Neuroanesthesia for the Pregnant Woman

Abstract

Neuroanesthesia for the pregnant patient is required infrequently, and evidence-based recommendations for neuroanesthetic management are sparse. We present a framework for a practical approach to anesthesia of the pregnant patient with subarachnoid or intracerebral hemorrhage, intracranial tumor, traumatic brain injury, spinal tumor, or spinal injury. The importance of a team-approach is emphasized. The anesthesiologist may have to anesthetize the pregnant patient for neurosurgery well before delivery, for cesarean delivery at the time of the neurosurgical procedure, or for delivery after neurosurgery. These scenarios are discussed along with fetal safety and anesthetic considerations for interventional neuroradiology.

Anesthetic management of labor and delivery in patients with elevated intracranial pressure

“…47 Loss of CSF secondary to dural puncture may increase the pressure gradient between the supratentorial and infratentorial compartments, resulting in rapid brain stem herniation or intracranial hemorrhage. 48 The use of narrow gauge needles (25-gauge or smaller) significantly decreases, but does not eliminate, the risk of complications from dural puncture. 49 Epidural anesthesia potentially may be hazardous in patients with increased ICP.…”

“…51 Patients may be at increased risk for developing a subdural hematoma due to acute CSF changes. 48 If epidural anesthesia is utilized, slow injection of incremental volumes is strongly recommended.…”

“…Rocuronium 1.2 mg/kg may be a better alternative in terms of ICP to succinylcholine. 48 Both succinylcholine and rocuronium provide excellent intubating conditions during a rapid-sequence induction. A 2008 Cochrane review of 37 studies comparing the intubating conditions achieved with succinylcholine using at least 1 mg/kg and rocuronium 1.2 mg/ kg during rapid-sequence induction and intubation found no significant difference between the two drugs.…”

“…Utilizing lower tidal volumes during mechanical ventilation minimizes changes in intrathoracic pressure and subsequent increases in ICP. 48 The effect of positive end-expiratory pressure (PEEP) on ICP and CPP is controversial. One non-obstetric study demonstrated a significant increase in ICP as PEEP was incrementally increased from 5 cmH 2 O to 15 cmH 2 O.…”

“…113 Ventilation increases as part of the physiologic changes of pregnancy, and normal steady-state PaCO 2 in the full term parturient is 30-32 mmHg. 48 Additional hyperventilation could have detrimental effects on the fetus. Hyperventilation to a PaCO 2 <25 mmHg can cause uterine artery vasoconstriction and a left shift of the maternal oxyhemoglobin dissociation curve.…”