Neurosurgery notes/Paediatrics/Pregnancy and Neurosurgery/Pregnancy and neurovascular diseases

Pregnancy and neurovascular diseases

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Pregnancy and Neurosurgery

Intracranial haemorrhage of pregnancy (ICHOP) (ICH/SAH)

  • 0.01-0.05% of all pregnancy
    • But responsible for 10% of maternal death in pregnancy
  • Risk of recurrent haemorrhage following ICHOP from aneurysm or AVM during remainder of pregnancy is 40%
  • There is an increasing tendency for bleeding with advancing gestational age for both aneurysm and AVM
  • Common in the setting of eclampsia is more common ICH due to loss of auto-regulation
  • ICHOP-related SAH:
    • Aneurysmal
      • Numbers
        • Incidence: 77%
        • Mortality: 35%
        • most common cerebral vascular complication encountered during pregnancy
          • The risk of rupture parallels the hemodynamic changes, reaching an apex in the third trimester, in concert with blood volume changes.
          • Aneurysms are most prone to rupture during the seventh and eighth months of pregnancy and at delivery.
      • Ix:
        • CT with shielding of foetus
        • MRI: do not do MRI with contrast in first trimester as contrast (gadopentetate) use is not studied in human pregnancy
        • DSA with shielding of foetus: iodinated contrast has little risk to foetus
        • Fluoroscopy during DSA and coiling
          • A phantom study has demonstrated that the effective radiation dose to the foetus during DSA for coil embolization is so small that it confers no additional risk to the foetus.
          • If there is still concern then a medical physicist should be consulted.
      • Tx:
        • For ruptured cerebral aneurysms in pregnant women
          • Aneurysm treated first and the pregnancy allowed to continue to term
            • Except in cases of rupture during labour when delivery should be completed prior to aneurysm treatment.
          • <26 weeks,
            • proceed as best for the mother and if aneurysm treatment is successful vaginal delivery should be attempted.
          • Between 26 and 34 weeks
            • aneurysm exclusion should proceed and, if the foetus is stable, pregnancy allowed to continue to term.
            • Deciding whether to undertake endovascular coiling or surgical clipping is difficult.
              • Cons of coiling
                • Coil prolapse require antiplatelet agents that need to be considered in unexpected labour or emergency caesarean section soon after coiling.
          • >34 weeks
            • caesarean section under general anaesthesia, followed immediately by aneurysm exclusion, is advised.
        • Antiepileptic drugs: use specific ones that have least teratogenic effect
        • Diuretics
          • Avoid mannitol as it can cause foetal dehydration + uterine hypoperfusion
        • AntiHTN
          • Do not use nitroprusside
        • Nimodipine: potentially teratogenic in animals and is unknown in humans
          • Only use if there is certain of SAH and try to use for shorter time
        • Surgical
          • Performed C section to avoid haemodynamic stresses of labour and vaginal delivery
            • Clip aneurysm
            • Coil
              • Radiation shielding of fetus
              • Tilting patient to left side to decrease pressure on IVC
    • AVM
      • Incidence: 23%
      • Risk of haemorrhage:
        • 3.5% if had no previous haemorrhage
        • 5.8% if had previous haemorrhage
      • Mortality: 28%
      • It is accepted that the overall rate of haemorrhage from cerebral AVMs is not increased during pregnancy compared to nonpregnant periods of life.
        • However, in pregnant patients with intracranial AVMs it is important to know that most ruptures occur in the 2nd and 3rd trimester, and not during the first trimester, labour or puerperium.
      • Management of AVMs in pregnancy:
        • Fully treated AVMs before 35 weeks gestation
          • unassisted vaginal delivery should be possible.
        • Unruptured intracranial AVM
          • the risk of haemorrhage during vaginal delivery low if epidural analgesia and an assisted second stage is used.
        • Elective caesarean section
          • Indicated for
            • Untreated AVM
            • Partially treated AVM
              • especially if it has bled during pregnancy.

Moyamoya pregnancy

  • Normal pregnancy and vaginal delivery is possible under specialist joint care.
  • Cerebral infarction and intracranial haemorrhage are the major concerns in pregnancies with moyamoya disease due to Intrapartum, changes in cerebral blood flow
    • CBF decreases due to hyperventilation AND
    • CBF increases due to elevation of blood pressure caused by pain and uterine contractions.
  • Increases and decreases of cerebral blood flow cause cerebral ischemia and haemorrhage.
  • However, vaginal delivery is possible if cerebral blood flow can be controlled, and this may be achieved by controlling blood flow to the brain with epidural anaesthesia.
  • When vaginal delivery is selected, there is evidence to suggest that good cerebral circulation on SPECT or absence of frequent symptoms due to moyamoya disease within 1 year before pregnancy is important for avoiding complications.