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Intracerebral Hemorrhage in a Pregnant Patient
Abstract Number: T-80
Abstract Type: Case Report/Case Series
We present the case of a third trimester patient with elevated ICP due to intraparenchymal hemorrhage who underwent emergent craniotomy for AVM resection.
A healthy 32yo G2P1 at 29 weeks 6 days noted sudden severe headache. CT showed large left parieto-occipital hemorrhage with concern for underlying vascular malformation. On transfer to our center, GCS was E3V4M6 with mild aphasia and right-sided weakness. Repeat CT showed enlarging hematoma and edema with 1cm midline shift. She was given hypertonic saline, betamethasone for fetal lung maturity, and magnesium for tocolysis. Continuous fetal monitoring showed normal heart rate and moderate variability. Cerebral angiogram was attempted under sedation but aborted due to intractable nausea.
On day 2, her exam worsened, thus she underwent angiogram under GA with rapid sequence induction and intubation with a Glidescope. Anesthesia was maintained with sevoflurane, N2O, and remifentanil. Angiogram revealed a 1.5cm left parietal AVM. On conclusion of the angiogram, pupils were dilated and became non-reactive over several minutes. She was given 23% saline, mannitol, furosemide, dexamethasone, and midazolam. Hyperventilation and mild hypothermia were initiated. She went emergently to the OR for left frontoparietal craniotomy for evacuation of hematoma and AVM resection. She was initially positioned supine with LUD, but as this hindered surgical access, she was repositioned in right lateral decubitus. EFM showed normal fetal heart rate with no decelerations despite minimal variability. Due to poor responsiveness to phenylephrine, MAP was maintained at 70-80 with norepinephrine. ABG showed hyperchloremic acidosis likely from hypertonic saline.
She was extubated on POD 1. Neurologic exam improved with patient following simple commands but showed right neglect.
ICH occurs in about 5:10,000 pregnancies and has a mortality of 40% . Pregnancy is a risk factor for AVM hemorrhage with a rate of 8.1% per pregnancy . There may be conflicting goals to optimize both mother and fetus, but data to guide management are sparse. We used a multidisciplinary approach to determine ideal blood pressure goals; EFM provided reassurance throughout periods of relative hypotension. Hyperventilation is controversial due to risk of uterine artery vasoconstriction and left shift of the maternal oxyhemoglobin dissociation curve but was used in this case to prevent impending brain herniation. A case series showed no fetal complications with hyperventilation to PaCO2 of 28 . Similarly there are concerns with use of osmotic diuretics due to possible fetal hyperosmolality and intrauterine volume reduction, but case reports have shown safe use of mannitol up to doses of 1.7 g/kg [3,4]. Overall, management should be tailored to the individual patient.
1. J Obstet Gynaecol 2003;23:484-489
2. Neurosurgery 2012;71:349-355
3. J Neurosurg Anesthesiol 2014;26:234-240
4. Anesth Analg 2015;120:1099-1103