Intracranial Haemorrhage in Pregnancy

 

Ms. Sneha R. Dubey*

Shridevi College of Nursing, Tumakuru, Karnataka.

*Corresponding Author E-mail: dubeysneha176@gmail.com

 

ABSTRACT:

Intracranial haemorrhage (ICH) is a rare, yet potentially devastating event in pregnancy. There is a risk of maternal mortality or morbidity and a significant risk to the unborn child. The risk of haemorrhage increases during the third trimester and is greatest during parturition and the puerperium. ICH can be extradural, subdural, subarachnoid or intraparenchymal. Causes of bleeding include trauma, arteriovenous malformations, aneurysms, preeclampsia/eclampsia and venous thrombosis. Urgent neurosurgical conditions generally outweigh obstetric considerations in management decisions, although anaesthetic and surgical modifications can be made to minimize adverse effects to the fetus.

 

KEYWORDS: stroke, intracerebral haemorrhage, pregnancy, cerebral aneurysms, subarachnoid haemorrhage, arteriovenous malformations.

 

 


INTRODUCTION:

Intracerebral hemorrhage (ICH) associated with pregnancy commonly occurs in the postpartum period in the setting of preeclampsia/eclampsia. When stroke - ischemic or hemorrhagic - occurs during pregnancy, both woman and child may have devastating out comes. The incidence of strokes in pregnant patients is estimated at 34.2 per 100,000 deliveries, and the mortality rate is 1.4 per 100,000 deliveries, accounting for both types. Vascular anomalies, preeclampsia/eclampsia, and coagulopathy have been described as leading causes of intracranial hemorrhage (ICH).

 

DEFINITION:

Intracerebral hemorrhage (ICH) associated with pregnancy commonly occurs in the postpartum period in the setting of preeclampsia/eclampsia

 

INCIDECE AND RISK FACTOR:

·       6 per 100,000 deliveries (12% of maternal death)

·       Maximum risk postpartum period

·       Advanced maternal age, obesity

·       Pre existing hypertension, diabetes

·       Pre eclampsia, superimposed preeclampsia

·       Gestational hypertension, heart disease

·       Coagulopathy

·       Tobacco abuse

 

PROGNOSIS:

·       Inferquent complication of pregency and puerperium

·       Sever complication

·       High mortality (in hospital 20%)

·       Poor prognosis (morbidity and disability)

 

PATHOPHYSIOLOGY:

 

Fig. 1: pathophysiology of intracranial hemorrhage in pregency

 

TYPE OF INTRA CRANIAL HAEMORRHAGE:

ICH may be classified anatomically as extradural, subdural, subarachnoid or intracerebral. Extradural and subdural haemorrhages are usually related to trauma, as are some intracerebral haemorrhages. Spontaneous SAH is usually caused by aneurysmal rupture. Spontaneous intracerebral haemorrhage in obstetric patients is most often caused by AVM, hypertension or venous occlusion.

 

Extradural haemorrhage:

The chief cause of extradural haemorrhage is trauma. This type of haemorrhage is commonly associated with skull fracture and injury to the middle meningeal artery. Primary brain damage is usually minimal and the prognosis is good with timely surgical treatment.

 

Subdural haemorrhage:

Acute subdural haemorrhage (SDH) is usually a result of severe traumatic brain injury and carries a poor prognosis. The epidemiology and treatment of this injury in pregnancy are no different from the non-pregnant population. Chronic SDH is extremely uncommon in pregnancy, as it is a disease usually affecting the elderly. There are several reports in the literature referring to SDH after epidural or spinal anaesthesia, presumably related to intracranial cerebrospinal fluid hypovolaemia and low intracranial pressure causing stretching and tearing of bridging veins between the cortex and dural venous sinuses.

 

Subarachnoid haemorrhage:

The overall frequency of pregnancy-related SAH during pregnancy is thought to be 0.01–0.03%. Up to 90% of these SAHs occur during pregnancy, 2% during delivery and 8% during the puerperium. There appears to be a tendency for a higher frequency of SAH with advancing gestation, suggesting that haemodynamic or other physiological changes in pregnancy do influence the rate of aneury small growth or rupture.

