N e u ro l o g i c C o m p l i c a t i o n s

in Pregnancy
a b,
Mauricio Ruiz Cuero, MD , Panayiotis N. Varelas, MD, PhD *

KEYWORDS
 Pregnancy  Stroke  Eclampsia  Status epilepticus  Brain death

KEY POINTS
 This article discusses the neurologic complications during pregnancy.
 This article analyzes and summarizes the most recent data about stroke, eclampsia, status
epilepticus, neuromuscular disease, and brain death during pregnancy.
 This article emphasizes the physiopathology, epidemiology, and modality of treatments of
the previously mentioned conditions.

INTRODUCTION

Obstetric practice occasionally mandates for admission of unstable patients to

an intensive care unit. The reasons why such patients become critical can either be
linked directly to the physiologic changes that occur during pregnancy and the puer-
perium or can be independent and coincidental. Because of its complexity and impor-
tance for the functional outcome of the mother, the nervous system, if affected,
requires specialized management that in the past was offered by consulting services
in neurology or neurosurgery. These days it may be better delivered by a team that in-
cludes neurointensivists and obstetricians in the neurosciences intensive care unit
(NSU).

PREECLAMPSIA-ECLAMPSIA

Preeclampsia (PREC) is defined as the constellation of newly diagnosed hypertension

(systolic/diastolic blood pressure [BP] 140/90 mm Hg on 2 occasions at least 4 hours
apart after 20 weeks’ gestation in a woman with previously normal BP; or BP 160/
110 mm Hg, confirmed within a few minutes to facilitate timely antihypertensive

Disclosures: The authors have nothing to disclose.

a
Neurocritical Care, Henry Ford Hospital, 2799 West Grand Boulevard, Detroit, MI 48202, USA;
b
Neurosciences Critical Care Services, Neuro-Intensive Care Unit, Department of Neurology,
Henry Ford Hospital, Wayne State University, K-11, 2799 West Grand Boulevard, Detroit, MI
48202, USA
* Corresponding author.
E-mail address: [email protected]

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2 Cuero & Varelas

treatment) and proteinuria (>300 mg/24 h or 11 in dipstick testing; because of vari-
ability of qualitative determinations, this method is discouraged for diagnostic use
unless other approaches are not readily available1; or protein/creatinine ratio 0.3).
Alternatively, in the absence of proteinuria, it is defined by the presence of new onset
of hypertension, as described earlier, with new onset of any of the following: serum
creatinine level greater than 1.1 mg/dL or a doubling of the serum creatinine level in
the absence of other renal disease, new onset of cerebral or visual symptoms, right
upper quadrant or epigastric pain, pulmonary edema, thrombocytopenia less
than,100,000/mL, or increased aspartate aminotransferase (AST) or alanine amino-
transferase (ALT) level (to twice the normal concentration).1 These systemic organ
dysfunctions together with BP greater than or equal to 160/110 mm Hg should be
considered severe features of PREC. Eclampsia (EC) is defined as seizures occurring
before, during, or after delivery, and in up to 38% of cases it can occur without symp-
toms or signs of PREC.1,2

Epidemiology and Pathophysiology

In the developed world the incidence for PREC is 6% to 8% of pregnancies and for EC
1 in 2000 deliveries, although in the developing countries the numbers are much
higher. EC confers a 1.8% maternal mortality and a 35% complication rate and in
the United States ranks second only to embolic events as cause of maternal mortal-
ity.3 PREC and its sequelae account for 20% to 50% of obstetric admissions to the
NSU.4
The cause of PREC-EC is unknown. Pathophysiologic changes in the placental
circulation, such as alteration of the ratio of prostacyclin/thromboxane/Flt-1, platelet
activation/aggregation, and endothelial damage with fibrin deposition, lead to placental
ischemia, diffuse maternal vasospasm, and microangiopathy.5 The cerebral features
include disruption of the capillary tight junctions and extravasation of fluids into the
perivascular spaces, white matter edema, and cortical microhemorrhages or macrohe-
morrhages. Areas of infarction or ischemia are common, and are usually seen in the
parieto-occipital watershed zones.6,7 Because EC may develop at BPs that are consid-
erably lower than those reported with hypertensive encephalopathy, a shift of the ce-
rebral autoregulatory curve to the left or a reduced shift to the right, or loss of
autoregulation with development of hydrostatic-vasogenic cerebral edema as a result
of brain hyperperfusion at less than the necessary cerebral perfusion pressures, has
been postulated.8

Clinical Presentation
Seizures are the hallmark of EC. They usually occur before childbirth or during labor,
but in some women they occur as late as 10 to 23 days postpartum.3 After the first
48 hours postpartum, clinicians should look for another cause, because only 3% of
women experience late seizures from EC.9 Seizures are usually generalized tonic-
clonic, but occasionally may have a focal onset.10 Headache, visual hallucinations,
photophobia, confusion, and coma are other symptoms associated with EC.

