Pregnancy and ventriculoperitioneal shunt. Report of a case and literature review

Safety of Pregnancy in Ventriculoperitoneal Shunt Dependent Women: Meta-analysis and Systematic Review of the Literature

Objective

To assess the safety of pregnancy in ventriculoperitoneal (VP) shunt-dependent women.

Methods

Three electronic databases MEDLINE (PubMed), EMBASE, and the Cochrane Library were systematically searched to identify studies published in English between 1950 and 2019. We additionally searched Web of Science, Google Scholar, and ClinicalTrials.gov.

Results

Among the 38 cases of pregnant VP shunt-dependent women, median age was 25.5 years and shunting duration was 15.5 years with 11 women being shunted at birth or soon after. Congenital diseases were the most common reason for shunting, present in 63.2% of women. The antepartum complications were reported in 50% of cases with the symptoms of increased ICP being the most commonly reported (73.7%). In the majority of cases the complications were resolved with cerebrospinal fluid aspiration (26.3%). Eight women (42.1%) had spontaneous vaginal delivery, 4 had assisted vaginal delivery, while 7 women underwent cesarian section. There was one fetal demise occurred in a woman that was diagnosed with tuberous sclerosis and presented with status epilepticus during the pregnancy.

Conclusion

A multidisciplinary approach is needed in managing the VP shunts during the pregnancy and post-partum periods to ensure the best pregnancy outcome for both mothers and the fetus. Based on our findings, VP shunt appears not to be a contraindication for pregnancy. The routine use of prophylactic antibiotics to prevent shunt infection is not recommended. Vaginal delivery should be attempted unless a cesarean section is inevitably required for obstetrics reasons.

Anesthetic considerations for labor and delivery in women with cerebrospinal fluid shunts

BACKGROUND

The anesthetic management of labor and delivery in pregnant women with cerebrospinal fluid shunts can be challenging. We conducted a literature review to understand the anesthetic implications in pregnant women with cerebrospinal fluid shunts.

METHODS

We searched PubMed, EMBASE, and Medline databases to identify reports of pregnant women with cerebrospinal fluid shunts during the 30-year period from 1985 to 2015. Twenty-four studies reporting anesthetic techniques for labor and delivery were included in the analyses.

RESULTS

A total of 97 women with 130 pregnancies were included. Ventriculo-peritoneal shunts (77%) were the most common type of shunt. Twenty-eight (29%) women had shunt malfunction during pregnancy, with 20 (71%) requiring shunt revision. Overall, 73 women (56%) delivered vaginally and 23 (40%) received epidural analgesia. Fifty-seven women (44%) underwent cesarean delivery and general anesthesia was used in 45% of cases.

CONCLUSION

This review suggests that shunt malfunctions occurred commonly during pregnancy. The presence of neurological symptoms warrants careful evaluation of shunt function. Anesthetic management for labor and delivery varied and was dependent on shunt function. Epidural analgesia appears to be safe in women with functional shunts.

Ventriculoperitoneal Shunt Dysfunction in Adults Secondary to Conditions Causing a Transient Increase in Intra-abdominal Pressure: Report of Three Cases

OBJECTIVE AND IMPORTANCE:

Ventriculoperitoneal (VP) shunts function because of the pressure differential between the intracranial space and the peritoneal cavity. The pressure in the peritoneal cavity is the lower of the two in a properly functioning shunt; thus, cerebrospinal fluid flows distally. Although not reported in the literature, adult constipation, ileus, or small bowel obstruction can alter this pressure balance and cause dysfunction. If not recognized as a transient, easily treated phenomenon, patients may be subjected to unnecessary shunt revisions. This study analyzed the occurrence of shunt malfunction in three adults secondary to transient increases in intra-abdominal pressure.

CLINICAL PRESENTATION:

Three patients with clinical symptoms and radiographic evidence of VP shunt malfunction at presentation were found to have transient conditions causing a significant increase in intra-abdominal pressure. These patients' records were evaluated with an emphasis on risk factors, treatments, and outcomes.

INTERVENTION:

After resolution of the patients' abdominal issues, clinical signs and symptoms of VP shunt dysfunction resolved within 24 hours. Radiographic evidence of the resolution of shunt failure also was observed.

