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Anesthetic Management of Pregnant Patients Undergoing Neurosurgical Procedures
Abstract Number: S 40
Abstract Type: Case Report/Case Series
INTRODUCTION: Neurosurgery is rarely undertaken electively during pregnancy, and cases are typically performed in an urgent or emergent setting. Given the limited literature, the anesthetic management for such procedures is largely based on theoretical principles rather than evidence. Furthermore, the use of osmotic diuretics and hyperventilation to control intracranial pressure (ICP) in pregnant patients is controversial due to the theoretical harm to the fetus. Our study objective was to retrospectively review the intraoperative anesthetic management of all pregnant patients undergoing neurosurgical procedures at our institution and specifically to assess adverse outcomes associated with the use of measures to control ICP in this population.
METHODS: We retrospectively reviewed the charts of all pregnant patients who underwent neurosurgical procedures at our institution. We used the Discharge Abstract Database (DAD) to identify patients assigned both neurological and obstetrical International Classification of Disease (ICD) 10-A codes between 2001 and 2012.
RESULTS: Thirty-three patients met inclusion criteria and underwent chart screening for possible inclusion in the study. Twenty-four patients were excluded, because either they did not undergo neurosurgery or were not pregnant at the time of neurosurgery. Thus, 9 patients were included in the study and underwent full chart review. The median age at presentation was 28 (range 17-35) years, and the median gestational age was 23 (range 7-30) weeks. The primary neurosurgical diagnoses were intracranial vascular lesions (4 cases), intracranial neoplasms (3 cases), and traumatic brain injury (2 cases). All patients underwent a craniotomy. The lowest median intraoperative EtCO2 and PaCO2 recorded were 28mmHg (range 25-31mmHg) and 33mmHg (range 28-39mmHg), respectively. Intraoperative mannitol and furosemide were used in 4 and 3 patients, respectively and one patient received both. There were no immediate perioperative maternal or fetal complications noted from hyperventilation or the use of osmotic agents. Maternal outcomes were satisfactory in 5 patients (GCOS 4 or 5) and poor in 3 patients (GCOS 3) and one patient died. Fetal outcomes were good in 5 patients and poor in 4 patients (one therapeutic abortion and 3 cases of intrauterine fetal demise). All cases of intrauterine fetal distress or demise occurred remote from the neurosurgical procedure.
CONCLUSION: To our knowledge, this is the first case series describing the anesthetic management of pregnant patients undergoing neurosurgery. Overall, there were no adverse outcomes directly associated with the anesthetic management and, specifically, the use of osmotic diuretics and mild hyperventilation in pregnant patients. Although our review supports the use of these techniques in pregnant patients, further research is required to determine the optimal management of pregnant patients presenting for neurosurgical procedures.