SUBARACHNOID HEMORRHAGE
Specifics of SAH treatment during pregnancy
David Goldemund M.D.
Updated on 14/12/2023, published on 20/10/2021
- the risk of rupture during pregnancy and delivery is relatively low (1.4 and 0.05%, respectively), which is similar to the risk in the general population ⇒ conservative approach is recommended
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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 cerebral perfusion and prevent progression of cerebral edema and increase of intracranial pressure (ICP)
- hemodynamic stability (avoid both hypotension and hypertensive episodes with increased risk of rebleeding)
- invasive blood pressure (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 is ~ 2.8 mGy
- iohexol (Omnipaque) is the most commonly used contrast agent
- no fetal harm or fertility problems have been reported in animal studies (using 100x higher doses); human studies are not available
- always consider the risk-benefit ratio before administering a contrast agent; use the lowest dose possible
- use heparin, as it does not cross the placenta and its effects can be easily neutralized
- standard monitoring
- ECG
- blood pressure
- O2 saturation
- body temperature
- end-tidal carbon dioxide (ETCO2)
- intraoperative invasive BP monitoring
- fetal heart rate (FHR) monitoring
- if problems are detected, neutralize heparin and perform an emergent cesarean section
- monitor fluid balance
- consider the use of a central venous catheter
- extended neuromonitoring
- EEG (Electroencephalogram)
- SSEP (Somatosensory Evoked Potentials)
- MEP (Motor Evoked Potentials)
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- maintain normotension to preserve maternal cerebral perfusion pressure (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 larger fluid volumes 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
- however, it is commonly used in routine practice
- magnesium sulfate
- known to reduce the severity of vasospasms (VSP)
- no improvement in outcome was shown in the MASH-2 (Magnesium for aSAH) trial
- known to reduce the severity of vasospasms (VSP)
- the risk of VTE increases during pregnancy (by 4-5 times, according to some sources)
- it is safe to use intermittent pneumatic compression (IPC)
- medical prophylaxis is advised only after securing the aneurysm (consult its use with a neurosurgeon)
