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Management of the parturient with an unstable arterio-venous malformation
Abstract Number: 168
Abstract Type: Case Report/Case Series
Intracranial hemorrhage from an AVM in the parturient is a rare cause of peripartum morbidity, but may present a significant dilemma for the anesthesiologist.
Case: A 33 year old G2P0 woman with gestational diabetes at 34 weeks gestation presented to the emergency room complaining of progressively worsening headaches. At the time of admission, she rated her headache pain as "10 of 10". She also complained of nausea, vomiting, generalized weakness, photophobia, phonophobia and bilateral foot numbness. She denied visual field defects, fever, chills, bowel or bladder incontinence or focal weakness.
Neurologic exam at the time of presentation was within normal limits. Obstetric workup for pre-eclampsia was negative. MRI/MRA/MRV revealed an arteriovenous malformation within the left anterior temporal lobe with a moderately large left lateral intraventricular hemorrhage.
Neurosurgical intervention was deferred, and she was admitted for close neurologic and blood pressure monitoring, and seizure prophylaxis. After admission she remained stable with improvement of her headache and no new neurologic changes. Fetal testing remained reassuring. Two weeks after initial admission (36 weeks) the patient underwent another cerebral angiogram, which confirmed the left AV malformation but did not reveal more bleeding. During the procedure,however, she began having regular contractions and was found to be in early labor. A decision to deliver the infant was made.
Prior to her cesarean section, an arterial line was placed. Subsequently, an epidural was easily placed at L3-L4. A 3cc lidocaine test-dose was negative, and the epidural was dosed slowlyin divided doses of 2% lidocaine (5/5/5/3). A sensory level to T5 was achieved bilaterally. A healthy male fetus was delivered within 15 minutes of incision. Mother and baby were discharged home on post-operative day 4.
Whereas AVMs account for only 5% of all intracranial hemorrhages in non-pregnant people, they are the cause of 50% during pregnancy. When intracerebral hemorrhage has occurred in the setting of an AVM in pregnancy,management depends on the extent of hemorrhage. If the patient remains neurologically stable, surgical intervention is not warranted prior to delivery of the fetus. If the fetus is near term (>36 weeks),pregnancy termination should be considered. Because AVMs are prone to bleeding, cesarean section is recommended. Regional anesthesia is not a contraindication, and may be preferable to general anesthesia to avoid large hemodynamic perturbations.
Conclusions: The medical managment for parturients with an unstable AVM is predicated on input from obstetric, neurosurgical and anesthesia services. Whether to operate on the AVM depends upon the stability of the hemorrhage. The primary goal for cesarean delivery is hemodynamic stability, which can be achieved by either regional or general anesthesia. The choice depends upon the level of expertise and "comfort level" of the anesthesiologist.