Radiographic Features
In most EC cases computed tomography (CT) of the head is normal,11 but in some it
reveals focal lesions, such as cerebral edema, subarachnoid hemorrhage (SAH) or
intraparenchymal hemorrhage, or, in patients with cortical blindness, occipital sym-
metric hypodensities.6,12 MRI may show reversible low-signal intensities in T1 and
high-signal intensities in T2-weighted images (with high apparent diffusion coefficient;
ie, without diffusion restriction).13
 Neurologic Complications in Pregnancy 3

Management
Management of patients with EC includes treatment of seizures and prevention of their
recurrence, control of hypertension, timely delivery of the infant, and avoidance of
further complications. Magnesium remains the cornerstone of treatment. One large
international study of 10,141 pregnant women treated for PREC showed that Mg11
treatment conferred a 58% lower risk of EC, 33% lower risk for placental abruption,
and a trend toward lower maternal mortality.14 Superior Mg11 effectiveness in pre-
venting and treating seizures in pregnant women has also been shown in 2 large
randomized studies, comparing it with diazepam and phenytoin.15,16 In addition,
Mg11 was more effective than nimodipine for prophylaxis against seizures in women
with severe PREC.17
Although several Mg11 treatment protocols exist, the one that is most commonly
used in EC is a 4-g to 6-g intravenous (IV) bolus over 15 minutes, followed by 1 to
3 g/h IV infusion for at least 48 hours postpartum. If the treatment is used prophylac-
tically in PREC, it can be stopped after 24 hours.18 Careful monitoring for potential
Mg11 toxicity should be done, preferably in an NSU setting. Loss of patellar reflexes,
increasing drowsiness and dysarthria, muscle weakness, and respiratory depression,
all should prompt for Mg11 level measurement, discontinuation of the infusion (ther-
apeutic levels, 4–8 mEq/L) and use of calcium gluconate (1 g IV in 10% solution) in
case of impending respiratory arrest. If seizures recur after Mg11 is given, either an
extra 1 to 2g IV16 or a loading dose of phenytoin (18 mg/kg IV at a maximum rate
50 mg/min) can be tried.

Blood pressure and volume control

The aim in BP control is not to normalize it but to bring it to a level of 140 to 150 mm Hg
systolic and 90 to 100 mm Hg diastolic.19 First-line therapies are IV hydralazine and
labetalol, as well as oral nifedipine. Hydralazine has been successfully used in patients
with PREC/EC as a 5-mg to 10-mg IV dose, which can be repeated every 20 minutes
(as 10 mg, then 20 mg) and, if there is no appropriate response, followed by labetalol
40 mg IV in 10 minutes. If there is a response, the dose can be repeated every 6 hours.
Labetalol can also be used, at a 20-mg IV dose, which can be repeated as a doubled
dose (40 mg, then 80 mg) in 10-minute intervals and, if no appropriate response, fol-
lowed by hydralazine 10 mg IV. Nifedipine can also be given as 10 mg by mouth and
repeated as a 20 mg dose by mouth every 20 minutes, times 2 (if no appropriate
response, then 40 mg IV labetalol is recommended). Specific order sets are provided
in the most recent guidelines from the American College of Obstetricians and Gynecol-
ogists.19 The dose of the antihypertensive medications is lowered after delivery and in
most cases the drugs can be stopped within the first 6 weeks postpartum.18 Ketan-
serin, a selective serotonin-2 receptor blocker, is considered inferior to hydralazine
at reducing very high BP during pregnancy.20 Angiotensin-converting enzyme inhibi-
tors and angiotensin II receptor blockers should be avoided in PREC and EC.21,22
Volume status of patients with EC should be carefully assessed. Total fluid intake
should not exceed 80 mL/h22 and central venous pressure kept at less than 5 mm
Hg,18 because of a higher risk for pulmonary edema.