 

Pregnancy does not seem to alter the clinical presentation of SAH. One-third of patients present in a poor neurological grade with coma or depressed consciousness. Those patients who present with a preserved level of consciousness typically describe sudden onset of severe headache invariably associated with vomiting. Focal neurological deficits may be present, especially if there is associated intracerebral haemorrhage. The initial symptoms may be similar to eclampsia or preeclampsia.

 

Fig. 2: type of hemorrhage

 

SIGN AND SYMPTOMS:

·       Sudden weakness, tingling, or paralysis in your face, arm, or leg, especially if it occurs on only one side of your body

·       Sudden onset of severe headache

·       Trouble swallowing

·       Trouble with vision in one or both eyes

·       Loss of balance and coordination, dizziness

·       Trouble with language skills (reading, writing, speaking, understanding)

·       Nausea, vomiting

·       Apathy, sleepiness, lethargy, loss of consciousness, confusion, delirium

 

INVESTIGATION:

Diagnostic testing for ICH may include a CT scan. This type of test creates images of your brain, which can confirm bleeding, and also assess for other evidence of trauma to your head.

 

An MRI scan may help your doctor see your brain more clearly to better identify the cause of the bleeding. An angiogram uses X-ray technology to take pictures of blood flow within an artery, and can reveal any abnormalities with the blood vessels themselves, such as aneurysms or arteriovenous malformations.

 

Blood tests can identify immune system disorders, inflammation, and blood clotting problems that can cause bleeding in your brain.

 

Computed tomography CT is the mainstay for urgent investigation of suspected intracranial pathology, especially if haemorrhage is suspected. It is always prudent to limit the amount of ionizing radiation received during pregnancy; however, it is estimated that a non-contrast head CT results in shielded fetal radiation exposure of less than 0.005 mGy. This is far less than the 100 mGy generally considered the threshold for the development of fetal malformations from radiation exposure. The incidence of adverse fetal effect with contrast media appears low, although there is a small risk of neonatal hypothyroidism as iodine-based contrast media may cross the placenta. CT is the preferred investigation for detection of acute ICH; it is also superior to MRI for non-invasive arteriography and venography.

 

Fig. 3: Non contrast computed tomography demonstrating left putaminal hemorrhage (arrow)

 

Magnetic resonance imaging MRI has been used in fetal diagnosis for over 25 years and its safety is well established. MRI also has a greater sensitivity than CT in demonstrating non-acute haemorrhage. Given the fact that there is no ionizing radiation, this modality may be superior to CT when repeated surveillance of a previously detected ICH is required.

Digital subtraction angiography DSA is a sensitive and specific test for cerebral aneurysms; however, radiation doses from DSA are appreciably higher than from CT. Feygelman estimates up to 3.6 mSv cranial exposure with angiography, a value 5–8 fold higher than that for CT; it follows that fetal exposure would still be less than 0.025 mGy. Thus ionizing radiation exposure to the fetus is minimal in the investigation of ICH and its endovascular treatment, if applicable.

 

TREATMENT:

The management principles for ICH are similar in pregnant and non-pregnant patients. After resuscitation, the first priority is the evacuation of any haemorrhage causing critical mass effect; the next priority is to investigate and address the underlying source of the haemorrhage such as aneurysm or AVM. Attention then turns to preventing further haemorrhage. It is important that management of these patients takes place in facilities where there is appropriate neurosurgical, obstetric, neurological and neuro radiological expertise. In the event that surgery is undertaken, precautions related to the pregnancy should be followed.

 

In some centres it might be considered appropriate to manage certain patients in a stroke unit, although generally the management of acute haemorrhage is reserved for the neurosurgical and intensive care units. The multidisciplinary care provided in a stroke unit does produce better outcomes for the rehabilitation phase after stroke, so where possible patients should be managed in such units after the acute phase has resolved.

 

Operative considerations:

Inferior vena cava compression in the supine position may be significant after 24 weeks pregnancy. During surgery, the woman's trunk should therefore be positioned in a partial left lateral position where possible.

 

Hypothermia as a neuro protective strategy has been a traditional neuro anaesthetic adjunct in some centres when treating aneurysms and AVMs. This generally serves to decrease CBF and metabolic requirements. Moderate hypothermia (30–32°C) reduces fetal heart rate by up to 25%. There is concern that placental oxygen transfer is less efficient at low temperatures and uterine contractions may be provoked. In a retrospective review of cardiopulmonary bypass in pregnancy, fetal mortality was substantially increased when hypothermia was used. Recent evidence suggests that any benefit from hypothermia for aneurysm surgery is slender, if present at all; thus, it is recommended that hypothermia be avoided for all neurosurgical procedures in pregnancy.

