gms | German Medical Science

Objective: Treatment for aneurysmal subarachnoid hemorrhage (aSAH) in pregnancy is a challenging and multidisciplinary task. The limited number of cases published renders it difficult to develop guidelines for the management of aSAH.

Method: A case of pregnant woman recently treated for aSAH at our department is presented. Additionally, search of PUBMED database and collection of all pertinent English language articles from 1990-2012. On top, cases were identified in publications included in the reference lists of the respective papers.

Case illustration:A 36-year-old pregnant woman (37^th GW/gestational week) presented to our department in WFNS grade II following an aSAH from a basilar artery tip aneurysm. After a multidisciplinary discussion a Caesarian section (CS) was performed followed by endovascular therapy (ET) of the aneurysm. CS and ET were performed without complications. On the 4^th day following aSAH the patient developed symptomatic cerebral vasospasm. Induced hypertension and eventually endovascular spasmolysis were initiated. The patient developed severe cardiopulmonary failure (insertion of an intra-aortic balloon counter-pulsation (IABP)) and died on day seven from cerebral infarctions despite maximum treatment.

Literature review:We identified 27 patients with aSAH during pregnancy. Patient age ranged from 19-41 years. Two patients died before aneurysm treatment. In one case the child could be rescued by CS. Of the remaining cases, 13 patients had microsurgical clipping and 12 had endovascular coiling of their aneurysm. 10 patients presented in their early 3^rd trimester or earlier. Two patients (both in their 10^th GW) had induced abortions. In 8/10 cases (80%) pregnancy was continued and the aneurysm treated. 15 patients presented in their mid or late 3^rd trimester. In 13/15 (87%) cases CS was performed prior to aneurysm treatment. The treatment sequences in both groups differ statistically significant (p<0.01). Radiation exposure to the uterus during angiography and CT is calculated by several authors and reported to be <10 mSi.

Results:

Conclusions: In the mid or late 3^rd trimester primary CS prior to the definitive treatment of a ruptured aneurysm seems safe for both mother and child. During earlier stages aneurysm rupture can be successfully managed by aneurysm treatment and continuation of the pregnancy. There seems to be no indication to induce abortion based on X-ray exposure. Finally, in each case a careful individual decision making will be mandatory.