Intracranial dynamics
Cerebral edema and increased intracranial pressure management are not different
from those for nonpregnant women. Adequate oxygenation, hyperventilation,
mannitol infusion, loop diuretics, and correction of hyponatremia are general mea-
sures that can be taken, although their role in EC has not been tested in controlled
studies.11,23 Mannitol use during pregnancy should be judicious (US Food and Drug
4 Cuero & Varelas

Administration [FDA] category C medication). The same is true for loop diuretics, like
furosemide. In serious or life-threatening situations during pregnancy, both drugs can
be used.24 We suggest that mannitol be used at 0.25 to 0.5 g/kg of prepregnancy
maternal weight every 4 to 6 hours IV in such cases.
Termination of pregnancy
The time of delivery is decided by obstetricians. Patients should be hemodynamically
stable and seizure free. The risk of prematurity should weigh against the risks for intra-
uterine growth restriction for the fetus and continuation of the eclamptic process for
the mother. If the BP is controlled, pregnancy can be extended by an average of
2 weeks.25 Maternal and fetal guidelines for expedited delivery or conservative man-
agement of severe PREC remote from term have been previously published.1,26,27

HEMOLYSIS, ELEVATED LIVER ENZYME LEVELS, AND LOW PLATELET LEVELS

SYNDROME

The hemolysis, increased liver enzyme levels, and low platelet levels syndrome is a
laboratory defined severe form of PREC. The acronym stands for hemolysis (anemia,
increased bilirubin level, schistocytes in blood smear), increased liver enzyme levels
(AST or ALT >70 U/L), and low platelet levels (<100,000/mm3). It is associated with
poor maternal (0%–24%) and perinatal (8%–60%) mortality caused by multisystem
involvement. The incidence has been reported as 4% to 12% of patients with severe
PREC, with higher risk in white, older patients.28

Pathophysiology and Clinical Features

Fibrin capillary deposition, organ hypoperfusion, microangiopathic hemolysis, and
consumptive thrombocytopenia are the pathophysiologic mechanisms. Clinically, it
presents as severe PREC with nausea, vomiting, and right upper quadrant pain.
Hepatic hypoperfusion may lead to periportal and focal parenchymal necrosis, sub-
capsular hemorrhage, or hepatic rupture. Other complications include acute renal fail-
ure, adult respiratory distress syndrome, hypoglycemia, hyponatremia, diabetes
insipidus, and organ hemorrhage (intracerebral, intraventricular, and retinal).29–31
Ischemic cerebellar strokes have also been reported.32,33 Cerebral angiography or
transcranial Doppler may reveal diffuse vasospasm.29

Management
The treatment is similar to that of PREC, with prophylactic Mg11 sulfate infusion, anti-
hypertensive therapy, and early delivery, as well as platelet and fresh frozen plasma
(FFP) transfusions. Plasma exchange with FFP has been successfully used when
thrombocytopenia, hemolysis, and organ dysfunction have persisted for greater
than 72 hours postpartum.34
Dexamethasone leads to significantly shorter hospital length of stay, reduced mean
interval to delivery, and greater mean birth weight. It was also significantly better than
betamethasone for mean arterial pressure, platelet count, urinary output increase, and
liver enzyme level increases.35 Dexamethasone is administered as 10 mg IV every 6
hours for 2 doses, followed by 6 mg every 6 hours for another 2 doses. For more se-
vere disease, the dose can be increased to 20 mg IV every 6 hours for 4 doses.28

MYASTHENIA GRAVIS

Myasthenia gravis (MG) is an autoimmune disorder of the neuromuscular junction,

commonly affecting women in their third decade of life, who are of childbearing age.36
 Neurologic Complications in Pregnancy 5

Clinical Course
The course of MG during pregnancy is at best unpredictable, with 10% to 19% of
patients experiencing clinical worsening and most remaining stable or improving
(59% and 22% respectively).37,38 No correlation has been reported between the
severity of MG before pregnancy and the risk for exacerbation during gestation. The
highest risk for maternal mortality and clinical deterioration is within the first year after
diagnosis, therefore women may consider delaying their pregnancies for at least 1 to
2 years after been diagnosed.39 The first trimester and the puerperium are periods of
MG exacerbation.37,38
MG may also affect the outcome of the fetus. Maternal antibodies crossing the
placenta block the function of the fetal nicotinic acetylcholine receptor isoform, lead-
ing to arthrogryposis multiplex congenita, or more commonly to transient neonatal MG
in 10% to 20% of infants.40

