gms | German Medical Science

With improvements in antenatal care and management of deliveries, non-obstetric causes of maternal death became increasingly significant over the last decades. Although subarachnoid hemorrhage (SAH) rarely occurs during pregnancy, SAH due to cerebral aneurysmal rupture is the third leading cause of maternal mortality. Mortality rate is 13-35% for the mother and 7-25% for the fetus. We report on three cases indicating different management strategies.

The first patient, 25 years old, suffered of SAH Hunt and Hess grade III in the 13^th gestation week. In the 36^th gestation week Cesarean section was followed by surgical clipping of superior cerebellary artery aneurysm in one-time anaesthesia. Middle cerebral artery aneurysm was diagnosed in another SAH patient in the 30^th gestation week. Surgical clipping was performed under obstetric monitoring of the fetus on the same day of the hemorrhage and cesarean section was done in the 38^th gestation week. Both women are now able to provide for their children after recovering. The third patient, 36^th gestation week, had a SAH, Hunt and Hess grade IV. Misdiagnosis of eclampsia lead to emergent cesarean section before CT-imaging revealed massive SAH suspecting left middle cerebral artery aneurysm. The patient died prior to definite treatment of the aneurysm and due to recurrent SAH.

An interdisciplinary management is warranted in pregnant SAH patients where medical, obstetric and neurological complications reveal high mortality rates for the mother and the fetus. If the hemorrhage occurs at late time in pregnancy, Cesarean section saves fetus life and does allow occlusion of the aneurysm and aggressive SAH treatment. In high grade SAH patients recurrent bleedings have to be expected as well as secondary complications. Therefore urgent obstetric and neurosurgical treatment has to be performed at any time, reducing fatal outcome.