Neurocritical care complications of pregnancy and puerperum

Acute Intracranial Hypertension During Pregnancy: Special Considerations and Management Adjustments

Pregnancy is associated with a number of pathophysiological changes (including modification of vascular resistance, increased vascular permeability, and coagulative disorders) that can lead to specific (eclampsia, preeclampsia) or not specific (intracranial hemorrhage) neurological complications. In addition to these disorders, pregnancy can affect numerous preexisting neurologic conditions, including epilepsy, brain tumors, and intracerebral bleeding from cerebral aneurysm or arteriovenous malformations. Intracranial complications related to pregnancy can expose patients to a high risk of intracranial hypertension (IHT). Unfortunately, at present, the therapeutic measures that are generally adopted for the control of elevated intracranial pressure (ICP) in the general population have not been examined in pregnant patients, and their efficacy and safety for the mother and the fetus is still unknown. In addition, no specific guidelines for the application of the staircase approach, including escalating treatments with increasing intensity of level, for the management of IHT exist for this population. Although some of basic measures can be considered safe even in pregnant patients (management of stable hemodynamic and respiratory function, optimization of systemic physiology), some other interventions, such as hyperventilation, osmotic therapy, hypothermia, barbiturates, and decompressive craniectomy, can lead to specific concerns for the safety of both mother and fetus. The aim of this review is to summarize the neurological pathophysiological changes occurring during pregnancy and explore the effects of the possible therapeutic interventions applied to the general population for the management of IHT during pregnancy, taking into consideration ethical and clinical concerns as well as the decision for the timing of treatment and delivery.

Neurocritical care of the pregnant patient

INTRODUCTION

An estimated 0.1%-0.8% of obstetric patients require admission to an intensive care unit (ICU) during pregnancy or the puerperium. When neurologic emergencies occur in pregnancy, collaboration between the neurointensivist, obstetric anesthesiologist, and obstetrician is key in minimizing morbidity and mortality.

PRINCIPLES

Care of the critically ill pregnant patient mirrors that of the critically ill nonpregnant patient with some minor exceptions. Special care must be taken to consider the normal physiologic changes of pregnancy as well as possible fetal exposure to medical interventions. Timing and method of delivery must be carefully considered when caring for patients with neurologic emergencies. Common neurologic emergencies in pregnancy include hypertensive disorders of pregnancy, intracranial neoplasms, noneclamptic seizures, cerebrovascular disorders, and ventriculoperitoneal shunt malfunctions.

CONCLUSION

While neurologic emergencies in pregnancy are overall rare, when they do occur, they can be devastating. As in the nonpregnant population, prompt recognition and rapid intervention are crucial in optimizing patient outcomes. When neurologic emergencies occur in pregnancy, maternal and fetal care is optimized through a multidisciplinary care team.

Neurological Emergencies During Pregnancy

This article serves as a comprehensive review of neurologic emergencies in pregnancy. Common initial presentations of neuroemergencies are reviewed with a clinical algorithm. Neurovascular disorders in pregnancy are reviewed, including acute ischemic strokes with data on tPA and thrombectomy; cerebral venous sinus thrombosis diagnosis and management; posterior reversible encephalopathy syndrome management; reversible cerebral vasoconstriction syndrome; and intracerebral hemorrhage. Attention is paid to management of cerebral edema and safety of osmotic therapies. A review of seizures in pregnancy is provided, including new-onset causes and decreased seizure thresholds. For status epilepticus, a low teratogenicity risk medication protocol in pregnancy is provided.

Intracranial emergencies during pregnancy requiring urgent neurosurgical treatment

OBJECTIVE

Despite contemporary diagnostic and therapeutic techniques intracranial emergencies in the obstetric setting pose still a major challenge for the clinicians. There are limited guidelines and differing ethical views. Multidisciplinary teams are needed to support the pregnant woman in a way that she can deliver a viable and healthy child. The aim of the present study was to scrutinize the management of intracranial emergencies during pregnancy which needed urgent neurosurgical treatment.