Management
The overall management of patients with MG should not change during pregnancy.
However, vigilance is appropriate, because one or more complications occur during
pregnancy in 21%, or during delivery in 41%, of patients.38 Approximately 20% of
patients develop respiratory crisis requiring mechanical ventilation caused by a com-
bination of respiratory muscle weakness and decreased ability of the lungs to inflate
fully secondary to the growing fetus. Acetylcholinesterase inhibitors, such as neostig-
mine 15 to 30 mg by mouth every 4 to 6 hours and pyridostigmine 30 to 60 mg by
mouth 4 to 5 times daily remain the mainstay of treatment. Corticosteroids (predni-
sone, 40–80 mg by mouth daily) should be continued if they were started before
conception.41 There is only a slight increased risk for cleft lip and palate if taken during
the first trimester and at high dose, and an increased risk of premature rupture of
membranes and infectious complications.36 Azathioprine, an FDA category D drug,
is associated with teratogenicity in animals and, rarely, of malformations in humans.37
A reasonable approach may be to delay the pregnancy until MG improvement permits
reduction or discontinuation of this drug.38 Methotrexate should be avoided during
pregnancy because of a high risk for fetal abnormalities.36 Thymectomy, performed
before pregnancy, seems to correlate with a better course during subsequent
pregnancy.42 Plasmapheresis (PLA) and IV immunoglobulin (IVIG) are effective treat-
ments in MG crisis43–45 and can be used in pregnancy, either alone or sequentially.37
PLA may carry a risk for premature labor because of large hormonal shifts and should
be reserved for treatment of myasthenic crises.
Myasthenic crisis is usually caused by severe dysphagia and aspiration. It can be
subtle and may be missed initially if arterial gases and pulmonary function tests are
not done. PaO2 (arterial partial pressure of O2) less than 60 mm Hg and PaCO2 (arterial
partial pressure of CO2) 45 to 50 mm Hg, vital capacity less than 15 mL/kg, and nega-
tive inspiratory force less than 25 cm H2O are indications for elective intubation and
positive pressure ventilation. Tracheostomy is performed if the patient requires naso-
tracheal or orotracheal intubation for more than 2 weeks, but by that time greater than
50% of myasthenics are extubated.46
The striated muscles of the pelvic floor are involved and may fatigue during the
expulsive efforts of the second stage of labor. Careful monitoring of the respiratory
function during labor for signs of fatigue and hypoventilation, as well as parenteral
administration of medications, is also recommended.40 Outlet forceps or vacuum
extraction should be used. In one study, cesarean sections were performed more
frequently in women with MG.47
6 Cuero & Varelas

GUILLAIN-BARRÉ SYNDROME

Guillain-Barré syndrome (GBS), or acute inflammatory demyelinating polyradiculo-

neuropathy (AIDP), is the most common cause of acute neuromuscular generalized
paralysis. The diagnosis is made when there is progressive areflexic weakness (usually
starting in the lower extremities), preceded in 50% of patients by back pain or leg par-
esthesias. Increased protein levels without cells in the cerebrospinal fluid (after the first
week), prolonged distal latencies, and F-waves and antiganglioside antibodies
strengthen the diagnosis.48,49
Epidemiology
The incidence of AIDP is approximately 0.75 to 2 in 100,000 per year and increases
with age. Lower risk for GBS during pregnancy has been reported in a Swedish popu-
lation (relative risk [RR], 0.86; 95% confidence interval [CI], 0.4–1.84).50 However,
nearly all of these cases occur in the second or third trimesters, but increased risk
was also found during the 30 and 90 days postpartum (RR [95%CI], 2.21 [0.55–8.94]
and 1.47 [0.54–3.99], respectively), suggesting a putative hormonal role.50 Fetal sur-
vival is close to 96%, but premature delivery is common in severe GBS cases. Unlike
MG, there is no GBS involvement of the fetus or neonate, except for 1 reported case.51
In a review of 30 cases, 33% of patients required ventilatory support, but none died.52
Management
The management of GBS in pregnancy should be done in an NSU and is similar to that
in nonpregnant patients. It is mainly supportive care until the patient regains her
strength, with the addition of treatments that may change the natural course of the dis-
ease. These include PLA or IVIG, but pregnancy was an exclusion criterion for enroll-
ment in the largest randomized studies.53,54 Therefore, data during pregnancy are
derived from case reports. GBS in pregnancy has been successfully treated with
IVIG alone within 2 weeks from the onset of symptoms (0.4 g/kg/d for 5 days),55–58
PLA alone (200–250 mL/kg over 4–6 sessions, up to a maximum of 402 mL/kg over
4 weeks),59,60 or with a combination of IVIG-PLA (with PLA preceding).51,61,62
Close monitoring of the respiratory function with assessment of forced vital capacity
(FVC) and the ability to cough and protect the airway is highly recommended in
patients with GBS. The signs of respiratory failure are more insidious than in MG,
because patients with autonomic dysfunction of the vagus nerve may lack the psycho-
logical feeling of breathlessness. If FVC is less than 1.5 L, the patient should be
admitted to the NSU, and if less than 15 mL/kg, the patient should be intubated and
mechanically ventilated. Another reason for NSU admission is dysautonomia. A tem-
porary cardiac pacer is indicated in cases of bradyarrhythmia (usually after vagal stim-
ulation following tracheal suction).
The risk of deep vein thrombosis and pulmonary embolism in patients with GBS has
been estimated as between 2% and 13%.63,64 The risk for venous thromboembolism
among pregnant or postpartum women is 4.29 times higher than for nonpregnant
women.65–67 There is no reported estimate for when GBS and pregnancy coexist,
but it may be inferred that it is even higher. Thus, pregnant patients with GBS should
be treated for potential thromboembolic disease, although the optimal treatment and
duration are unclear.

