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Debrah AF, Adebusoye FT, Shah MH, Awuah WA, Tenkorang PO, Bharadwaj HR, Wellington J, Ghosh S, Abiy L, Fernandes C, Abdul-Rahman T, Lychko V, Volodymyrivna BT, Mykolayivna NI. Neurological disorders in pregnant women in low- and middle-income countries-Management gaps, impacts, and future prospects: A review perspective. WOMEN'S HEALTH (LONDON, ENGLAND) 2023; 19:17455057231210265. [PMID: 37955275 PMCID: PMC10644749 DOI: 10.1177/17455057231210265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 09/25/2023] [Accepted: 10/10/2023] [Indexed: 11/14/2023]
Abstract
Neurological disorders during pregnancy are a substantial threat to women's health, particularly in low- and middle-income countries. Furthermore, a critical shortage of mental health workers and neurologists exacerbates the already pressing issue, where a lack of coordination of respective healthcare among multidisciplinary teams involved in managing these conditions perpetuates the current state of affairs. Financial restrictions and societal stigmas associated with neurological disorders in pregnancy amplify the situation. Addressing these difficulties would necessitate a multifaceted approach comprising investments in healthcare infrastructure, healthcare professional education and training, increased government support for research, and the implementation of innovative care models. Improving access to specialized treatment and coordinated management of antenatal neurological diseases will precipitate improved health outcomes for women and their families in low- and middle-income countries.
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Affiliation(s)
| | | | | | | | | | | | - Jack Wellington
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | | | - Lydia Abiy
- Donetsk National Medical University, Kropyvnytskyi, Ukraine
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Cauldwell M, Bredaki E, Dassan P, Dhanjal MK, Kaler M, Madipola N, Mahmud M, Paviour D, Senvar N, de Silva R, Watt-Coote I, Williams D, Yulia A, Steer PJ. Maternal and fetal outcomes in women with cerebrovascular malformations in pregnancy: A multicentre retrospective cohort study. BJOG 2021; 129:1151-1157. [PMID: 34882960 DOI: 10.1111/1471-0528.17046] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 11/30/2021] [Accepted: 12/03/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine maternal, obstetric and neonatal outcomes in a cohort of women with cerebrovascular malformations (CVMs) that include arterial venous malformations (AVMs) and cavernomas. DESIGN Retrospective cohort study. SETTING Six specialist centres managing pregnant women with neurological disorders. POPULATION Sixty-three women with CVMs in 83 pregnancies of ≥20 completed weeks' gestation. METHODS Retrospective case notes review. MAIN OUTCOME MEASURES Neurological outcomes including rates of acute cerebral bleeding in pregnancy and reported seizures during pregnancy. Maternal outcomes included number of women with a livebirth and the proportion of women being delivered by caesarean section. RESULTS Most women had a good pregnancy outcome with high rates of vaginal delivery (73%) at term. There were no maternal deaths. Six women had an acute cerebral bleed, all of whom were delivered by planned caesarean section. In total, ten women had seizures in pregnancy (of whom four also had a bleed). Six (7%) babies were admitted to a neonatal unit. There was no significant difference in outcomes between women with AVMs and those with cavernomas. CONCLUSION In the majority of cases, pregnancy outcomes were favourable, with most women having a vaginal delivery. All cases of cerebral bleeds that occurred were at a remove from the peripartum period. TWEETABLE ABSTRACT Women with cerebrovascular malformations have high rates of vaginal delivery.
