Specifics of SAH treatment during pregnancy

Created 20/10/2021, last revision 11/01/2023

  • the risk of rupture during pregnancy and delivery is relatively low (1.4 and 0.05%, respectively) and close to the general population ⇒ conservative approach
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  • general anesthesia is preferred
  • it is important to:
    • maintain placental perfusion and fetal oxygenation – to avoid hypoxia, hypotension, hypocapnia, acidosis, and hypothermia
    • adequate maternal brain perfusion and prevention of progression of cerebral edema and ↑ ICP
    • hemodynamic stability (avoid both hypotension and hypertensive attacks with increased risk of rebleeding)
      • invasive BP measurement is preferred
  • use a shield to protect the fetus
  • according to the ICRP (International Commission on Radiation Protection), abortion is recommended at a dose > 100 mGy
  • according to the experiment, the measured dose during a conventional endovascular procedure was about 2.8 mGy
  • most commonly, iohexolomnipaque is used
  • no fetal harm or fertility problems have been reported (animal studies with 100x higher dose); human studies are not available
  • always consider the risk-benefit ratio before using a contrast agent; use the lowest dose possible
  • use heparin, which does not cross the placenta, and its effect can be easily neutralized
  • standard monitoring (ECG, blood pressure, O2 saturation, temperature, ETCO2)
  • intraoperative invasive BP monitoring
  • fetal heart rate (FHR) monitoring
  • if problems are detected, neutralize heparin and perform an emergent cesarian section
  • fluid balance
  • consider central venous catheter
  • extended neuromonitoring
    • EEG
    • SSEP, MEP
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  • maintain normotension to preserve maternal CPP and prevent intrauterine asphyxia
  • invasive blood pressure (BP) monitoring is recommended
  • consider central venous catheter (CVC) placement:
    • enables central venous pressure (CVP) monitoring
    • allows administering more fluids and concentrated solutions
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  • nimodipine, according to animal studies, increases the risk of growth retardation and congenital defects – consider the risk-benefit ratio
    • it is often used in routine practice
  • magnesium sulfate
  • the risk of VTE is increased during pregnancy ( 4-5 times, according to some sources)
  • it is safe to use intermittent pneumatic compression (IPC)
  • medical prophylaxis only after the aneurysm is secured (consult with a neurosurgeon)

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Specifics of SAH treatment during pregnancy