gms | German Medical Science

Objective: Aneurysmal subarachnoid hemorrhage (SAH) during pregnancy bears a challenge regarding treatment and management of these patients. Due to the limited number of cases there are no treatment guidelines available. Thus, treatment is usually done on a case-by-case basis. Here we report on four cases of SAH under pregnancy, illustrating the different management strategies, followed by a review of the latest literature.

Method: Patients treated between 2003 and 2013 in our center were included in this retrospective study. Clinical data were obtained by chart review. Data collection was focused on time management concerning gestation week (GW), external ventricular drainage (EVD), microsurgical or endovascular treatment, on intensive care procedures and on the outcome of the patients and the fetus. Results were compared to the present literature on this issue.

Results: The four patients ranged in age from 25 to 37 yrs (mean 30,8). Initial Hunt & Hess (H&H) grade was: III in 1 case, IV in 1 case and V in 2 cases. All patients suffered from SAH during the 3^rd trimenon of pregnancy between the 27^th and the 36^th GW (mean 31.8). In two cases a microsurgical immediate clipping was performed and in one case endovascular treatment was conducted after an external ventricular drainage (EVD) was inserted. In the fourth case the patient was in an instable condition combined with a pathological CTG of the fetus, so that only an emergency EVD for hydrocephalus treatment was carried out before further diagnostic and ultimate therapy was done. In the four cases, two emergency caesarean sections (CS) were performed, none of them in the patients treated by clipping. Median follow-up was 10.3 (2-20) months. Among the two H&H grade V patients, one showed a slightly hemiparesis with dysaesthesia, and one died, whereas the fetus recovered. Two patients were reported to be without focal neurological deficit at the time of discharge. Fetal mortality was 0%.

Conclusions: SAH during pregnancy occurs most often in the 3^rd trimester. Both, coiling and clipping as treatment options in these patients are discussed in the current literature and were performed in the reported cases. X-ray exposure is considered not to be an indication for abortion in the third trimenon of pregnancy. To select a type of treatment as well as time and mode of delivery of the fetus, individualised decisions are essential, including medication on intensive care unit.