The Risk of Aneurysmal Subarachnoid Hemorrhage During Pregnancy, Delivery, and the Puerperium in the Utrecht Population

Abstract

Background and Purpose-It is unclear whether the risk of aneurysmal subarachnoid hemorrhage (aSAH) is increased during pregnancy, labor, and the puerperium. We compared the risk of aSAH during this period with the risk outside this period. Methods-We included women with aSAH between 18 and 42 years of age (nϭ244) from our prospectively collected database of patients with subarachnoid hemorrhage treated in the University Medical Center Utrecht, the provincial referral center, between January 1987 and April 2006. We estimated the relative risk of aSAH during pregnancy, delivery, or the puerperium by a case-crossover design and calculated a standardized incidence ratio, dividing the observed number of patients with aSAH during pregnancy, delivery, or puerperium by the expected number based on the incidence in the general population of women of the same age during the study period. Results-Of the 244 women, 4 were pregnant, 3 in the puerperium and none in labor. The relative risk of aSAH during pregnancy, delivery, or the puerperium was 0.4 (95% CI, 0.2 to 0.9). Based on the number of women aged 18 to 42 years within the catchment area of our hospital and the number of pregnancies within the study period, the expected number of patients with aSAH during pregnancy, delivery, or the puerperium was 12, resulting in a standardized incidence ratio of 0.6 (95% CI, 0.2 to 1.1). Conclusions-The risk of aSAH is not increased during pregnancy, labor, and the puerperium. There is no need to advise against pregnancy in women with an increased risk of subarachnoid hemorrhage and no evidence to advise against vaginal delivery in such women.

Subarachnoid Hemorrhage from Posterior Cerebral Artery Aneurysm during Puerperium – Case Report and Review of Literature

“…Admittedly, in their analysis of the Utrecht population (n=244) Groenestege et al [4] found no increased risk for SAH during pregnancy, delivery and puerperium but in a nationwide epidemiological overview, de Swiet [5] correlated approx. 10% of all maternal deaths in the UK with spontaneous SAH [5] and Barno and Freeman [10] found 4.4 % of all maternal deaths between 1950 and 1973 in Minnesota directly linked to SAH.…”

“…In the Western world, maternal aneurismal subarachnoid hemorrhage (SAH) occurs in 8 -31 per 100,000 deliveries [4] and accounts for up to 10% of maternal deaths in pregnant women [5]. In an epidemiological survey Jung et al [1] investigated a history of hypertension and diabetes, a family history of stroke, smoking status and alcohol consumption as potential confounders of hemorrhagic stroke in 471 women with parity.…”

“…Particularly pregnant women, suffering from preeclampsia-eclampsia or cardiomyopathy are at high risk [3,6,7]. Some authors suggested transient degeneration and turnover of the vessel wall -presumably based on hormonal changes -in combination with postpartum or pregnancy-related hypertension as potential causes of aneurysm formation and rupture [1,2,4,6,7]. Due to our knowledge, spontaneous SAH due to an aneurysm of the quadrigeminal (P3-) segment of the Posterior Cerebral Artery (PCA) during puerperium has not been reported yet.…”

“…Due to our knowledge, spontaneous SAH due to an aneurysm of the quadrigeminal (P3-) segment of the Posterior Cerebral Artery (PCA) during puerperium has not been reported yet. Inoue et al [8] reported one case of SAH postpartum due to a dissecting aneurysm of the PCA in a young and healthy Asian woman that fully recovered [8] and Groenestege et al [4] described the rupture of a PCA aneurysm in a 32-year old healthy woman during the late-pregnancy, resulting in a fatal outcome.…”

Endovascular Treatment in Pregnancy

“…33,51) The increased cardiac output, increased circulatory volume, increased systemic blood pressure, and change of hormonal balance during pregnancy most probably contribute to the rapid growth of cerebral aneurysms during pregnancy, particularly in the 3rd trimester. While several reports have stated that the rate of aneurysm rupture is similar to that in the non-pregnant population, 48) it is necessary to check for possible growth of any known aneurysms.…”