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Management of a Parturent with Recent Stroke
Abstract Number: S-34
Abstract Type: Case Report/Case Series
A 27-year-old G2P1 at 36+6 weeks’ gestation with a past medical history of 2 DVTs, prothrombin gene mutation on therapeutic enoxaparin, and a BMI of 47 kg/m2 presented with possible preterm labor and worsening neurologic deficits over the past 24 hours. A CT scan revealed acute left intra-parenchymal bleeding near the central sulcus. Discussion ensued between the obstetric, neurosurgical, and anesthesiology teams to determine which mode of delivery would balance the risk of re-bleeding with the overall risk from a cesarean delivery (CD). The patient was therapeutic on enoxaparin and regional anesthesia was contraindicated. General anesthesia presented concerns with aspiration, potential for a difficult airway with an elevated BMI, and risk of increasing ICP with direct laryngoscopy and succinylcholine. Further dilemma included the location of delivery, labor and delivery provided proximity to the obstetricians and pediatric teams while the main operating rooms were close to the neurosurgical operating rooms should intervention be required.
The patient was ruled out for preterm labor and was transferred to the NICU for tight blood pressure control and monitoring. The patient had a negative angiogram and magnetic resonance venogram with no etiology identified. The neurosurgical team stopped enoxaparin due to the acute bleed. There was concern for her risk for recurrent DVTs while not anti-coagulated and an IVC filter was placed. The patient remained stable during hospitalization and repeat imaging showed no progression of the bleed. On day 4, she was deemed stable to leave NICU, and was transferred to the obstetric service. The patient had a prior vaginal delivery and an assisted vaginal delivery was the desired mode of delivery. Imaging and physical exam were not concerning for increased ICP and an epidural technique was determined to be appropriate to provide analgesia to allow a forceps assisted vaginal delivery (FAVD). On day 6, she went into spontaneous labor. An early epidural was uneventfully placed and she underwent a FAVD in the operating suite. Post-delivery CT scan showed no progression of bleed.
Literature remains insufficient regarding management of a parturient in labor with an acute intracranial bleed. The incidence is rare and approximately 6-34/100,000, with 40% of those occurring around the time of delivery.^1 A literature review of 18 patients with an unsecured hemorrhage found no difference in outcome between CD and assisted vaginal delivery.^2 While there is a paucity of literature guiding anesthetic management of a parturient with a recent intracranial bleed, a multidisciplinary approach is paramount in deciding management to ensure optimal patient outcome.
1) Khan M, Wasay M. Haemorrhagic strokes in pregnancy and puerperium. Int J Stroke 2013;8:265–72.
2) Dias M, Sekhar, L. Intracranial hemorrhage from anuerysms and arteriovenous malformations during pregnancy and the puerperium. Neurosurgery 1990 Dec; 27(6):855-65