The prevalence of mental disorders is high among pregnant women.11. Botega NJ, Dias MK. Gravidez e puerpério. In: Botega NJ, editor. Prática psiquiátrica no hospital geral: interconsulta e emergência. Porto Alegre: Artmed; 2006. p. 341-54. Major depression during pregnancy is a risk factor for negative outcomes for both mother and child.22. Rahman A, Iqbal Z, Bunn J, Lovel H, Harrington R. Impact of maternal depression on infant nutritional status and illness: a cohort study. Arch Gen Psychiatry. 2004;61:946-52. Psychotherapy and pharmacotherapy are well-established conventional treatments for depression. However, some cases fail to respond, and the safety of some psychopharmaceuticals during pregnancy is unclear. Within this context, certain neuromodulation techniques, including repetitive transcranial magnetic stimulation (rTMS), have been studied in pregnant women with depression.
A review of the recent literature33. Felipe RM, Ferrão YA. Transcranial magnetic stimulation for treatment of major depression during pregnancy: a review. Trends Psychiatry Psychother. 2016;38:190-7. suggested that rTMS is an effective alternative for the treatment of depression in pregnant women, and there have been no reports of malformations or other relevant negative fetal outcomes.44. Eryılmaz G, Sayar GH, Özten E, Gül IG, Yorbik Ö, Işiten N, et al. Follow-up study of children whose mothers were treated with transcranial magnetic stimulation during pregnancy: preliminary results. Neuromodulation. 2015;18:255-60. However, use of the rTMS technique in pregnant women has only been evaluated in one open study55. Kim DR, Epperson N, Pare E, Gonzalez JM, Parry S, Thase ME, et al. An open label pilot study of transcranial magnetic stimulation for pregnant women with major depressive disorder. J Womens Health (Larchmt). 2011;20:255-61. and a few case reports; there have been no randomized clinical trials evaluating its use in this setting. Here, we report the cases of four nulliparous pregnant women (one with a twin pregnancy) diagnosed with major depressive disorder and treated with rTMS.
Sociodemographic and clinical features are summarized in Table 1. In three patients, rTMS was applied to the left dorsolateral prefrontal cortex (DLPFC) at 3,000 pulses/session (120% of the motor threshold; frequency 10 Hz; figure-eight coil). In the remaining patient, rTMS was applied to the right DLPFC at 1,800 pulses/session (120% of the motor threshold; frequency 1 Hz; figure-eight coil). To evaluate symptoms of depression and anxiety, the 21-item Hamilton Depression Rating Scale (HDRS-21), the 14-item Hamilton Anxiety Rating Scale (HARS-14), and the Clinical Global Impression-Severity (CGI-S) scale were applied before and after rTMS. Three of the patients were medicated, two with sertraline and one with fluoxetine, and the prescribed dosages were maintained throughout rTMS treatment.
Sociodemographic and clinical features of four pregnant women who received rTMS for major depression, and 5-minute Apgar scores for their children
According to the HDRS-21 and HARS-14, all patients presented a response, with a 65% mean reduction in depressive and anxiety symptoms. CGI-S scores also showed a 66% reduction in depressive symptoms. All patients tolerated the treatment, although all but one reported some side effects. None of the patients had complications at delivery. All infants had 5-minute Apgar scores of 9, except for the twins born to patient 2, who were preterm (36 weeks) and had Apgar scores of 6 and 8.
Our results are in agreement with existing experience regarding the responses obtained with rTMS in pregnant women with depression. Our choice of the prefrontal cortex as the rTMS target was based on previous reports.55. Kim DR, Epperson N, Pare E, Gonzalez JM, Parry S, Thase ME, et al. An open label pilot study of transcranial magnetic stimulation for pregnant women with major depressive disorder. J Womens Health (Larchmt). 2011;20:255-61.,66. Klirova M, Novak T, Kopecek M, Mohr P, Strunzova V. Repetitive transcranial magnetic stimulation (rTMS) in major depressive episode during pregnancy. Neuro Endocrinol Lett. 2008;29:69-70. The frequency of stimulation varies according to the side of application. Studies of rTMS in pregnant women with depression have employed 10-25 Hz and 1 Hz in the left and right DLPFC, respectively, quite similar to the frequencies used in the general population of adults with depression.22. Rahman A, Iqbal Z, Bunn J, Lovel H, Harrington R. Impact of maternal depression on infant nutritional status and illness: a cohort study. Arch Gen Psychiatry. 2004;61:946-52. Despite these promising findings, there is a need for controlled, double-blind studies involving larger samples, with well-designed rTMS parameters, and even for prospective studies (following pregnant women and their offspring) to assess the long-term safety of rTMS in children exposed in utero.
References
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1Botega NJ, Dias MK. Gravidez e puerpério. In: Botega NJ, editor. Prática psiquiátrica no hospital geral: interconsulta e emergência. Porto Alegre: Artmed; 2006. p. 341-54.
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2Rahman A, Iqbal Z, Bunn J, Lovel H, Harrington R. Impact of maternal depression on infant nutritional status and illness: a cohort study. Arch Gen Psychiatry. 2004;61:946-52.
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3Felipe RM, Ferrão YA. Transcranial magnetic stimulation for treatment of major depression during pregnancy: a review. Trends Psychiatry Psychother. 2016;38:190-7.
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4Eryılmaz G, Sayar GH, Özten E, Gül IG, Yorbik Ö, Işiten N, et al. Follow-up study of children whose mothers were treated with transcranial magnetic stimulation during pregnancy: preliminary results. Neuromodulation. 2015;18:255-60.
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5Kim DR, Epperson N, Pare E, Gonzalez JM, Parry S, Thase ME, et al. An open label pilot study of transcranial magnetic stimulation for pregnant women with major depressive disorder. J Womens Health (Larchmt). 2011;20:255-61.
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6Klirova M, Novak T, Kopecek M, Mohr P, Strunzova V. Repetitive transcranial magnetic stimulation (rTMS) in major depressive episode during pregnancy. Neuro Endocrinol Lett. 2008;29:69-70.
Publication Dates
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Publication in this collection
June 2018
History
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Received
21 Oct 2017 -
Accepted
17 Dec 2017