PATIENTS AND METHODS

Data of all pregnant women who presented with newly diagnosed intracranial pathologies and neurological symptoms caused by these pathologies in an emergency setting were collected over a 10-year period (2008-2018). Patient characteristics including maternal age, gestational age, and preoperative work-up of both mother and fetus were recorded. Furthermore, the surgical treatment, mode of delivery, and neonatal and maternal outcomes were analysed.

RESULTS

The mean maternal age was 32.7 years and most patients were in their third trimester. There was one twin pregnancy (total of 12 fetuses). Five out of eleven pregnant women suffered from intracerebral haemorrhage (epidural haematoma (1), arteriovenous malformation (1), subarachnoid haemorrhage (2) and intracerebral haemorrhage (1)) and the other six patients had intracranial neoplasms (primary meningeal sarcoma (1), trigeminal schwannoma (1), anaplastic astrocytoma (2), glioblastoma (1) and sphenoid wing meningioma (1)).Neurosurgical procedures were performed via craniotomies in eight patients. A stereotactic biopsy via a frontal burr hole was achieved one patient. The two other patients with subarachnoid haemorrhage due to rupture of PICA aneurysms were treated with coil embolization. Depending on the gestational age and the clinical condition of the pregnant women it was decided to perform an emergency Caesarean section prior to further therapeutic measures in seven patients. Two out of 12 fetuses were unviable. Six women survived, while five women succumbed to the intracranial pathology.

CONCLUSION

The individualized treatment approach in this peculiar obstetric scenario needs to consider various issues such as the clinical condition of the pregnant woman, prognosis of the disease, gestational age and the status of the pregnancy. The primary concern in this context must be the mother`s health and safety. Caesarean section is the primary mode of delivery in most cases. While contemporary care can insure survival for the majority of infants, maternal mortality still poses an extraordinary challenge. Interdisciplinary consulting of the patient and/or her family is necessary to develop a treatment strategy for both the expectant woman and her offspring.

Association between hypertensive pregnancy disorders and future risk of stroke in Taiwan: a Nationwide population-based retrospective case-control study

Background

The incidence of female stroke has increased gradually and has begun occurring at a younger age in recent years. Given that women live longer than men, stroke would cause more negative and longer-term impacts on the rest of the lives of women. There are few related studies on Asian women. We aimed to evaluate stroke risk in Asian women following hypertensive pregnancy disorders.

Methods

Using the Taiwan National Health Insurance database, we designed a retrospective study that included pregnant women between 2000 and 2013. We selected an age-matched control group of women without hypertensive pregnancy disorders at a 1:3 ratio. The endpoint was any episode of stroke; otherwise, the patients were tracked until December 31, 2013. After the index date until the end of 2013, Cox proportional hazards analysis was used to compare the risk of incident stroke. The risk factors for stroke were determined using Cox proportional regression to calculate the hazard ratio (HR) compared with the control group.

Results

During the follow-up period, the Kaplan-Meier analysis indicated that patients with hypertensive pregnancy disorders had a significantly higher risk of developing stroke than did patients without hypertensive pregnancy disorders (log-rank test P < 0.001). Multivariate Cox regression analysis demonstrated that the case group had a 2.134-fold increased risk of stroke (HR = 2.134; 95% CI = 1.817–2.505; P < 0.001).

Conclusion

Our study provided evidence of an increased risk of stroke in patients with hypertensive pregnancy disorders. Compared with those without such disorders, the patients who had experienced the disorders had a 2.134-fold (P < 0.001) higher risk of developing stroke in the future.

Neurological manifestations and neuroimaging presentations in patients with severe preeclampsia: predisposing factors and clinical implications

BACKGROUND AND PURPOSE

Neurological manifestations and neuroimaging abnormalities are common in patients with severe preeclampsia; however, the differences between these abnormal features occurring during early- and late-onset severe preeclampsia are unclear, and the factors associated with abnormal imaging changes in patients with neurological manifestations have not yet been fully elucidated.

