Effect of pathology and gestational age on the management of neurosurgical emergencies in pregnant women

摘要

BACKGROUND: The diagnosis of neurosurgical pathology in a pregnant lady is a stressful event to the patient, her family and attending physician and the managment of these problems challenges the skills of obstetricians and neurosurgeons to secure both the baby and his mother. In this study, the author presents 10 pregnant women presented acutely to neurosurgery with different neurosurgical problems, the management of each patient was individualized according to the pathology and gestational age.OBJECTIVE: To establish a protocol for managment of acute neurosurgical lesions during pregnancy according to the pathology and gestational age. PATIENTS AND METHODS: Retrospective review of all pregnant ladies who had surgery for acute neurosurgical problem during the period 1995 – 2007.RESULTS: 10 patients, 9 multiparous and one primigravida ( one in the first trimester and 9 in the 2nd or 3rd trimester). The patient age ranged from 24 -40 years , mean 30.2 years. Six patients had brain lesions (5 brain tumors and 1 tuberculoma), 2 had aneurysmal subarachnoid hemorrhage (SAH), and 2 had traumatic fracture of the spine. The brain tumors were 3 meningiomas, 1 malignant astrocytoma (grade III), and 1 colloid cyst. Five patients had the neurosurgical operation first and pregnancy was completed to full term. Two patients had emergency cesarean section (CS) followed by neurosurgical operation in the same session, 2 patients completed pregnancy to full term and had neurosurgical operation after delivery, and one patient had therapeutic abortion followed by the neurosurgical operation. No maternal or foetal complications were recorded in this series.CONCLUSION: The management of pregnant patients with acute neurosurgical problem must be individualized according to intracranial pathology and gestational age. A multidisciplinary and cooperative approach, which involves neurosurgeon, anesthesiologist, obstetrician and neonatologist, is required to imrove maternal and fetal outcome. For patients in the 2nd and early 3rd trimister, it is possible tto perform neurosurgical operation first and complete pregnancy to full term. Patients at 34 weeks or more gestation, emergency CS followed by neurosurgical operation is recommended, and for patients in the 1st trimister, it is advisable to terminate pregnancy to allow safe management. In some patients who had benign tumor and responded to corticosteriods, it is possible to complete pregnancy and do surgery after delivery. Introduction Physiological changes that take place in pregnant women almost exclusively affect the whole body systems. The cardiovascular system expands to support the needs of the growing fetus. The circulating blood volume increases by 40% to 50% and resting heart rate increases by about 15 to 20 beats per minute by the third trimester, and there is reduction of resting blood pressure due to vasodilatation. Pregnancy hormones stimulates lengthening and laxity in the ligaments and other connective tissues which leaves joints more vulnerable to injury. All metabolic functions are increased during pregnancy to meet the demands of fetus, placenta and uterus as well as for the gravida's increased basal metabolic rate and oxygen consumption. Pregnancy is also associated with a hypercoagulable state due to a combination of venous stasis and altered levels of circulating clotting factors during pregnancy and the puerperium (1) .These changes make the mother and her foetus vulnerable and requires utmost attention during the whole course of illness. The diagnosis of brain lesion might be delayed in pregant wome as the clinical picture (headache, vomiting, or seizure) can be confused with hyperemesis gravidarium early in pregnancy or with eclampsia late in pregnancy. However, the presence of an abnormal fundoscopic examination, visual impairment, focal seizures, and lateralizing neurological deficits should alert physicians to the possibility of an intracranial lesion and prompt further investi