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Affiliation(s)
- Matthew Cauldwell
- Department of Obstetrics, Maternal Medicine Service, St George's Hospital, London, UK
| | - Emma Bredaki
- UCL EGA Institute for Women's Health, London, UK
| | - Pooja Dassan
- Department of Neurology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Mandish K Dhanjal
- Directorate of Maternity, Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Mandeep Kaler
- Department of Obstetrics and Gynaecology, Royal London Hospital, Whitechapel, London, UK
| | - Nissanka Madipola
- Department of Obstetrics and Gynaecology, Queen's Hospital Barking, Havering and Redbridge University Hospitals NHS Trust, London, UK
| | - Mohammad Mahmud
- Department of Neurology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Dominic Paviour
- Department of Neurology, Queen's Hospital Barking, Havering and Redbridge University Hospitals NHS Trust, London, UK
| | - Naz Senvar
- Department of Obstetrics, Maternal Medicine Service, St George's Hospital, London, UK
| | - Rajith de Silva
- Department of Neurology, Queen's Hospital Barking, Havering and Redbridge University Hospitals NHS Trust, London, UK
| | - Ingrid Watt-Coote
- Department of Obstetrics, Maternal Medicine Service, St George's Hospital, London, UK
| | | | - Angela Yulia
- UCL EGA Institute for Women's Health, London, UK
| | - Philip J Steer
- Academic Department of Obstetrics and Gynaecology, Chelsea and Westminster Hospital, London, UK
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Joseph NK, Kumar S, Brown RD, Lanzino G, Flemming KD. Influence of Pregnancy on Hemorrhage Risk in Women With Cerebral and Spinal Cavernous Malformations. Stroke 2021; 52:434-441. [PMID: 33493052 DOI: 10.1161/strokeaha.120.031761] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Pregnancy as a hemorrhage risk factor in women with cavernous malformations (CMs) is controversial. We describe prospective hemorrhage risk in women who become pregnant after an established CM diagnosis. METHODS Beginning in 2015, we recruited consecutive patients with radiologically confirmed CM of the brain or spinal cord to participate in a prospective registry. Participants underwent a baseline and annual medical record review, imaging review, and annual surveys to ascertain pregnancies, deliveries, and neurological complications. We collected prospective hemorrhage data on reproductive age women. We calculated prospective hemorrhage rates on childbearing age patients based on the number of hemorrhages occurring post-CM diagnosis during pregnancy and nonpregnancy, divided by the years of follow-up and censored at last follow-up, age 46, or surgery in sporadic-form CM. The hemorrhage rates were compared and the 95% CI presented with a P value of <0.05. RESULTS Of 160 women, 90 presented with CM under the age of 46 (average age 31.6 years; 25.6% familial form; 46.7% with hemorrhage; 24.4% brain stem location). These 90 patients had 136 pregnancies before CM diagnosis; 36 pregnancies occurred at or after the diagnosis of CM. Four patients had a hemorrhage while pregnant or postpartum leading to the first CM diagnosis. During 402.6 years of follow-up while not pregnant, 42 hemorrhages occurred prospectively yielding a 10.4% per year (95% CI, 7.5-14.0) risk of hemorrhage while not pregnant. No hemorrhages occurred during 32 prospective pregnancies (26 live births including 1 twinset and 7 nonviable fetuses) after CM diagnosis during 26.9 years of pregnancy time yielding a rate of 0% per year (95% CI, 0-13.6). We found no statistical difference in the rates of hemorrhage during pregnant and nonpregnant time (P=0.09). No hemorrhage occurred during delivery. CONCLUSIONS Our prospective data suggest that pregnancy does not increase the risk of hemorrhage in women with a known brain or spinal cord CM and that vaginal delivery is safe in appropriate candidates.
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Affiliation(s)
- Nycole K Joseph
- Department of Neurology (N.K.J., S.K., R.D.B., K.D.F.), Mayo Clinic, Rochester, MN
| | - Shivram Kumar
- Department of Neurology (N.K.J., S.K., R.D.B., K.D.F.), Mayo Clinic, Rochester, MN
| | - Robert D Brown
- Department of Neurology (N.K.J., S.K., R.D.B., K.D.F.), Mayo Clinic, Rochester, MN
| | | | - Kelly D Flemming
- Department of Neurology (N.K.J., S.K., R.D.B., K.D.F.), Mayo Clinic, Rochester, MN
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Cerebral cavernous malformation: Management and outcome during pregnancy and puerperium. A systematic review of literature. J Gynecol Obstet Hum Reprod 2020; 50:101927. [PMID: 33035718 DOI: 10.1016/j.jogoh.2020.101927] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 08/12/2020] [Accepted: 09/28/2020] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Cerebral cavernomas malformations (CCMs) are vascular malformations that occur with an incidence of 0,4-0,8 % in general population. The most feared complication is cerebral hemorrhage. Currently there are no guidelines for pregnant women with CCMs. Some authors claimed that many physiological changes related to pregnancy could be linked to an high risk of rupture and bleeding of the cerebral cavernoma. However, more recent studies highlight that the presence of cerebral cavernomatosis is not a contraindication for pregnancy and that the risk of bleeding is similar in pregnant and in non-pregnant women. AIM OF THE STUDY The purpose of our work is to analyze, through the study of controversial findings in literature, all the information currently available trying to establish a common approach for management of women with cerebral cavernomatosis in pregnancy, during childbirth and in the puerperium. FINDINGS In accordance with existing literature, pregnancy does not appear to be a significant risk factor for the worsening of clinical manifestations associated with the presence of CCMs. Vaginal delivery is not contraindicated in patients with CCMs and there is no indication to perform cesarean section to reduce the incidence of hemorrhage. The only indication for neurosurgery of CCMs in pregnancy is the presence of rapidly progressive symptoms and should be postponed to the puerperium if arises after 30 weeks. The puerperium is a critical time for the woman with cavernomas for the possibility of bleeding and clinical observation must be continued. CONCLUSION The patients with a diagnosis of a CCMs can have a pregnancy without any particular risk to themselves and the fetus but should be addressed to highly specialized obstetrics center to assesses the initial individual risk related to their pathology and to follow the pregnancy.
