Pregnancy and Cerebral Aneurysm: A Complex Medical Journey

Introduction

Subarachnoid hemorrhage (SAH) is a severe form of brain hemorrhage, where blood leaks into the space between the brain and its surrounding membranes. This condition is highly dangerous, often resulting from the rupture of a cerebral aneurysm, a weakened spot in the blood vessels of the brain. During pregnancy, the risk of developing a spontaneous SAH is five times higher compared to non-pregnant individuals. This elevated risk arises from the physiological changes that occur during pregnancy, particularly the increased cardiac output in the second and third trimesters. SAH occurs in approximately 1 per 10,000 pregnancies, presenting significant challenges for the medical teams involved.

This article focuses on the case of a 36-year-old woman treated at Sterling Hospital in Vadodara for a ruptured cerebral aneurysm. What makes this case unique is that the patient was 28 weeks pregnant with twins conceived via in vitro fertilization (IVF), a highly complex scenario that involved saving not just one life but three. The team at Sterling Hospital, led by Dr. Archana Dwivedi and neurosurgeon Dr. Maulik Vaja, faced numerous hurdles in managing this high-risk case, but the successful outcome highlights the strength of multidisciplinary medical collaboration.

Case Presentation: A Race Against Time

The patient, a 36-year-old woman, presented with sudden, severe headaches and altered sensorium. Having struggled with infertility for years, she had conceived twins through IVF. Her pregnancy was progressing well until the 28th week, when she experienced these alarming symptoms. Initially, she was taken to her primary obstetrician, who quickly referred her to Sterling Hospital in Vadodara, suspecting a severe neurological issue.

Upon admission, Dr. Archana Dwivedi, the obstetrician on duty, assembled a team of specialists that included neurosurgeon Dr. Maulik Vaja, internal medicine physicians, and critical care consultants. A brain scan revealed that the patient had suffered an intracranial subarachnoid hemorrhage (SAH). Further evaluation confirmed that the SAH was caused by a ruptured cerebral aneurysm. The doctors now faced the daunting task of treating the patient's life-threatening brain condition while also managing the health of the unborn twins.

The challenge escalated when the patient developed respiratory distress due to pulmonary edema, a complication arising from the SAH. She was quickly intubated and placed on mechanical ventilation. Given the high risks to both the mother and the fetuses, the medical team made the critical decision to perform an emergency cesarean section to deliver the twins, followed by immediate brain surgery for the mother. The primary goal was to ensure the best possible outcome for both mother and babies.

The Complex Medical Procedure

The medical team had to balance several conflicting priorities. On one hand, it was crucial to manage the mother's cerebral aneurysm by keeping her blood pressure low to avoid re-rupture, yet maternal hypotension could compromise blood flow to the fetuses. Time was of the essence, as delaying treatment for either the mother or the fetuses increased the risk of severe complications, including death.

The cesarean section was performed successfully, delivering two premature but stable infants—one boy and one girl. Immediately after the delivery, the mother underwent a craniotomy, during which Dr. Vaja performed clipping of the aneurysm. This delicate neurosurgical procedure involved placing a clip across the neck of the aneurysm to prevent further bleeding.

Postoperatively, the mother was transferred to the ICU, while the neonates were moved to the Neonatal Intensive Care Unit (NICU). The mother remained in a critical but stable condition, and intensive neuro-monitoring continued around the clock.

Postoperative Complications and Management

While the initial surgeries were successful, the mother faced another significant hurdle on the third day post-surgery when she developed vasospasm—a common complication in up to 35% of SAH cases. Vasospasm involves the narrowing of blood vessels, leading to reduced blood flow to the brain and potentially causing further brain damage. In this case, the vasospasm was severe and required immediate intervention.

The medical team performed an endovascular procedure known as chemical angioplasty in the catheterization lab, injecting medication directly into the affected blood vessels to relieve the spasm. This minimally invasive procedure was crucial in restoring normal blood flow to the brain and preventing additional complications such as stroke.

Despite these challenges, the mother showed steady improvement over the following weeks. After nearly a month in the hospital, she was discharged without any lasting neurological impairments, such as paralysis or speech difficulties. Her recovery was nothing short of remarkable, given the severity of her condition. Both twins, managed by a team of neonatologists, were also discharged in good health.

Medical Insights: Treating Cerebral Aneurysm During Pregnancy

The management of SAH due to a ruptured aneurysm in pregnant patients is particularly challenging. The literature suggests that the mean age for pregnant women with aneurysmal hemorrhages is around 29.4 years, with the average gestational age being 30.5 weeks. The second and third trimesters pose an increased risk of rupture, likely due to the increase in cardiac output that occurs during these stages of pregnancy.

In this case, the doctors faced several unique challenges:

· Blood Pressure Management: The mother’s blood pressure had to be carefully controlled to prevent further rupture of the aneurysm. However, low blood pressure could impair blood flow to the fetuses, making it a fine balance to strike.

· Risk of Re-Bleeding: The risk of recurrent bleeding in patients with an untreated aneurysm during pregnancy is exceptionally high, with a maternal mortality rate ranging from 50% to 68%. Surgical intervention, such as aneurysm clipping, significantly reduces this risk.

· Seizure Prevention: Seizures are common in SAH cases and pose a significant risk to both the mother and the fetus. Anti-epileptic drugs, however, must be used cautiously during pregnancy due to their potential toxicity.

· Timing of Delivery: The decision to perform a cesarean section was made to protect the fetuses from potential radiation exposure during brain imaging and to allow for more aggressive treatment of the mother’s aneurysm.

· Endovascular Techniques: While endovascular techniques such as coiling or chemical angioplasty are increasingly used in pregnant patients, they come with the risk of bleeding complications due to the necessity of anticoagulants and antiplatelet medications.

· Missed Diagnosis: Intracranial hemorrhages are not always immediately suspected in pregnant women, especially those in the second or third trimesters. Symptoms like headaches and elevated blood pressure can mimic other pregnancy-related conditions, such as preeclampsia.

Conclusion: A Unique Case with a Triumphant Outcome

Managing a ruptured cerebral aneurysm in a pregnant woman carrying IVF-conceived twins presents a rare and intricate medical challenge. The complexity is heightened by the need to save both the mother and the fetuses, all while navigating the life-threatening condition of SAH. The team at Sterling Hospital rose to the occasion, using a combination of advanced medical techniques, quick decision-making, and a multidisciplinary approach to achieve a positive outcome.

The successful treatment of this case underscores the importance of collaboration among obstetricians, neurosurgeons, neonatologists, and critical care specialists in handling high-risk pregnancies with complicated neurological conditions. Each specialist brought their expertise to the table, resulting in a meticulously coordinated medical effort that ultimately saved three lives.

This case serves as a testament to the advancements in medical technology and the expertise available at institutions like Sterling Hospital, enabling even the most complex cases to have positive outcomes. The family's gratitude, alongside the medical team's dedication, stands as a shining example of what can be achieved with perseverance, expertise, and care.