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Godoy DA, Robba C, Paiva WS, Rabinstein AA. Acute Intracranial Hypertension During Pregnancy: Special Considerations and Management Adjustments. Neurocrit Care 2022; 36:302-316. [PMID: 34494211 PMCID: PMC8423073 DOI: 10.1007/s12028-021-01333-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 08/12/2021] [Indexed: 12/19/2022]
Abstract
Pregnancy is associated with a number of pathophysiological changes (including modification of vascular resistance, increased vascular permeability, and coagulative disorders) that can lead to specific (eclampsia, preeclampsia) or not specific (intracranial hemorrhage) neurological complications. In addition to these disorders, pregnancy can affect numerous preexisting neurologic conditions, including epilepsy, brain tumors, and intracerebral bleeding from cerebral aneurysm or arteriovenous malformations. Intracranial complications related to pregnancy can expose patients to a high risk of intracranial hypertension (IHT). Unfortunately, at present, the therapeutic measures that are generally adopted for the control of elevated intracranial pressure (ICP) in the general population have not been examined in pregnant patients, and their efficacy and safety for the mother and the fetus is still unknown. In addition, no specific guidelines for the application of the staircase approach, including escalating treatments with increasing intensity of level, for the management of IHT exist for this population. Although some of basic measures can be considered safe even in pregnant patients (management of stable hemodynamic and respiratory function, optimization of systemic physiology), some other interventions, such as hyperventilation, osmotic therapy, hypothermia, barbiturates, and decompressive craniectomy, can lead to specific concerns for the safety of both mother and fetus. The aim of this review is to summarize the neurological pathophysiological changes occurring during pregnancy and explore the effects of the possible therapeutic interventions applied to the general population for the management of IHT during pregnancy, taking into consideration ethical and clinical concerns as well as the decision for the timing of treatment and delivery.
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Affiliation(s)
- Daniel Agustin Godoy
- Neurointensive Care Unit, Sanatorio Pasteur, Catamarca, Argentina.
- Intensive Care, Hospital Carlos Malbran, Catamarca, Argentina.
| | - Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, Investigational Research for Critical Care for Oncology and Neurosciences, Genoa, Italy
| | - Wellingson Silva Paiva
- Division of Neurological Surgery, University of Sao Paulo Medical School, Sao Paulo, Brazil
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Carbone L, Somma T, Iorio GG, Vitulli F, Conforti A, Raffone A, Bove I, Pagano S, Pontillo M, Carbone IF, Farina A, Maruotti GM, Maiuri F, Cappabianca P, Alviggi C. Meningioma during pregnancy: what can influence the management? A case series and review of the literature. J Matern Fetal Neonatal Med 2021; 35:8767-8777. [PMID: 34822317 DOI: 10.1080/14767058.2021.2004585] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Purpose: Meningioma is a benign tumor, more frequent in female population. During pregnancy, distinguishing a meningioma from other common conditions presenting with similar symptoms (headache, vomiting, visual impairment) is challenging. Moreover, the management must consider not only maternal but also fetal health. The rarity of the condition does not allow to define the features to which look in order to stratify the risk for the need of surgery during pregnancy. We reported three cases of meningioma in pregnant women treated at our department and reviewed those previously reported in the literature. The aim of this review is to evaluate which factors are more determinant in such management.Methods: Electronic databases were searched from year 2000 until June 2020, to identify clinical studies on management of meningioma diagnosed during pregnancy. The primary outcome was surgical timing. Secondary outcomes were delivery methods, maternal and neonatal outcomes.Results: Surgery after pregnancy is more frequently performed in PR + tumor (p-value 0.038) and with HA (p-value 0.0445), as well as in meningioma diagnosed during the third trimester, compared to those diagnosed before (p-value 0.0012). Surgery during pregnancy was more frequent in patients with visual loss (p-value 0.006). No significant differences were found in surgical management, according to age, WHO grade, tumor location, lesion diameter and ER positivity. Delivery method is independent from both hormonal receptor status and main symptoms, but women who had neurosurgery during pregnancy delivered more frequently with spontaneous vaginal delivery (p-value <0.01).Conclusion: The decision regarding surgical timing of meningioma diagnosed during pregnancy depends on PR + and impending symptoms as visual loss or headache. It seems that timing of neurosurgery does not affect the delivery method. A multidisciplinary approach is always useful to perform a rapid and appropriate diagnosis and to better evaluate pros and cons of surgery during pregnancy and following management both for maternal and fetal wellness.