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Esmaeilzadeh M, Uksul N, Hong B, von Kaisenberg C, Scheinichen D, Lang JM, Hermann EJ, Hillemanns P, Krauss JK. Intracranial emergencies during pregnancy requiring urgent neurosurgical treatment. Clin Neurol Neurosurg 2020; 195:105905. [PMID: 32428795 DOI: 10.1016/j.clineuro.2020.105905] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 04/19/2020] [Accepted: 05/07/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Despite contemporary diagnostic and therapeutic techniques intracranial emergencies in the obstetric setting pose still a major challenge for the clinicians. There are limited guidelines and differing ethical views. Multidisciplinary teams are needed to support the pregnant woman in a way that she can deliver a viable and healthy child. The aim of the present study was to scrutinize the management of intracranial emergencies during pregnancy which needed urgent neurosurgical treatment. PATIENTS AND METHODS Data of all pregnant women who presented with newly diagnosed intracranial pathologies and neurological symptoms caused by these pathologies in an emergency setting were collected over a 10-year period (2008-2018). Patient characteristics including maternal age, gestational age, and preoperative work-up of both mother and fetus were recorded. Furthermore, the surgical treatment, mode of delivery, and neonatal and maternal outcomes were analysed. RESULTS The mean maternal age was 32.7 years and most patients were in their third trimester. There was one twin pregnancy (total of 12 fetuses). Five out of eleven pregnant women suffered from intracerebral haemorrhage (epidural haematoma (1), arteriovenous malformation (1), subarachnoid haemorrhage (2) and intracerebral haemorrhage (1)) and the other six patients had intracranial neoplasms (primary meningeal sarcoma (1), trigeminal schwannoma (1), anaplastic astrocytoma (2), glioblastoma (1) and sphenoid wing meningioma (1)).Neurosurgical procedures were performed via craniotomies in eight patients. A stereotactic biopsy via a frontal burr hole was achieved one patient. The two other patients with subarachnoid haemorrhage due to rupture of PICA aneurysms were treated with coil embolization. Depending on the gestational age and the clinical condition of the pregnant women it was decided to perform an emergency Caesarean section prior to further therapeutic measures in seven patients. Two out of 12 fetuses were unviable. Six women survived, while five women succumbed to the intracranial pathology. CONCLUSION The individualized treatment approach in this peculiar obstetric scenario needs to consider various issues such as the clinical condition of the pregnant woman, prognosis of the disease, gestational age and the status of the pregnancy. The primary concern in this context must be the mother`s health and safety. Caesarean section is the primary mode of delivery in most cases. While contemporary care can insure survival for the majority of infants, maternal mortality still poses an extraordinary challenge. Interdisciplinary consulting of the patient and/or her family is necessary to develop a treatment strategy for both the expectant woman and her offspring.
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Affiliation(s)
| | - Nesrin Uksul
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | - Bujung Hong
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | | | - Dirk Scheinichen
- Department of Anaesthesiology, Hannover Medical School, Hannover, Germany
| | - Josef M Lang
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | - Elvis J Hermann
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | - Peter Hillemanns
- Department of Gynaecology & Obstetrics, Hannover Medical School, Hannover, Germany
| | - Joachim K Krauss
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
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Maor GS, Faden MS, Brown R. Prevalence, risk factors and pregnancy outcomes of women with vascular brain lesions in pregnancy. Arch Gynecol Obstet 2020; 301:665-670. [PMID: 32060681 DOI: 10.1007/s00404-020-05451-3] [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] [Received: 07/17/2019] [Accepted: 01/23/2020] [Indexed: 01/23/2023]
Abstract
BACKGROUND Vascular brain lesions (VBL) occur in up to 4.0% of the general population. With the increasing availability and use of sophisticated imaging techniques, there are more patients being diagnosed with asymptomatic intracranial AVMs and cavernous hemangiomas. OBJECTIVES Here we evaluate the association between VBL in pregnancy and the maternal and fetal outcomes. STUDY DESIGN The study cohort was identified by isolating all pregnancies from the nationwide inpatient sample (NIS), from the healthcare cost and utilization project (HCUP) over a five-year period. Within this cohort, cases with an arteriovenous malformation (AVM) or cerebral vascular malformations (CVM) were identified and their prevalence was calculated. Baseline demographic characteristics were compared and the odds ratios for various complications and outcomes were calculated. RESULTS Amongst 4,012,396 deliveries, VBL were identified in 214 cases: a prevalence of 5.33 cases per 100,000 deliveries. Majority of VBL cases were identified in women between 25 and 35 years of age, but the proportion of women aged 35 and older was greater amongst those patients with VBL. 74% of cases were of Caucasian race and more cases with VBL had a private insurance payer (62.1%). Seizure disorders were present in 63.6% of the cases with VBL. Whilst VBL are not associated with unfavorable obstetrical complications, they are more likely to be delivered by caesarean section (CS) - 79% of VBL cases were delivered by CS compared to 33% of the patients without VBL (OR 7.03 CI 95% 4.98-9.92). Instrumental delivery was performed in 10.3% of the vaginal deliveries for index cases. Index cases were less prone to fetal growth restriction. VBL accounted for 8.4% of 166 cases of intracranial bleeding occurring during the antepartum period within the entire pregnant population. CONCLUSIONS Presence of VBL does not appear to carry additional risk to mother or fetus during pregnancy.