STROKE

Pregnancy is a physiologic state. However, it causes remodeling of the heart and all
blood vessels. In animal studies, the walls of systemic arteries have shown a reduction
 Neurologic Complications in Pregnancy 7

in collagen and elastin content as well as a loss of distensibility. These biomechanical

changes, along with the hemodynamic variation and changes in the levels of procoagu-
lant factors, coagulation inhibitors, and other mediators of clot formation and lysis, make
pregnancy a state of hypercoagulability. The incidence and the types of pregnancy-
associated strokes remain open to question. The risk of stroke seems to be higher during
the postpartum period. In the largest population-based study using the data of the
Nationwide Inpatient Sample between 2006 and 2007, the rate of any stroke among
antenatal hospitalizations was 0.22 per 1000 deliveries, 0.27 per 1000 deliveries for de-
livery hospitalizations, and 0.22 per 1000 deliveries among postpartum hospitalizations.
The risk of stroke increased with age more than 35 years and was associated with Afri-
can American race, migraine, thrombophilia or thrombocytopenia, systemic lupus ery-
thematosus, heart disease, sickle cell disease, baseline or gestational hypertension,
postpartum hemorrhage, PREC, transfusion, and postpartum infection.68
Specific pregnancy-related causes of stroke are presented in Box 1. The diagnostic
work-up of stroke in pregnancy is similar to that in nonpregnant women, with the
exception of radiological procedures and shielding for CT and angiography (first
trimester, and especially the first month).69,70

Ischemic Stroke
Most of the strokes in pregnancy are attributed to arterial occlusions and cardioembolic
events, which remain the most important cause.71 Levels of procoagulant factors I, VII,
VIII, IX, X, XII, and XIII increase during pregnancy, leading to a procoagulant state.
In addition, the levels of some coagulation inhibitors, like antithrombin III or protein S,
decrease during pregnancy, especially during the third trimester. Additional
pregnancy-associated causes of stroke include peripartum cardiomyopathy, choriocar-
cinoma, and embolization of amniotic fluid or air. The incidence of ischemic stroke has
been estimated at 3.5 per 100,000 per year72 or 4.3 to 26 per 100,000 deliveries in the
early 1990s.71
Although the frequency of the various causes of ischemic stroke is not known
(see Box 1), it is widely thought that EC remains one of the commonest mecha-
nisms, accounting for 24% to 47% of cases.73,74 Within this spectrum should be
included the posterior reversible encephalopathy syndrome (PRES) and the revers-
ible cerebral vasoconstriction syndrome (RCVS), which often overlaps with PRES or
EC and may also increase the risk for ischemic stroke and intracerebral hemor-
rhage (ICH).75 Choriocarcinoma, a trophoblastic tumor associated with molar preg-
nancy, metastasizes in 20% of cases to the brain. The malignant cells invade the
cerebral vessels, resulting either in local thrombosis and/or distal embolization or
pseudoaneurysm formation and intracranial bleeding. Markedly increased serum
beta–human chorionic gonadotrophin level is characteristic and measurement of
this should be included in the diagnostic work-up of stroke during pregnancy.76
Amniotic fluid embolism is a rare complication of labor in multiparous women, pre-
senting with respiratory failure or cardiogenic shock and leading to disseminated
intravascular coagulation (DIC). The neurologic symptoms consist mainly of
encephalopathy or seizures in 10% to 20% of cases. Paradoxic cerebral embolism
can also occur, the incidence of which is unknown. It can be diagnosed on
cytologic examination of pulmonary artery catheter samples.69,73 Other causes of
cardioembolic stroke include peripartum cardiomyopathy, a rare dilating cardiomy-
opathy within the last month of pregnancy or 5 months postpartum, leading to
stroke in 5% of cases. Anticoagulation is recommended. Another reason for
anticoagulation is cervical artery dissection, reported in 6% to 7% of cases of
pregnancy-related stroke. Antiphospholipid antibodies syndrome can lead to
8 Cuero & Varelas

