Maternal Aneurysmal Subarachnoid Hemorrhage During Pregnancy as an Interdisciplinary Task

Abstract

Maternal aneurysmal subarachnoid hemorrhage (aSAH) during pregnancy presents a challenge regarding treatment and management. Due to the limited number of cases there are no treatment guidelines available. Thus, treatment is usually done on a case-by-case basis. Here we report on four cases of aSAH during pregnancy, describing the different management strategies and suggesting a possible treatment algorithm. Patients treated between 2003 and 2013 in our center were included in this retrospective study. Clinical data focused on time management concerning gestation week (GW), microsurgical or endovascular treatment, and outcome of the patients and the fetuses. Results were compared to the present literature on this issue. Mean age was 30.8 years, initial Hunt & Hess (H&H) grade ranged from III to V. All patients suffered from aSAH during the 3rd trimester of pregnancy. In the four cases, two emergency Caesarean sections (CS) were performed. Two aneurysms were occluded by microsurgical clipping and one was treated endovascularly. One patient died before definitive treatment of the aneurysm could be achieved, whereas fetal mortality was 0%. The mean follow-up was 83 months. aSAH during pregnancy needs individualized interdisciplinary management. Efforts must focus on the mother so that a delay in the best available treatment for the pregnant patient is avoided. Therefore treatment modality should be primarily determined by the aneurysm itself. However, timing in terms of delivery of the fetus and aneurysm treatment is a crucial point.

Zusammenfassung

Die maternale aneurysmatische Subarachnoidalblutung (aSAB) während der Schwangerschaft bedeutet eine besondere Herausforderung hinsichtlich Behandlung und zeitlichen Managements. Aufgrund geringer Fallzahlen in der Literatur existieren keine standardisierten Behandlungsrichtlinien. Anhand von 4 Patientenfällen und der Darlegung der verschiedenen Behandlungsstrategien möchten wir einen neuen Algorithmus zur Behandlung schwangerer Patienten mit aSAB vorstellen. Es wurden Daten zwischen den Jahren 2003 und 2013 erhoben und hinsichtlich des zeitlichen Managements bezüglich Diagnostik und Therapie in Abhängigkeit von der Schwangerschaftswoche restropektiv analysiert. Die Art der Aneurysma-Behandlung, das Outcome der Patientinnen und der Neugeborenen wurde ausgewertet und mit der aktuellen Literatur verglichen. Das mittlere Alter lag bei 30,8 Jahren, der initiale Hunt & Hess Grad reichte von III bis V. Alle Schwangerschaften befanden sich im 3. Trimenon. Es erfolgten 2 notfallmäßige Kaiserschnitte. In 2 Fällen erfolgte ein mikrochirurgisches Clipping, eine Patientin wurde endovaskulär versorgt und eine verstarb vor der endgültigen Aneurysmaversorgung. Die fetale Mortalität lag bei 0%. Die Subarachnoidalblutung während der Schwangerschaft bedarf eines interdisziplinären und individualisierten Therapiemanagements. Die therapeutischen Anstrengungen müssen die Mutter als Patientin im Fokus haben und jede Verzögerung in Diagnostik und Therapie unbedingt vermeiden. Das zeitliche Management einer eventuell notwendigen verfrühten Geburt im Hinblick auf die Aneurysmaversorgung spielt hierbei eine wesentliche Rolle.

Key words

subarachnoid hemorrhage - pregnancy - aneurysm - Glasgow Outcome Scale (GOS)

Schlüsselwörter

Subarachnoidalblutung - Schwangerschaft - Aneurysma - Glasgow Outcome Scale (GOS)

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