MATERIALS AND METHODS

A retrospective study was conducted on 172 patients with severe preeclampsia from January 2017 to June 2018 in the Department of Neurology and Obstetrics, Shengjing Hospital of China Medical University. The neurological manifestations, clinical parameters, laboratory, and neuroimaging findings were analyzed.

RESULTS

Early- and late-onset preeclampsia were diagnosed in 83 and 89 patients, respectively. Headache and dizziness were more common in patients with early-onset preeclampsia than in patients with late-onset preeclampsia (p = 0.013, p = 0.004, respectively). Serum uric acid, creatinine, and urea nitrogen were significantly elevated in the patients with early-onset preeclampsia (p < 0.001, p = 0.004, and p = 0.005, respectively). Neuroimaging was performed in 81 patients, of which 57 were positive. Findings indicating cerebral edema were the most common neuroimaging abnormality. Gestational weeks (p = 0.014), headache (p < 0.001), and blood urea nitrogen level (p = 0.027) may be associated with positive imaging findings. By multiple logistic regression, headache (OR = 10.2, 95% CI, 2.4-42.7; p = 0.002) proved to be an independent factor associated with neuroimaging abnormality.

CONCLUSIONS

Neurological symptoms such as headache and dizziness were more common in patients with early-onset preeclampsia. Renal dysfunction may also associate with early-onset severe preeclampsia. Cerebral edema was the most common neuroimaging abnormality, and headache might be independently associated with abnormal imagine changes.

Ischemic stroke and floating thrombosis in dissection of the common carotid artery in patient at third week of pregnancy: Surgical technical success and maintenance of pregnancy

Thrombosis, especially in pregnancy, is due to a prothrombotic state and involves the venous system. Localization in an arterial segment is rare. Floating carotid arterial thrombosis is a very rare occurrence, but it is very devastating. The authors report the case of a pregnant patient in whom are associated a thrombotic predisposition and a traumatic event of the neck which resulted in a limited dissection and a floating thrombosis of the common carotid artery. The onset was characterized by sudden neurological deficits, including numbness of the right-hand fingers and right limb weakness, which regressed after admission. The patient underwent a surgical operation with success. Her pregnancy continued, and an ultrasound scan 12 months later confirmed the patency of the prosthesis, in the absence of neurological symptoms. Hormonal changes may reveal the condition of thrombophilia, which, however, occurs more frequently in the venous system and is a condition related to the free-floating thrombus. No guidelines exist for medical or surgical management. The endovascular approach appears to present a greater risk of embolization as an alternative to open surgery. This case demonstrates that the prothrombotic state and the presence of neurological symptoms are suggestive of arterial thrombosis in pregnancy and that the multidisciplinary approach is mandatory to achieve good results.

Combined reperfusion therapy to treat cryptogenic acute ischemic stroke during the first trimester of pregnancy: case report and literature review

Cerebral infarction due to acute embolism in the large artery during pregnancy is a rare but severe condition threatening both the mother's and child's life. Physicians lack diagnostic and therapeutic guidance to manage this particular situation due to the paucity of published cases. Furthermore, the pathogeny is poorly known, rendering preventive strategies difficult. We describe the case of a young woman presenting cryptogenic acute cerebral infarction during the first trimester of pregnancy who was successfully treated with combined reperfusion therapy. We reviewed the literature to collect data about pathogeny and management. A 28-year-old pregnant woman was diagnosed with acute cerebral infarction due to left middle cerebral artery occlusion at 9 weeks of gestation. Endovascular thrombectomy combined with intravenous thrombolysis allowed cerebral reperfusion leading to a decrease in the National Institute of Health Stroke Score from 13 to 1 at 24 hours. Comprehensive etiological investigation was negative. Anticoagulation therapy with low-molecular-weight heparin was administered as preventive treatment during the pregnancy and postpartum. Neither the mother nor the child experienced any complications: the baby was born by normal vaginal delivery and the outcome was good at 1 year. We identified 21 other cases of patients treated with reperfusion therapies, four of which consisted of endovascular thrombectomy, and only one a combined strategy. Pregnant women with acute cerebral infarction due to arterial occlusion can benefit from combined reperfusion therapy. More cases should be collected to assess treatment in these patients, to understand pathogeny, and propose the best preventive strategy.