Box 1
Causes of stroke during pregnancy

1. Ischemic
Watershed
Severe hypotension, Sheehan syndrome
EC
Choriocarcinoma
Angiopathies
Infectious: syphilis, borreliosis, tuberculosis, malaria, chlamydia pneumonia, herpes
zoster, mycoses
Inflammatory: collagen disorders, granulomatous angiitis of nervous system,
sarcoidosis, Takayasu
Noninflammatory: dissection, postpartum cerebral angiopathy, moyamoya,
fibromuscular dysplasia, atherosclerosis, subarachnoid hemorrhage, vascular
malformation
Hematologic diseases
Protein C, protein S, antithrombin III deficiency, factor V Leiden, homocystinuria,
paraneoplastic coagulopathy, disseminated intravascular coagulation, thrombotic
thrombocytopenic purpura, sickle cell disease, antiphospholipid antibodies, Sneddon
syndrome
Cardiac or pulmonary disorders
Infective or marantic endocarditis, atrial myxoma, fibroelastoma, rheumatic heart
disease, mitral valve prolapse, prosthetic valve, patent foramen ovale, amniotic fluid/
fat/air embolism, atrial septal aneurysm, atrial fibrillation, acute myocardial infarct,
dilated cardiomyopathy, peripartum cardiomyopathy, hereditary hemorrhagic
telangiectasia
Metabolic or channel dysfunction
Cerebral Autosomal Dominant Arteriopathy with Subcortical infarcts and
Leukoencephalopathy (CADASIL), migraine
Air, fat, amniotic fluid embolism
2. Intracerebral hemorrhage
EC, hypertension, cerebral venous and sinus thrombosis (discussed later), angiopathies
(see earlier), choriocarcinoma, arteriovenous malformation (AVM), aneurysm, bacterial
endocarditis, pituitary apoplexy, anticoagulation, cocaine abuse
3. Subarachnoid hemorrhage
Aneurysm, AVM, EC, angiopathies (see earlier), choriocarcinoma, cerebral venous and
sinus thrombosis (discussed later), bacterial endocarditis, pituitary apoplexy,
anticoagulation, cocaine abuse
4. Cerebral venous and sinus thrombosis
Hematologic diseases (see earlier), volume depletion, brain, sinus or mastoid infection, EC,
cesarean section

Data from Refs.24,69,124,125

transient ischemic attacks or true infarcts, also occur during pregnancy or the
puerperium, with or without the presence of a coexisting patent foramen ovale.77
Low-dose heparin combined with aspirin in women with at least 2 fetal losses is
recommended during pregnancy.69
The management of ischemic stroke during pregnancy requires admission to the
NSU. Fibrinolysis has been considered a relative contraindication during pregnancy,
but has been successfully used in 30 patients, 6 of whom received it intravenously
and the rest intra-arterially. Complication rates and outcomes for children did not
seem to be affected.78,79 Use of aspirin during the first trimester is controversial.
 Neurologic Complications in Pregnancy 9

However, low-dose aspirin (60–150 mg/d) during the second to third trimester was
safely used in the CLASP (Collaborative Low dose Aspirin Study in Pregnancy)
trial.69,80
Reported maternal mortality after ischemic stroke is 0% to 25% and one-third of
patients have modified Rankin Disability Score less than 3. The risk for recurrence
in subsequent pregnancies is estimated to be 2.3% within 5 years and is higher in pa-
tients with stroke of definite cause and during the postpartum period.81

