ECT use in the first trimester was recently reviewed (76). Of 15 cases, 14 were published before 1964; 5 of these (33.3%) reported complications, including premature birth, miscarriages, and vaginal bleeding. The authors recommend caution in prescribing ECT to patients in the first trimester of pregnancy, with the risk of possible spontaneous abortion to be clarified for informed consent. ECT during the third trimester of pregnancy has recently been described in case reports of 2 patients who were treated effectively (77).

Potential Risks of ECT Use During Pregnancy

There are potential risks related to the physiology of pregnancy that may be increased by ECT. Consequences include spontaneous abortion, preterm labour, uteroplacental insufficiency, or placental abruption. Table 1 outlines the risks associated with ECT during pregnancy. An obstetrician must be consulted prior to ECT to clarify the risks.

Preparation for ECT during pregnancy should include a pelvic examination, discontinuation of nonessential anticholinergic medication, uterine tocodynamometry, intravenous hydration, and administration of a nonparticulate antacid. During ECT, elevating the pregnant woman’s right hip, external fetal cardiac monitoring, possible intubation, and avoiding excessive hyperventilation are recommended. With these extra precautions, ECT may be administered with relative safety and effectiveness during pregnancy (62,85).

Postpartum Risks

Breastfeeding does not need to be interrupted during a course of ECT (7). In contrast to some psychotropic agents, anesthetic agents administered with ECT pose little risk to the nursing infant (86). The exposure to medication administered during ECT is lessened if breastfeeding is delayed by a few hours posttreatment or by collection and storage of breast milk the day prior to ECT.

ECT Use in Patients with Medical Conditions

Patients being considered for ECT—especially in the elderly where ECT is commonly used—often experience coexisting medical conditions that may cause concern. These are generally related to the central nervous system (CNS), cardiovascular, and respiratory systems. The pre-ECT medical evaluation should identify these conditions, assess their contribution to the overall risk during ECT, and suggest ways to reduce the risk. The treating psychiatrist, in collaboration with the anesthetist, should consider these medical risks to arrive at a final recommendation for ECT, in addition to considering any procedural modification needed to administer the ECT safely. It is important to recognize that medical management is often very difficult in patients with mental disorders. Conversely, effective psychiatric treatment often improves medical outcome and reduces mortality (87).

Medical Conditions of Concern During ECT

CNS

Space-Occupying Lesions. Patients with space-occupying lesions (SOL) of the brain, with increased intracranial pressure (ICP), have historically been considered to be high-risk during ECT. This view was based primarily on older literature describing neurological deterioration occurring in such patients following ECT (88–91). In these cases, most of the tumours were discovered only after clinical decompensation had occurred. More recently, the APA’s task force on ECT (7,72) concluded that there was no absolute contraindication to ECT, although patients with cerebral SOLs pose a substantially increased risk. Most clinicians continue to view these lesions as contraindications to ECT, especially in cases associated with raised ICP. Much of the ECT risk in patients with SOLs has been attributed to the exacerbation of ICP as a result of ECT’s cerebral hemodynamic effects.