to unhealthy behaviours, such as smoking or taking addictive drugs, which can lead to a low quality of life for the mother and the child.²

Safety concerns and risks

General safety considerations of ECT

ECT has had a negative reaction to its acceptance because of how it has been shown in the media such as films and TV shows. These portrayals of ECT are usually exaggerated and as such may be inaccurate about how this procedure happens in real life, whether it's painful or not or if it's effective or not, as they don’t show how healthcare providers currently do this procedure safely and humanely.

Potential risks and side effects of ECT

Some of the risks and side-effects of ECT that you might experience^3,4 include: 

• Cognitive impairments such as memory loss and confusion
• Stroke
• Heart block
• Hypertension 

However, you should note that ECT is classified as a low-risk procedure by the AHA-ACC guidelines as it is safe and well tolerated with a low mortality rate.⁵

Specific concerns related to pregnancy and foetal well-being

As we have previously explored, the mother's general health can positively or negatively influence her risk of having mental health problems as well as the likelihood of a difficult pregnancy and childbirth.²

Maternal health considerations

The suggested most common risks to the mother during the use of ECT are premature contractions and pre-term labour or miscarriages due to the link with the electric current administered to the brain (this has been shown not to be the case).⁶

Foetal development and potential effects of ECT

The risk of foetal congenital anomalies, emotional or behavioural issues, and neurocognitive problems in the child (this also has been shown not to be the case).⁶

Research and studies

Overview of existing research on ECT during pregnancy

A study regarding the use of ECT in pregnancy showed that the use of ECT in pregnancy has been documented as safe with reports over the last 50 years. The review showed that the adverse effects of ECT use in pregnancy are similar to the risks of ECT in any individual.⁶ 

Summary of findings regarding safety and efficacy

In addition, the review reported that pre-term labour or premature contractions only occurs infrequently and was not linked to the use of ECT. Also, the rates of miscarriages were not significantly different from those of the general population. However, if a pregnant patient develops any of the symptoms, the ECT procedure may be postponed.

The study also showed that ECT did not cause congenital anomalies or behavioural issues, and no neurocognitive problems in the child.⁶

In general, ECT is considered a safe and effective treatment alternative for the management of many mental health conditions in pregnant patients, and may offer some advantages over the use of medications during pregnancy.⁶ You should therefore speak to your doctor if you would like to consider ECT.

Gaps in current knowledge and areas for future research

Despite evidence that ECT is a safe and effective treatment for many mental health illnesses during pregnancy, clinicians must ensure that they weigh the risks to both the mother and the baby. Further knowledge of the risk of not treating the mother against the risk with the ECT procedure should be further explored to determine the most appropriate treatment intervention or improved ECT technique.

Summary

Electroconvulsive therapy (ECT) is a relatively safe and low-risk procedure that is helpful in the treatment of common mental health disorders. It usually requires a multidisciplinary team approach among different healthcare professionals. 

Most patients require several sessions to see a good effect and you should speak to your doctor if you would like to consider ECT. 

The stigma associated with ECT is due to the exaggerated portrayals in the media and the early treatment approach with lack of anaesthesia which resulted in adverse effects such as injury and severe memory loss. 

Mental health illness in pregnant women is quite common and the balance of the risk and benefits of safe and effective treatment is important to the mother and the baby.

Several studies have reviewed the use of ECT in pregnancy and found that the modern approach to ECT is relatively safe for both the mother and the baby.

Overall, the risk of death is very low with ECT if administered in a controlled setting, but there is still a continued risk of mild memory loss in the long term. 

ECT should be considered in pregnant patients as it avoids the risks usually seen in the traditional use of medication.