Hemorrhagic Stroke
Hemorrhagic stroke is uncommon during pregnancy and the puerperium. The inci-
dence from 3 population-based series is 0 to 6 per 100,000.82 However, despite the
low absolute risk, pregnancy increases the risk for hemorrhagic stroke much more
than that for ischemic stroke. This risk increase is substantial during pregnancy (RR,
2.5) and peaks during the early postpartum period (RR, 28.5).74 The major established
causes of pregnancy-related cerebral hemorrhage are PREC/EC, followed by cerebral
arteriovenous malformations (AVMs) and aneurysms.
The incidence of SAH during pregnancy is estimated at 20 per 100,000 deliveries and
that of ICH at 4.6 to 6.1 per 100,000 deliveries. This incidence puts pregnant patients at
higher risk for both compared with the nonpregnant population in the same age range.
The most common nontraumatic causes of SAH in pregnancy are AVMs and
aneurysms in roughly equal proportions (see Box 1). The risk of aneurysmal rupture
seems to increase several fold during pregnancy, increasing with gestational age until
it peaks at 30 to 34 weeks. Dias and Sekhar83 reported the mortality of pregnancy-
associated aneurysmal SAH to be 35%, with a fetal mortality of 17%. In this retrospec-
tive study of 118 patients, 90% of aneurysmal bleeding occurred during pregnancy,
2% during labor, and 8% postpartum,83 although others may not share this
opinion.84,85
Causes of ICH during pregnancy included EC (44%), AVM, aneurysm, and
cavernous angioma (12.5% each) or were undetermined (19%) in a large retrospec-
tive study73 (see Box 1). In a US cohort, independent risk factors for pregnancy-
related ICH included advanced maternal age, African American race, preexisting
or gestational hypertension, PREC/EC, preexisting hypertension with superimposed
PREC/EC, coagulopathy, and tobacco abuse.86 AVMs are the most frequent cause
of intracranial bleeding during pregnancy, constituting 4% to 5% of all ICH causes in
nonpregnant women and up to 50% of ICHs in pregnant women.87 Six percent of
AVM-related ICH occurs during labor and 94% during pregnancy.83,87
The treatment of SAH or ICH is not different during pregnancy. Before and after
securing the aneurysm, those patients should stay in the NSU. Clipping of the aneurysm
can be achieved in any stage of pregnancy and is associated with lower maternal and
fetal mortality.69,83 Successful endovascular treatment with GDCs (Guglielmi Detach-
able Coils) has also been reported in a small number of patients,88–90 but concerns
have been raised regarding exposure to radiation and contrast (especially during the first
trimester), systemic anticoagulation necessity, and partial obliteration of the aneurysm
with subsequent need for follow-up angiographies.84,89 Vasospasm can be treated
with hypervolemia using crystalloids or colloids.91 Triple H therapy (hypertension, hyper-
volemia, and hemodilution) has been abandoned in more recent guidelines for nonpreg-
nant patients. Only hypertension is supported in those patients.92 Pressors should be
used with caution during pregnancy, because they diminish uteroplacental blood flow.
Nimodipine has been used during pregnancy, but probably should be avoided because
of teratogenic potential in animals.91 There are no reported cases of balloon angioplasty
for severe vasospasm after SAH, although it has been reported with EC-related
10 Cuero & Varelas

vasospasm93 and RCVS.94 Delivery is preferred after the aneurysm is secured. Treat-
ment at less than 24 weeks should be focused on the well-being of the mother. After
34 weeks, cesarean section followed by aneurysm exclusion may be preferred.
Between 24 and 34 weeks, aneurysm exclusion with simultaneous fetal monitoring
and, if needed, emergent cesarean section has been advocated. If, after treatment of
the aneurysm, pregnancy continues to term, vaginal delivery is preferable.91
The treatment of AVMs does not differ from that in nonpregnant women.69 In those
patients with high operative risk or inoperable lesions, conservative management
should be pursued during pregnancy, with stereotactic radiosurgery or embolization
as options after delivery. Cesarean section is preferred in these cases. In low-risk,
operable patients, surgery may improve the risks of poor outcome. The same can
be said for surgery in comatose patients with large hematomas.87
Intraventricular hemorrhage can be treated with external ventricular drainage. Bilat-
eral intraventricular thrombolysis with 5 mg/d of r-tPA (recombinant tissue Plasmin-
ogen Activator) in each side for 4 days has also been reported.95
SAH may result in 27% to 40% maternal mortality and may constitute the third most
common cause of nonobstetric death in pregnancy.69 The in-hospital mortality for
pregnancy-related ICH is 20.3%86 and the average maternal case-fatality rate can
reach 30%.96

Cerebral Sinus Thrombosis

Cerebral venous thrombosis (CST) accounts for 6% to 64% of all pregnancy-
associated strokes in large reported series.82,96
A high incidence of CST associated with pregnancy has been reported and is asso-
ciated with a hypercoagulable state in 64% of cases and in 73% it occurred post-
partum.97 It presents with headache and ICH, with focal neurologic signs or seizures.
CST occurs 1 to 4 weeks after childbirth and follows an otherwise normal delivery.
Postdelivery headache should not be automatically attributed to spinal anesthesia dur-
ing labor98 and prompt diagnosis of CST should be made by MRI/magnetic resonance
venography or CT venography.99 Homocystine levels should be measured, because
homocystinemia may be associated with peripartum CST.100 A more extensive hyper-
coagulability work-up is also optional (see Box 1).
IV heparin, fluid administration, antibiotics for infection, and measures to reduce the
increased intracranial pressure are all used in CST. Oral anticoagulation is usually
given for 6 months in those patients with idiopathic venous thrombosis and indefinitely
in those with a persistent or familial thrombophilic state. The risk for hemorrhagic con-
version has been used as the major argument against anticoagulation and the only
data from randomized studies are in nonpregnant populations.101,102 In an uncon-
trolled study, 24% of patients with CST complicating pregnancy who received heparin
died, compared with 45% of untreated patients. One fatal hemorrhage occurred in the
group with heparin.103 Combined intrathrombus r-tPA and IV heparin with good
outcomes has also been reported.104,105
Mortality from pregnancy-associate CST is 10% to 50%,99 with case-fatality rate in
the range of 4% to 36%.106

