Maternal–fetal Safety During Electroconvulsive Therapy in Pregnancy: Anaesthetic Management of a High-risk Psychiatric Emergency

Abstract

Background: Severe depression during pregnancy with persistent suicidal ideation requires timely intervention, particularly when pharmacotherapy is ineffective. Electroconvulsive therapy (ECT) may provide rapid symptom control; however, uncertainty regarding periprocedural maternal-fetal safety and anaesthetic technique continues to influence its use. This case report describes the multidisciplinary anaesthetic management of modified ECT in a second-trimester high-risk psychiatric emergency. Case Presentation: A 26-year-old primigravida at 27 weeks and 2 days of gestation presented with recurrent major depressive disorder, nutritional decline, treatment-refractory symptoms, and persistent suicidal ideation despite sequential pharmacotherapy. Following multidisciplinary planning by anaesthesia, psychiatry, obstetrics, and neonatology teams, six sessions of modified ECT were undertaken in an operating theatre with immediate obstetric and neonatal support available. Anaesthetic Management: For each session, the patient was fasted, positioned with 15° left uterine displacement, and monitored using standard ASA monitoring. Aspiration prophylaxis was administered before treatment. After three minutes of preoxygenation, anaesthesia was induced with propofol 1 mg/kg, followed by succinylcholine 1 mg/kg. Low-pressure mask ventilation with 100% oxygen was used, and seizure adequacy was assessed clinically using the isolated arm technique. Fetal assessment comprised cardiotocography before and after the procedure, with intermittent fetal heart rate auscultation when feasible. Outcomes: Mean motor seizure duration was 32.6 ± 5.4 seconds. Maternal oxygen saturation remained at or above 96%, and transient cardiovascular responses resolved spontaneously. No aspiration, airway event, arrhythmia, hypertensive crisis, prolonged seizure, uterine contraction, or fetal heart rate abnormality occurred. Suicidal ideation resolved after treatment. At 39 weeks and 3 days, the patient delivered a healthy female infant weighing 3,120 g with Apgar scores of 9 and 9 at one and five minutes. Conclusion: Carefully planned modified ECT during pregnancy was feasible in this case when supported by multidisciplinary coordination, pregnancy-specific anaesthetic precautions, and structured obstetric surveillance.