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Affiliation(s)
- Luigi Carbone
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, School of Medicine, Federico II University, Naples, Italy
| | - Teresa Somma
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, School of Medicine, Federico II University, Naples, Italy
| | - Giuseppe Gabriele Iorio
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, School of Medicine, Federico II University, Naples, Italy
| | - Francesca Vitulli
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, School of Medicine, Federico II University, Naples, Italy
| | - Alessandro Conforti
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, School of Medicine, Federico II University, Naples, Italy
| | - Antonio Raffone
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, School of Medicine, Federico II University, Naples, Italy
| | - Ilaria Bove
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, School of Medicine, Federico II University, Naples, Italy
| | - Serena Pagano
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, School of Medicine, Federico II University, Naples, Italy
| | - Martina Pontillo
- Department of Public Health, School of Medicine, Federico II University, Naples, Italy
| | - Ilma Floriana Carbone
- Department of Woman, Child and Neonate, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Antonio Farina
- Obstetric Unit, Department of Medical and Surgical Sciences, University of Bologna and IRCCS Azienda Ospedaliero-Universitaria S.Orsola-Malpighi, Bologna, Italy
| | - Giuseppe Maria Maruotti
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, School of Medicine, Federico II University, Naples, Italy
| | - Francesco Maiuri
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, School of Medicine, Federico II University, Naples, Italy
| | - Paolo Cappabianca
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, School of Medicine, Federico II University, Naples, Italy
| | - Carlo Alviggi
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, School of Medicine, Federico II University, Naples, Italy
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Higgins MF, Pollard L, McGuinness SK, Kingdom JC. Fetal heart rate monitoring in nonobstetric surgery: a systematic review of the evidence. Am J Obstet Gynecol MFM 2019; 1:100048. [PMID: 33345838 DOI: 10.1016/j.ajogmf.2019.100048] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 08/26/2019] [Accepted: 09/22/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Concern for fetal well-being during maternal nonobstetric surgery may result in obstetricians and other maternity care providers being asked to perform intraoperative fetal heart rate (FHR) monitoring. We systematically reviewed the evidence regarding the use of FHR monitoring during nonobstetric surgery after potential fetal viability (>22 weeks gestational age), and examined the FHR patterns and outcomes reported. DATA SOURCES A systematic review of the evidence was performed. Sources included databases (MEDLINE, EMBASE, Cochrane, and CENTRAL), hand searching, guidelines, conference proceedings, and literature reviews. Online searching was performed to include literature published from 1966 to May 2019. STUDY ELIGIBILITY CRITERIA All studies reviewing care of pregnant women undergoing nonobstetric surgery where FHR monitoring was performed intraoperatively. Data were extracted from appropriate full-text articles using a data abstraction form. STUDY APPRAISAL AND SYNTHESIS Case reports and case series only were identified. A total of 74 cases were reviewed, encompassing maternal general surgery (n = 41, cardiovascular surgery (n = 13) and neurosurgery/orthopedics (n = 20). Median gestational age at time of maternal surgery was 30 weeks (range, 22-36 weeks). In 41 cases, findings of FHR monitoring were not reported. Abnormal tracings were observed in 29 cases, as either reduced variability (n = 13) or fetal bradycardia (n = 17). All but 3 bradycardias reported occurred during maternal cardiac surgery involving aortic clamping and cardiopulmonary bypass. In 1 case, FHR monitoring was not possible because of a surgical pneumoperitoneum; there was 1 fetal tachycardia associated with maternal pyrexia, and three cases in which FHR monitoring was deemed stable or normal. Three preterm infants were delivered simultaneously at the time of general surgery as a result of FHR abnormalities (at 30, 33, and 34 weeks respectively), 2 as a result of fetal bradycardia and 1 because of protracted reduced variablity. CONCLUSION The evidence for intraoperative fetal monitoring is based on case reports and cases series. Maternal cardiac surgery involving cardiopulmonary bypass commonly results in fetal bradycardia, which may be challenging to interpret. Obstetricians should be aware of FHR pattern changes in response to anesthesia and surgery that do not justify iatrogenic preterm cesarean delivery.
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Affiliation(s)
- Mary F Higgins
- Maternal Fetal Medicine, Mount Sinai Hospital, Toronto, ON, Canada; Perinatal Research Center, Obstetrics and Gynaecology, School of Medicine and Medical Sciences, University College Dublin, National Maternity Hospital, Dublin, Ireland.
| | - Lindsay Pollard
- Department of Nursing, Mount Sinai Hospital, Toronto, ON, Canada
| | | | - John C Kingdom
- Maternal Fetal Medicine, Mount Sinai Hospital, Toronto, ON, Canada; Obstetrics and Gynaecology, University of Toronto, ON, Canada
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Huang J. Nonobstetric Surgery During Pregnancy. Anesthesiology 2017. [DOI: 10.1007/978-3-319-50141-3_51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Kanas M, Kunzle H, Martins DE, Kirsch LA, Puertas EB, Wajchenberg M. Diskectomy during Pregnancy: Case Report and Review of the Literature. Global Spine J 2015; 5:130-4. [PMID: 25844286 PMCID: PMC4369201 DOI: 10.1055/s-0034-1387178] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2014] [Accepted: 06/03/2014] [Indexed: 11/28/2022] Open
Abstract
Study Design Case report. Objective The purpose of this report is to discuss the management of a disk herniation during pregnancy and the indication and particularities of surgery in this situation. Methods We describe a case of diskectomy performed in a 35-year-old woman at 18 weeks of gestation. After 4 weeks of trying to manage the disk herniation with rest and medications without success, the muscle strength of the L5 right root decreased to grade 4, and the patient was not responding to intravenous analgesia. After discussion with the patient and family, a decision was made to perform the diskectomy. Results After surgery, the patient's pain lessened, and the Lasegue test became negative. Two weeks after the procedure, the patient's muscle strength was normal. In the 40th week of pregnancy, the patient gave birth without any complications. Conclusion When necessary, diskectomy can be indicated and performed during pregnancy. However, appropriate precautions must be taken. Awareness of these precautions is important for the success of the procedure and for the well-being of the mother and the newborn.