STATUS EPILEPTICUS

Most epileptic women have unchanged seizure frequency during pregnancy. Exacer-
bation of seizures can occur in 37% of pregnant epileptics.107 Status epilepticus (SE)
during pregnancy is rare. In a 1999 review of the English literature, 19 case reports
were identified. SE was previously experienced in only 3 of 19 women and occurred
 Neurologic Complications in Pregnancy 11

in the third trimester in 74% of cases.108 In a large prospective antiepileptic drugs and
pregnancy registry (EURAP [European Registry of Antiepileptic Drugs and
Pregnancy]), 36 of 1956 pregnancies developed SE (12 of them convulsive; 1.8%).
Thirteen occurred in the first, 11 in the second, and 13 in the third trimester (1 during
delivery). SE resulted in 1 stillbirth and no miscarriages or maternal deaths.109
If a nonepileptic pregnant woman develops new-onset seizures, EC should be
excluded in the third trimester and similar causes of seizures (tumor, stroke, central
nervous system infection, trauma, hypoglycemia), as in nonpregnant women, should
be sought.110 The most common cause is thought to be drug noncompliance (caused
by fear for teratogenicity) and changes in drug level. However, in the EURAP study, no
particular risk factor for SE was identified and antiepileptic drugs were either
unchanged since conception or the numbers or dosages were increased in 35 of 36
cases before developing SE.109 Increased plasma clearance of antiepileptic drugs
with advancing gestation has to be balanced against an increased ratio of unbound
free to total drug levels.111–113 Although acidosis and hypoxia from SE may double
maternal mortality, increase the risk for spontaneous abortion by 50%, and lead to
fetal or neonatal death in 48% of cases,112,114 more recent data showed that only 1
of 36 pregnancies complicated by SE ended with stillbirth and none was associated
with maternal mortality.109
The SE treatment algorithm does not differ from that in nonpregnant women115,116
and its goal is to stop the electrical and clinical seizure activity as soon as possible and
support the mother and fetus.117,118 Administration of IV antiepileptic drugs should not
be delayed, even during the embryogenesis period. Medications that are highly pro-
tein bound should initially be administered in lower dose to avoid toxic free drug
levels.119 Reduced loading doses of phenytoin are used (10–15 mg/kg), but eventually
full dosages can be given if seizures continue.115,116 Delivery should be started only for
obstetric reasons. The neonate should be supported in the neonatal intensive care unit
if benzodiazepines or barbiturates are given.

BRAIN DEATH

The criteria of diagnosing brain death during pregnancy do not differ from those for
nonpregnant women. However, there are several controversial ethical issues for sup-
porting the mother until or beyond the fetus is viable (24 weeks). Her right for auton-
omy should be balanced against fetal rights for survival. Her wishes and, if never
expressed, those of the next of kin, and particularly those of the biological father of
the fetus, should be respected.120
How often this catastrophic event happens is unknown. In a recent review, 30 cases
were reported between 1982 and 2010. The mean gestational age at the time of brain
death and the mean gestational age at delivery were 22 and 29.5 weeks, respectively.
Twelve viable infants were born and survived the neonatal period.121 Bernstein and
colleagues122 reported the case with the longest duration of post–brain death support,
which is also the one with the earliest gestational age when brain death occurred
(15 weeks’ gestation). She was supported for 107 days, when, because of fetal
distress, she delivered a 1550-g infant.
The myriad problems that should be addressed include continuous hemodynamic
support and monitoring; use of pressors (dobutamine, dopamine, or norepinephrine)
and IV fluids; left lateral recumbent position placement; monitoring of volume status
with Swan-Ganz catheterization; continuous ventilatory support, with a PaCO2 goal of
30 to 35 mm Hg; enteral or parenteral nutrition; tocolytic treatment, preferentially with
Mg11; physiologic vasopressin infusion rates for diabetes insipidus; hydrocortisone
12 Cuero & Varelas

and thyroxine replacement for panhypopituitarism; glucose monitoring and insulin-

need adjustments; treatment of infections; and rewarming of the frequently poikilo-
thermic mother. In addition, continuous fetal monitoring and psychological support
of the family and the medical and nursing staff involved in the care of a dead patient
used, in effect, as a fetal container120 or incubator123 is often needed during the pro-
longed NSU course.

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