CONCLUSION:

Shunt malfunction or dysfunction consumes many person-hours and healthcare dollars. This study provides anecdotal evidence that transient and easily reversible increases in the intra-abdominal pressure of adults with VP shunts can result in dysfunction. Although it may not be practical to delay shunt revision while attempting to correct constipation, ileus, or small bowel obstruction, clinicians treating patients with these abdominal conditions should be aware that they could cause transient VP shunt failure. It would seem prudent that patients with VP shunts be started on a prophylactic bowel regimen before surgical procedures to decrease the risk of this somewhat preventable result.

Ventriculoperitoneal shunt failure as a secondary complication of ovarian hyperstimulation syndrome. Case report

The authors report on a patient who presented with shunt failure due to ovarian hyperstimulation syndrome (OHSS) following in vitro fertilization treatment. Shunt dysfunction was attributed to intraabdominal hypertension as a consequence of ascites. At surgery, the shunt was found to be patent. The peritoneal catheter was externalized and subsequently revised to become a ventriculoatrial shunt system. This led to clinical improvement in the patient and restoration of ventricular size. Such a shunt complication has not previously been reported. Neurosurgeons should be alerted to this possibility in view of the increasing use of assisted conception in many developed countries.

Maternal shunt dependency: implications for obstetric care, neurosurgical management, and pregnancy outcomes and a review of selected literature

OBJECTIVE

Because more women with cerebrospinal fluid shunts are surviving to child-bearing age, neurosurgeons, obstetricians, and other health care professionals require information about the care of these patients, especially during pregnancy and delivery. The purpose of this study was to gather comprehensive data from women with shunts regarding their clinical histories during and immediately after pregnancy. The following questions were addressed. 1) How does maternal shunt dependency influence the course of pregnancies and pregnancy outcomes? 2) What neurosurgical complications characterize this population of patients? 3) What complications of shunt dependency influence obstetric management, including prenatal testing and delivery?

METHODS

A total of 37 respondents (age, 18-41 yr), accounting for 77 pregnancies, completed a questionnaire providing information on maternal background and medical history, shunt performance during pregnancy, management of delivery, pregnancy outcomes, and unusual complications.

RESULTS

Fifty-six pregnancies resulted in live births; of these, 47 occurred in women with ventriculoperitoneal shunts. Three women underwent therapeutic abortions, 1 experienced preterm delivery, and 8 experienced 17 miscarriages. Four women experienced seizures during pregnancy, five reported third-trimester headaches, and eight described abdominal pains during the first and third trimesters. Four babies were diagnosed as having congenital defects. Shunt malfunctions and revisions occurred 10 times in 7 women, either during pregnancy or within 6 months after delivery. No acute malfunctions occurred during delivery. Forty-seven cases, representing 84% of all pregnancies, exhibited no shunt malfunctions or revisions.

CONCLUSION

This study extends previous observations to a larger population of shunt-dependent mothers. The results suggest that maternal shunt dependency entails a relatively high incidence of complications but that proper care of these patients can lead to normal pregnancies and deliveries.

Adult patients with spina bifida cystica: genetic counselling, pregnancy and delivery

With more aggressive surgical management, patients born with spina bifida may now reach adulthood and achieve pregnancies. Any female patient with spina bifida is strongly recommended to have preconceptional genetic counselling. The risk for parents with spina bifida of having affected offspring (approx. 4%) is considerably increased compared with the general population (0.1-0.3%). This risk may be lowered when periconceptional folic acid supplements are given. In pregnancy, special care is needed in the management of urological, obstetric, neurological and anaesthetic problems. Urological complications like neurogenic bladder, incontinence, chronic infection, increased chance of developing bladder carcinoma and impaired renal function are common in the spina bifida patient. In case of urinary diversion, obstruction may complicate the pregnancy. The incidence of premature labour is increased. Clinical assessment of the pelvis is necessary because of a possibly contracted pelvis. If the head engages normally, vaginal delivery should be allowed if possible. Caesarean section should be performed for obstetric reasons only. Cerebrospinal fluid shunts may give neurological problems during pregnancy. In most cases reported, symptoms improved spontaneously after delivery. In case of a shunt, vaginal delivery is preferable, pushing during second stage not contra-indicated, and in case of caesarean section, prophylactic antibiotics and thorough irrigation of the peritoneal cavity are indicated.

Ventriculoperitoneal shunt and pregnancy

A pregnancy in a patient with ventriculoperitoneal (VP) shunt was recently managed at the authors's institution. Review of the literature showed only six previous case reports. The management of this uncommon neurosurgical condition in pregnancy is presented along with a review of the literature. We conclude that pregnancy in a patient with a VP shunt for maternal hydrocephalus, generally has a normal outcome and that the function of the shunt is unaffected by pregnancy.