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Anesthetic Management of Maternal Cerebral Palsy and Intracranial Hemorrhage
Abstract Number: T-17
Abstract Type: Case Report/Case Series
A paucity of data exists in the literature regarding pregnancy, labor & delivery in patients with cerebral palsy (CP). The incidence of intracranial hemorrhage (ICH) in pregnancy ranges from 0.01-0.05%(1) and of all neurologic complications during pregnancy, ICH represents 2-7%.(2) We present a case of a mother with CP, chronic hydrocephalus, and an acute ICH who underwent cesarean delivery (CD) at 32 6/7 WGA, delivered a viable infant & subsequently recovered.
A 22 y/o G1P0 at 31 2/7 WGA with a h/o CP and chronic hydrocephalus, for which she had bilateral VP shunts, was intubated after diagnosis of an ICH. Her initial CT demonstrated a large intraventricular hemorrhage (IVH), obstructive hydrocephalus & increased intracranial pressure (ICP). After extubation, she was at her baseline of mild cognitive dysfunction and lower extremity paraparesis. A repeat CT revealed global cerebral edema and possible impending infratentorial herniation. It was decided to perform a CD at 32 6/7 WGA due to concerns regarding the possibility of increasing cerebral edema or a subsequent IVH associated with the increased intravascular volume with further prolongation of the pregnancy. A multidisciplinary conference was held with obstetricians, MFM, anesthesiologists, and neurology. Although a general anesthetic (GA) would not allow for continuous monitoring of neurologic status, it was ultimately decided that a neuraxial technique was too risky given the potential for herniation.(3) The patient was taken to the OR where an A-line was placed prior to a RSI with propofol and rocuronium. She was given fentanyl, esmolol, labetalol, nitroglycerin & lidocaine to attenuate the response to laryngoscopy. She was maintained on propofol & remifentanil infusions during surgery. She underwent an uneventful CD and went to the ICU where she was extubated three hours later and found to be at her neurologic baseline. The source of her hemorrhage was never discovered.
ICH during pregnancy is uncommon.(2) Since the nature of our patient’s hemorrhage was never clear, it was assumed to be from vascular changes related to pregnancy in association with her preexisting VP shunts from the chronic hydrocephalus related to her CP. Prolongation of the pregnancy was thought to be too hazardous to maternal health & delivery was performed early. There was much debate at our multidisciplinary conference as to whether a neuraxial should be performed to be able to continuously monitor the patient’s neurologic status as well as to diminish the risk of aspiration.(3) Because of the global cerebral edema, obstructive hydrocephalus, increased ICP & impending herniation it was decided to proceed with a GA.(3) Given the rarity of these occurrences it is crucial to take a multidisciplinary approach to individual patients.
1. Neurosurgery. 1990; 27: 855-65.
2. J Neurol Neurosurg Psychiatry. 2008; 79: 240-5.
3. Anesthesiology. 2013; 119: 703-18.