Acute Intracranial Hypertension During Pregnancy: Special Considerations and Management Adjustments

Abstract

Pregnancy is associated with a number of pathophysiological changes (including modification of vascular resistance, increased vascular permeability, and coagulative disorders) that can lead to specific (eclampsia, preeclampsia) or not specific (intracranial hemorrhage) neurological complications. In addition to these disorders, pregnancy can affect numerous preexisting neurologic conditions, including epilepsy, brain tumors, and intracerebral bleeding from cerebral aneurysm or arteriovenous malformations. Intracranial complications related to pregnancy can expose patients to a high risk of intracranial hypertension (IHT). Unfortunately, at present, the therapeutic measures that are generally adopted for the control of elevated intracranial pressure (ICP) in the general population have not been examined in pregnant patients, and their efficacy and safety for the mother and the fetus is still unknown. In addition, no specific guidelines for the application of the staircase approach, including escalating treatments with increasing intensity of level, for the management of IHT exist for this population. Although some of basic measures can be considered safe even in pregnant patients (management of stable hemodynamic and respiratory function, optimization of systemic physiology), some other interventions, such as hyperventilation, osmotic therapy, hypothermia, barbiturates, and decompressive craniectomy, can lead to specific concerns for the safety of both mother and fetus. The aim of this review is to summarize the neurological pathophysiological changes occurring during pregnancy and explore the effects of the possible therapeutic interventions applied to the general population for the management of IHT during pregnancy, taking into consideration ethical and clinical concerns as well as the decision for the timing of treatment and delivery.

Pentobarbital Coma Use in a Pregnant Patient With Refractory Intracranial Hypertension

“…To our knowledge, there are no reported cases in the literature of pentobarbital coma for refractory intracranial hypertension in pregnant patients. 8 Major physiological changes during pregnancy include increased cardiac output and elevated intravascular volumes to facilitate placental and fetal perfusion. [9][10][11] Because barbiturates can cause hypotension, their use during pregnancy may affect fetal well-being.…”

Ten Rules for the Management of Moderate and Severe Traumatic Brain Injury During Pregnancy: An Expert Viewpoint

“…The aim of this review is to provide ten rules and suggestions to apply in the management of moderate to severe TBI in pregnant women, considering pathophysiological changes of pregnancy and differences of specific parameters—such as cerebral perfusion pressure (CPP) and carbon dioxide arterial pressure targets (PaCO 2 ) ( Figures 1A,B ) ( 9 ).…”

“…The first-line vasopressor is phenylephrine, an α-1 agonist that does not modify uterine tone. 0-negative blood type should be transfused in order to avoid Rh sensitization ( 9 , 24 ).…”

“…The gold standard for neuromonitoring in moderate to severe TBI is invasive ICP measurement obtained through a catheter insertion either into cerebral parenchyma or ventricles according to the clinical picture and center practice ( 56 , 57 ). Several studies conducted in acute TBI adult patients observed that IHT represents a risk factor for mortality or poor neurological outcome ( 9 ). Moreover, combining invasive ICP with advanced pressure of brain tissue oxygen (PbtO 2 ) monitoring may potentially improve patient outcome ( 58 ).…”

“…It is widely known that several physiological changes occur at many levels in the central nervous system during pregnancy. Although these adaptions act to preserve brain homeostasis, they can lead to neurological complications and IHT as a result of an exacerbated preexisting pathology or an unexpected acute event ( 9 ). Except for preeclampsia, head trauma is the most frequent cause of IHT during gestation ( 61 ).…”