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Affiliation(s)
- Michel Kanas
- Spine Group from Department of Orthopedics and Traumatology, Universidade Federal de Sao Paulo (Unifesp), Sao Paulo, Brazil,Address for correspondence Michel Kanas, MD Al. Joaquim Eugênio de Lima1656, ap. 141, Jardim PaulistaSão Paulo–SP, Brazil, CEP 01403-002
| | - Hugo Kunzle
- Spine Group from Department of Orthopedics and Traumatology, Universidade Federal de Sao Paulo (Unifesp), Sao Paulo, Brazil
| | - Delio E. Martins
- Spine Group from Department of Orthopedics and Traumatology, Universidade Federal de Sao Paulo (Unifesp), Sao Paulo, Brazil
| | - Luiz A. Kirsch
- Department of Anesthesia, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Eduardo B. Puertas
- Spine Group from Department of Orthopedics and Traumatology, Universidade Federal de Sao Paulo (Unifesp), Sao Paulo, Brazil
| | - Marcelo Wajchenberg
- Spine Group from Department of Orthopedics and Traumatology, Universidade Federal de Sao Paulo (Unifesp), Sao Paulo, Brazil
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Baldwin EA, Borowski KS, Brost BC, Rose CH. Antepartum nonobstetrical surgery at ≥23 weeks' gestation and risk for preterm delivery. Am J Obstet Gynecol 2015; 212:232.e1-5. [PMID: 25218955 DOI: 10.1016/j.ajog.2014.09.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Revised: 07/20/2014] [Accepted: 09/03/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE We sought to describe the influence of antepartum nonobstetrical surgical procedures performed at viable fetal gestational ages (GAs) on incidence of preterm delivery. STUDY DESIGN This was a retrospective case series of patients requiring nonobstetrical surgery at ≥23 weeks' gestation at the Mayo Clinic during the interval 1992 through 2014. Data were abstracted for maternal demographic variables, operative procedure, anesthetic type, whether intraoperative fetal monitoring was employed, and both GA and method of delivery. RESULTS In all, 111 patients underwent 121 operative procedures at a mean GA of 29.2 weeks (range, 23-37 weeks). The majority of procedures were completed under general anesthesia (88/121, 73%), with intraoperative fetal monitoring performed in 14 cases (14/121, 12%); fetal loss occurred during a single unmonitored procedure. Outcome data were available for the majority of patients (86/111, 78%) with preterm delivery occurring in 41% (35/86) at a mean GA of 36.9 weeks (range, 25-41 weeks). Mean interval from procedure to delivery was 7.7 weeks, with 9 patients (9/86, 10%) delivering within 1 week of surgery. Neither procedures requiring entry into the abdominal cavity (P = .65) nor GA at time of procedure (P = 1.0) statistically influenced the risk of preterm delivery. CONCLUSION Nonobstetrical surgical procedures performed at or beyond fetal viability increased the incidence of preterm delivery regardless of surgical site or timing of procedure, however the risk of intraoperative or immediate postoperative obstetrical complications was relatively low.
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Chowdhury T, Chowdhury M, Schaller B, Cappellani RB, Daya J. Perioperative considerations for neurosurgical procedures in the gravid patient: Continuing Professional Development. Can J Anaesth 2013; 60:1139-55. [DOI: 10.1007/s12630-013-0031-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2013] [Accepted: 08/19/2013] [Indexed: 11/25/2022] Open
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[Silent cardiotocogram during general anesthesia. Indication for emergency Cesarean section?]. Anaesthesist 2012; 61:1049-53. [PMID: 23223840 DOI: 10.1007/s00101-012-2105-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Revised: 09/28/2012] [Accepted: 10/12/2012] [Indexed: 10/27/2022]
Abstract
This case report of a silent cardiotocogram (CTG) registration during general anesthesia in a 33-week-pregnant patient undergoing non-obstetric surgery demonstrates the possibility of misinterpretation whereby typical CTG patterns of fetal reactions to anesthetics can be misinterpreted as fetal hypoxia or even asphyxia.
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Polavarapu HV, Kurian A, Antanavicius G, Myers VS. Intraoperative fetal monitoring an invaluable tool in pregnant patients with internal hernia after gastric bypass and review of literature. Surg Obes Relat Dis 2012; 8:e40-2. [DOI: 10.1016/j.soard.2011.03.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2011] [Revised: 03/13/2011] [Accepted: 03/15/2011] [Indexed: 12/28/2022]
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García NIS, Morant JCG, González EH. Cirugía no obstétrica durante el embarazo. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2011. [DOI: 10.5554/rca.v39i3.51] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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