Imaging neurological emergencies in pregnancy and puerperium

The altered physiologic state of female patients during and just after pregnancy places them at an increased risk for several potentially life-threatening neurologic disorders. Swift diagnosis of such pathology and related complications is critical in order to reduce risk of morbidity and mortality to both the mother and the fetus. Neuroimaging plays an important role in the emergent diagnosis of pathology associated with pregnancy and puerperium, and it is critical for the radiologist to be cognizant of correlative imaging findings. Furthermore, given concerns regarding risks of neuroimaging to the fetus, it is important for the radiologist to act as an informed consultant regarding balancing fetal risks and the mother's health. The purpose of this review is to elucidate the underlying pathophysiology and neuroimaging findings associated with diagnoses that are unique to or highly associated with pregnancy and puerperium, as well as to understand the role that CT and MR play in diagnosis during and just after pregnancy, and their respective risks to the fetus.

Peak hyperammonemia and atypical acute liver failure: The eruption of an urea cycle disorder during hyperemesis gravidarum

Inborn urea cycle disorders are under-recognised metabolic causes of hyperammonemia in adults. A 28-year-old primigravida, seven weeks pregnant, affected by hyperemesis gravidarum developed acute liver injury (ALI) and then acute liver failure (ALF) in less than 48 h. Because the patient developed atypical features, especially mildly elevated aminotransferases contrasting with very high blood ammonia levels (281 μmol/L), concomitant with normal serum creatinine, an inborn error of metabolism was suspected. We performed emergency metabolic analyses, stopped all protein intake and started with intravenous (i.v.) high caloric intake, nitrogen scavenger drugs and haemodialysis. The neurological and hepatic status of the patient quickly improved together with normalisation of her ammonemia levels. High plasma glutamine and urinary orotic acid, alongside low plasma arginine, citrulline and ornithine were suggestive of an ornithine transcarbamylase deficiency, later confirmed by molecular analyses. Foetal sex was female, as determined by foetal DNA analysis in maternal blood, and foetal development was unremarkable throughout the pregnancy. Delivery was induced at 39 weeks with a close monitoring of ammonemia levels and i.v. perfusion of carbohydrates and lipids during labour and immediately post-partum to avoid hypercatabolism. Delivery was uneventful and the patient delivered a healthy female baby. Urea cycle disorders should be contemplated in non-jaundiced patients with ALI or ALF, severe hyperammonemia and normal serum creatinine regardless of serum aminotransferase levels. The prompt recognition of this rare condition and the rapid initiation of adequate metabolic therapy are mandatory to prevent irreversible neurological sequelae and to avoid liver transplantation.

Neurologic complications in critically ill pregnant patients

Neurologic complications in a critically ill pregnant woman are uncommon but some of the complications (such as eclampsia) are unique to pregnancy and the puerperal period. Other neurologic complications (such as seizures in the setting of epilepsy) may worsen during pregnancy. Clinical signs and symptoms such as seizure, headache, weakness, focal neurologic deficits, and decreased level of consciousness require careful consideration of potential causes to ensure prompt treatment measures are instituted to prevent ongoing neurologic injury. Clinicians should be familiar with syndromes such as pre-eclampsia, eclampsia, stroke, posterior reversible encephalopathy syndrome, and reversible cerebral vasoconstriction syndrome. Necessary imaging studies can usually be performed safely in pregnancy. Scoring systems for predicting maternal mortality are inadequate, as are recommendations for neurorehabilitation. Tensions can arise when there is conflict between the interests of the mother and the interests of the fetus, but in general maternal health is prioritized. The complexity of care requires a multidisciplinary and multiprofessional approach to achieve best outcome in an often unexpected situation.