 

Hypotension is sometimes used during the surgical approach to aneurysms in order to reduce the risk of intra-operative rupture. It is also commonly used in AVM surgery. Sodium nitroprusside has been associated with high fetal cyanide levels; hypotension also has a deleterious effect on uterine and placental perfusion and may lead to fetal anoxia. It is preferable to use temporary proximal clipping as an alternative method of softening the aneurysm as this does not affect the placental and fetal circulations.

 

Diuretic agents such as mannitol or frusemide are generally used to reduce intracranial tension and improve operative conditions. However, their use may result in significant negative fluid shifts affecting both mother and fetus, which may result in hypotension and placental hypoperfusion.

 

Neostigmine may be used for the reversal of muscle relaxants in neurosurgery. Glycopyrrolate or atropine is often given with neostigmine in order to block its muscarinic effects; glycopyrrolate does not cross the placenta whereas neostigmine does. Profound fetal bradycardia has occurred where glycopyrrolate has been given instead of atropine. Atropine should therefore be used in preference to glycopyrrolate when using neostigmine.

 

Hyperventilation is often used during neurosurgery to produce hypocarbia, which causes vasoconstriction, reduction of intracranial blood volume, and reduced intracranial pressure. In pregnant patients, this may lead to decreased placental oxygen transfer; however, this should not be significant with mild hyperventilation (partial pressure CO2 of 30–35 mmHg). Profound hypocarbia should be avoided.

 

Pharmacology:

A number of medications may be routinely administered to patients undergoing urgent surgery for ICH. These may include anticonvulsants, calcium channel antagonists or osmotic diuretics. Steroids are not routinely used in the management of ICH.

 

Anticonvulsants:

Phenytoin is commonly administered to neurosurgical patients yet its deleterious effects in pregnancy. The cluster of abnormalities includes microcephaly, craniofacial abnormalities, distal phalangeal hypoplasia and developmental delay. Similar abnormalities have been seen with barbiturate use. Neural tube defects have been observed with sodium valproate. Carbamazepine may have the least risk of teratogenicity, but it is not commonly used in acute neurosurgical practice because of the lack of an intravenous preparation.

 

Calcium channel antagonists:

Nimodipine is used commonly after aneurysmal SAH. It has been shown in some randomized trials to improve outcome in this situation. Nimodipine has been shown to be teratogenic in animals, yet a prospective, multicentre study of exposure of calcium channel antagonists in the first trimester of pregnancy showed no increase in the risk of major congenital malformations, and nifedipine and amlodipine are commonly used in pregnancy to treat hypertension without any evidence to suggest detrimental fetal effects. Although it is recommended by some to give nimodipine routinely for all expectant women with SAH, it would be nonetheless prudent to give nimodipine only to those patients with a large volume of subarachnoid blood, who are at high risk of vasospasm. In these patients, careful haemodynamic monitoring is necessary to ensure that hypotension does not jeopardize placental perfusion.

 

COMPLICATION:

Depending on the location of the hemorrhage and how long your brain was without oxygen, complications may include:

·       Impaired language skills

·       Fatigue

·       Problems with swallowing

·       Vision loss

·       Difficulty with sensations or movements on one side of the body

·       Pneumonia

·       Cognitive dysfunction (memory loss, difficulty reasoning), confusion

·       Swelling on the brain

·       Seizures

·       Depression, emotional problems

·       Fever

 

CONCLUSION:

ICH, although rare, is an important cause of morbidity and mortality in pregnancy. Treatment decisions should be based on the same principles as those for non-pregnant patients with awareness of the influence that pregnancy has on certain conditions.

 

ACKNOWLEDGEMENT:

I would like to thanks my parents to dr. neeraj bausker (residence medical officer) suretech hospital.

 

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Received on 07.06.2020          Modified on 29.07.2020

Accepted on 07.09.2020        © AandV Publications all right reserved

Int. J. Nur. Edu. and Research. 2020; 8(4):559-563.

DOI: 10.5958/2454-2660.2020.00123.4