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
  • 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)

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Specifics of SAH treatment during pregnancy