Pregnancy with intracerebral haemorrhage, a rare life threatening complication

1. Spontaneous Intracerebral
Haemorrhage in Pregnancy
Dr Nupur Gupta
Dept of Obstetrics & Gynecology
Paras Hospital, Gurgaon
A Life Threatening Emergency

2. Case Report
• Primigravida at 38 weeks
• Unconscious state since >24 hours
• No headache, vomiting, pain abdomen, or
breathing difficulty
• Restless – altered sensorium

3. Case Report
• GPE & Systemic Examination
- P 82/min, BP 120/70, RR 20/min
- Temp 98.4
- Chest normal
- CVS S1 S2 normal
- Neurophysician - Pupil reactive, no neck rigidity
- PA uterus term, cephalic, regular fetal heart, uterus
relaxed

4. INVESTIGATIONS
• Routine
• 2D Echo - normal
• Fetal doppler - normal
• MRI Brain – suspicion of intraventricular
haemorrhage

5. MRI Brain

6. MRI Brain

7. DELIVERY
• Planned to deliver by Emergency Caesarean
• Male child
• Apgar 5,8,9
• Average weight 3 Kg
• Intubated

8. Post Delivery
• Post caesarean, shifted for DSA to rule out
AVM, cavernoma, aneurysm
• Cerebral Neuroangiography (DSA) – normal
intracranial circulation & dural sinuses

9. Neurosurgical Management
• Right pupillary dilatation – urgent CT scan
(hydrocephalus/herniation)
• Both pupils dilated – immediate EVD (external
ventricular drainage)
• Pupils started responding (4mm to 2.5 mm, reactive
to light)

10. Neurosurgical Management…..
• Shifted to ICU on ventilator
• M6, irritable (continued on ventilator)
• EVD removed on 5th Day (to avoid hydrocephalus)
• After 2 days in ICU – conscious, irrelevant talking
due to brain irritation & cerebellar signs (severe
headache)

11. Neurosurgical Management….
• Repeat CT scan – normal ventricles, repeat EVD
from the same burrhole
• Then she became M6, CSF culture (pseudomonas),
intraventricular & IV antibiotics
• Removed EVD after 3 days
• Sent home

12. Prognosis
• Infrequent complication of pregnancy and
puerperium
• Severe complication
• High mortality (in hospital 20%)
• Poor prognosis (morbidity & disability)

13. Incidence & Risk Factors in pregnancy
• 6 per 100,000 deliveries (12% of maternal deaths)
• Maximum risk – postpartum period
• Advanced maternal age, obesity
• Pre existing hypertension, diabetes
• Pre eclampsia, superimposed preeclampsia
• Gestational Hypertension, heart disease
• Coagulopathy
• Tobacco abuse

14. Pregnancy
• There is not enough information currently … to say that
healthy pregnancy by itself will increase the risk of
complication
• Pregnancy increases the likelihood of cerebral infarction
to about 13 times the rate expected outside of pregnancy.
• In most, it is uncertain whether pregnancy is coincidental
or plays a role in the occurrence of stroke

15. Postpartum – high risk
• large decrease in blood volume or
• the rapid changes in hormonal status that follow a
live birth or stillbirth,
Perhaps by means of hemodynamic, coagulative, or
vessel-wall changes.

16. Diagnosis – Clinical & MRI
• Sudden onset
• Intraventricular Haemorrhage - Neuro MRI Brain
D/D
• Aneurysmal SAH
• AVM Bleed
• Hypertensive Bleed

17. Pregnancy as a Risk Factor
• Severe thrombotic microangiopathy
• Brain ischaemia and hemorrhage
Whether hypercoagulable state and vessel wall changes
associated with pregnancy may play a role in the
occurrence of these otherwise unexplained ischemic
strokes remains unknown.

18. Pregnancy & Preeclampsia
• Systemic small artery spasms,
• vascular endothelial cell damage,
• increased brain capillary permeability
• plasma and red blood cells can leak into the
extravascular space in the brain and cause spotting.

19. • BP - damaging to vessel walls, & it increases
sharply when the pressure in the brain's
blood vessels increases, which can easily lead
to rupture & bleeding
• Multiple organ failure
• Concurrent cerebral haemorrhage might be
the end-stage manifestation of pre-
eclampsia, and the presence of clotting
during late pregnancy can lead to ICH
Pregnancy & Preeclampsia

20. Etiology of ICH
• AVM & aneurysm most common cause 41%
• Preeclampsia 20%
• Moya moya disease
• Cavernous angioma
• Cerebral venous sinus thrombosis
• Tumor
• Unknown (OUR PATIENT)

21. Principles of Management
• Emergency Delivery (POG) – Vaginal or
Caesarean
• DSA ( Neuroangiography) – to rule out
aneurysm or AVM
• Neurosurgical decompression
There are no clear guideline for medical
management of subarachnoid or ICH in pregnancy

22. Principles of Management
• Neuro ICU care
• Multidisciplinary Team of Obstetrician,
Neurophysician & Neurosurgeon, ICU physicians,
Interventional Neuroradiologist

23. Drugs to be utilized with caution in
pregnant women
• Mannitol may result in fetal hypoxia & acid-base
shifts,
• Antiepileptic drugs - teratogenic risk
• Nimodipine - teratogenicity in some animal
experiments,
• However, ultimately, the use of these agents in
critically ill pregnant patients may outweigh the
potential risks

24. Conclusion
• Early detection & diagnosis is the key (Improving
our knowledge)
• To ensure appropriate management and success
• Route of delivery, cesarean versus vaginal, does not
affect outcome in patients with a vascular anomaly

25. Prevention
• Whether pregnant or planning to become pregnant
— to take measures to prevent the health problems
commonly associated with stroke.
• Eat a low-fat, low-sodium, high-fiber diet
• Maintain a healthy weight

26. Prevention
• Stay physically active
• Don’t smoke
• Women suffering from heart disease or diabetes
should also begin treatment far in advance of
pregnancy,
• Even those carrying a little extra weight can be
proactive by “dropping a few pounds before
pregnancy”

27. EVIDENCE
• There are no follow-up studies that consider the risk of
recurrent stroke in future pregnancies.
• No data are available on the risk associated with use of
OCPs in a woman who had ischemic stroke during
pregnancy.
• The frequency of cerebral venous thrombosis
associated with pregnancy and the puerperium is not
precisely known.

28. EVIDENCE
• Indeed, epidemiologic studies have been difficult to
perform because cerebral venous thrombosis may
have a misleading presentation and a definite
diagnosis requires angiography, MRI or autopsy.
• Whether pregnancy increases the risk of rupture of
an arteriovenous malformation is controversial.

29. Risk for Stroke in Women (ASA)
• High blood pressure
• migraine with aura,
• diabetes,
• atrial fibrillation,
• depression and emotional stress
• Pregnancy – preeclampsia (twice the risk of stroke and four
times the risk of high blood pressure later in life.)

30. FUTURE
There are many gaps in our knowledge about
pregnancy-related stroke, including detailed
knowledge about mechanisms and outcomes post-
hospital discharge.

31. THANK YOU