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Affiliation(s)
- Gil Shechter Maor
- Department of Obstetrics and Gynecology, Royal Victoria Hospital, McGill University, Montreal, QC, Canada. .,Department of Obstetric and Gynecology, Meir Medical Center, 59 Tcharnichovsky st., Kfar Saba, Israel.
| | - Majed S Faden
- Department of Obstetrics and Gynecology, Royal Victoria Hospital, McGill University, Montreal, QC, Canada.,Department of Maternal Fetal Medicine, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Richard Brown
- Department of Obstetrics and Gynecology, Royal Victoria Hospital, McGill University, Montreal, QC, Canada
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Tomita Y, Fujii K, Kurozumi K, Imoto R, Mitsui T, Mishima S, Inagaki K, Masuyama H, Date I. Cavernous malformation of the optic chiasm with continuous hemorrhage in a pregnant woman: A case report. INTERDISCIPLINARY NEUROSURGERY 2019. [DOI: 10.1016/j.inat.2019.100489] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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Renukesh S, Rai L. Neurological Disorders Complicating Pregnancy - Focus on Obstetric Outcome. J Clin Diagn Res 2016; 10:QC06-QC09. [PMID: 28208940 PMCID: PMC5296513 DOI: 10.7860/jcdr/2016/19839.8955] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Accepted: 09/06/2016] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Neurological disorders in pregnancy can be pregnancy related or can be caused by exacerbation of a pre-existing neurological condition or sometimes may even be detected for the first time during pregnancy in which it might be an incidental finding. The diagnosis and management of the neurological disorders in pregnancy is always a challenging task due to varied symptomatology and risks to the fetus. The evaluation and management should be performed in a stepwise fashion and requires multidisciplinary approach. AIM The present study was conducted with the aim to study the influence of neurological disorders on outcome of pregnancy. MATERIAL AND METHODS This was a prospective observational study conduted over a period of 1 year (2013-2014) including 54 pregnant women with neurological manifestations. The spectrum of neurological manifestations was divided into-pregnancy specific, incidental and pre-existing neurological disorders for analysis. Five unusual cases with varied manifestations were studied in detail. Any pregnant woman presenting with neurological manifestation, irrespective of gestational age were included in the present study. The neurological manifestation and the obstetric outcome were analysed in the present study. RESULTS There were 54 women with varied neurological manifestations, majority (74%) of them being primigravida. Seizure was the most common (63%) manifestation. The incidence of pregnancy specific disorder (eclampsia), pre-existing disease (epilepsy) and incidental causes were 40.8%, 37% and 22.2% respectively. Of the 22 women with eclampsia, 15(68%) had seizure during antepartum period and 7(32%) in the postpartum period. Three patients out of 22 who had eclampsia had intrauterine fetal demise on arrival itself, whereas the perinatal outcome was good in the other 19 patients who had live born babies. The most common incidental cause in the present study was tubercular meningitis (44%). There was however a maternal and perinatal mortality in woman with structural malformation who had massive intra-ventricular haemorrhage, secondary to ruptured cerebral cavernoma. Here we have described in detail 5 patients with varied clinical manifestation causing diagnostic dilemma. They are spinal arterio-venous malformation, disseminated toxoplasmosis, massive intra-ventricular haemorrhage (ruptured cerebral cavernoma), tubercular meningitis with cortical venous thrombosis, suspected Bartter syndrome presenting as coma. CONCLUSION Neurological manifestation during pregnancy may not always be a primary neurological disorder, instead may be manifestation secondary to any systemic illness. Hence, a wide index of suspicion and neuroimaging aids in arriving at the diagnosis certainly improves the pregnancy outcome.
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Affiliation(s)
- Sandya Renukesh
- Senior Resident, Department of Obstetrics and Gynaecology, St John’s Medical College, Bangalore, India
| | - Lavanya Rai
- Professor and Head of Department, Department of Obstetrics and Gynaecology, Kasturba Medical College, Manipal, Udupi, India
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