Neurosurgical disorders are rare during pregnancy and challenge the neuroanesthesiologist with conflicting anesthetic considerations and little evidence to guide decision-making. Our objective was to review the anesthetic management of pregnant patients undergoing intracranial neurosurgery at our institution and to describe the perioperative complications and outcomes.
Kazemi et al used the institutional Discharge Abstract Database to identify patients assigned both neurological and obstetrical International Classification of Disease 10-A codes between April 1, 2001 and March 1, 2012. Pregnant patients who underwent intracranial neurosurgical procedures underwent a detailed chart review to extract demographic data and details about their anesthetic management and outcome.
Nine patients underwent full chart review with a median age of 28 (range, 17 to 35) years and a gestational age of 23 (range, 7 to 30) weeks. Patients underwent a craniotomy for vascular lesions (4), neoplasms (3), and traumatic brain injuries (2). One patient was hyperventilated (PaCO2 28 mmHg), and mannitol and furosemide were used in 6 and 3 patients, respectively, without complication. Maternal neurological outcomes were good in 5 patients (Glasgow Outcome Scale of >3), poor in 3 patients (Glasgow Outcome Scale 3), and 1 patient died. Fetal outcomes were good in 5 patients and poor in 4 patients (1 therapeutic abortion, 3 intrauterine fetal demises). All cases of fetal distress or demise were either remote or occurred before the anesthetic management.
Pregnant patients undergoing neurosurgery experience a high rate of morbidity and mortality. There were no adverse outcomes directly attributed to the use of osmotic diuretics and hyperventilation in this series 1).
Radiologists must be familiar with the imaging findings of cerebrovascular complications and pathologic entities encountered during pregnancy and the puerperium. Ongoing improvements in understanding of molecular changes during pregnancy and the puerperium and advances in diagnostic tests should allow radiologists to continue to make important contributions to the care of this patient population 2).
In a multiinstitutional retrospective study, Peeters et al. identified 52 pregnancies in 50 women diagnosed with a glioma.
For gliomas known prior to pregnancy (n = 24), they found the following:
1) An increase in the quantified imaging growth rates occurred during pregnancy in 87% of cases.
2) Clinical deterioration occurred in 38% of cases, with seizures alone resolving after delivery in 57.2% of cases.
3) Oncological treatments were immediately performed after delivery in 25% of cases. For gliomas diagnosed during pregnancy (n = 28), we demonstrated the following:
1) The tumor was discovered during the second and third trimesters in 29% and 54% of cases, respectively, with seizures being the presenting symptom in 68% of cases.
2) The quantified imaging growth rates did not significantly decrease after delivery and before oncological treatment.
3) Clinical deterioration resolved after delivery in 21.4% of cases.
4) Oncological treatments were immediately performed after delivery in 70% of cases. Gliomas with a high grade of malignancy, negative immunoexpression of alpha-internexin, or positive immunoexpression for p53 were more likely to be associated with tumor progression during pregnancy. Deliveries were all uneventful (cesarean section in 54.5% of cases and vaginal delivery in 45.5%), and the infants were developmentally normal. CONCLUSIONS When a woman harboring a glioma envisions a pregnancy, or when a glioma is discovered in a pregnant patient, the authors suggest informing her and her partner that pregnancy may impact the evolution of the glioma clinically and radiologically. They strongly advise a multidisciplinary approach to management. ■ CLASSIFICATION OF EVIDENCE Type of question: association; study design: case series; evidence: Class IV 3).