Non-obstetric surgery during pregnancy is not new, and has been reported for various conditions with a frequency of 0.2–0.79%.[34
] It can be performed without increased risk to the fetus.[11
] But, brain tumors in a parturient patient are extremely rare scenarios, with an estimated incidence of about seven cases per 125,000 pregnancies.[17
] They can pose serious challenges to the treating physician balancing the act of treating mother and child during non-obstetric disease.
The overall incidence of intracranial neoplasm is equal if not lower than that in non-pregnant women of childbearing age, and was estimated for meningiomas to be about 1–4.5/100,000 females aged 15–44 years.[20
] But, for some tumors, and meningiomas in particular, symptoms may flare up due to metabolic changes during pregnancy, causing accelerated growth.[22
] A first such observation was published by Bernard in 1898[4
] and was related to a case of connective tissue tumor growing rapidly during pregnancy, but it took a few more decades until this specific correlation was recognized for intracranial meningiomas.[12
There are only a few case reports or small series on the topic available, but the overall lesson learned from these cases is that signs and symptoms can be significantly aggravated antepartum or post-partum and may mimic more common conditions such as hyperemesis gravidarum, eclampsia or puerperal psychosis.[29
] due to either (1) maternal metabolic changes causing fluid retention, vascular engorgement and edema or (2) accelerated tumor growth due to hormonal receptor expression. Triage in such cases needs to be individualized and based on very thorough observation of the clinical setting of such patients.[29
Previous publications have reported favorable outcomes if managed well.[2
] In this particular paper, we illustrate the associated difficulties in decision-making as encountered in a case of a rare, highly vascular,, atypical meningioma variant, the clear cell meningioma. This team effort contributed to the delivery of a healthy premature infant early in the 3rd
trimester and subsequent successful removal of the symptomatic intracranial lesion.
A 40-year-old right-handed Chinese female, 29 weeks pregnant (gravida 3, para 1, 1 miscarriage), presented with headaches and declined mental status. As per the patient’s husband, she complained of constant bitemporal headaches for 2 weeks prior to admission. Word-finding difficulties were noted for 1 week and the patient was unable to finish her sentences. She was able to speak English before the symptoms but developed difficulties even in Chinese, becoming forgetful and at times confused. For 3 days, her symptoms had progressed and she developed nausea and vomiting, becoming very lethargic, spending most of the day sleeping. Past medical history was only relevant for hepatitis-B carrier status and past surgical history was notable for a previous caesarean section for breech.
Review of Systems
Ultrasound examination had documented an uncomplicated pregnancy, the baby had been moving well and no bleeding or problems with the gestation were noted. Home medications included Telbivudine 600 mg daily, calcium supplement and fish oil; no drug allergies were noted. She lived with her husband and her 12-year-old daughter. There was no use of alcohol, tobacco or drugs and her family history was non-contributory.
The patient presented afebrile, with normal vital signs. The general exam was unremarkable. The neurological exam revealed depressed mental status with closed eyes, opening to voice, but non-cooperative. She followed simple commands poorly in English, but better in Chinese. There was an unremarkable cranial nerve exam, with brisk pupillary reactions to light and accommodation.
There was normal bulk and tone; no asterixis or myoclonus were noted, but there was right-sided hemiparesis 4/5 throughout with a right-sided pronator-drift.
There was perceived pain and touch; no obvious deficit or paresthesia were noted. Reflexes were symmetric and the plantar response was flexor.
Na 139, K 3.3, Cl 108, HCo3 21, BUN 4, Cr 0.4, Gluc 112, Ca 8.1, Mg 1.8, PO4 2.2, ALT 54, AP 53, Tbili 0.5, AST 39, Lip 21, HCG 27344.
WBC 13.4, HCT 32.9, PLT 93.
N 84.2, L 11.9, M 3.2, E 0.4, Bas 0.3, PT 12.0, PTT 23.8, INR 1.0.
Because computer tomography (CT) carries a hazardous risk of radiation damage, magnetic resonance imaging (MRI) is the method of choice for this work-up, although it remains suboptimal secondary to the inability to use contrast agents during pregnancy. We obtained a baseline study .
Figure 1 Magnetic resonance imaging of the brain. (a) Sagittal view (T1 weighted); (b) coronal view (T1 weighted); (c) axial view (FLAIR). Imaging demonstrated a 4.9 × 7.2 × 4.8 cm extraaxial mass with surrounding edema and resulting mass effect (more ...)
The patient was admitted and monitored until imaging could be completed for further assessment. An obstetric consult revealed an uncomplicated pregnancy at 29.2 weeks with unremarkable characteristics by fetal monitoring. The ultrasound revealed breech position. An urgent interdisciplinary conference was called to arrive at a balanced clinical judgement that must weigh a decision to resect the lesion during pregnancy vs. waiting until post-partum if deemed possible.
For a comprehensive evaluation and final decision on how to proceed, a multidisciplinary team meeting was called, including Neurosurgery, Maternal-Foetal Medicine, Neonatology and Anaesthesia, to discuss the most appropriate and most safe surgical approach. The management questions presented included the following key points:
From a neurosurgical perspective, a tumor of this size should be removed in a symptomatic patient. Although mainly composed of case reports, the available literature reflects an increased risk to both the mother and the baby over time.
As some tumors do progress rapidly in pregnancy secondary to responses mediated by sex-hormone receptor expression,[7
] and this patient was demonstrating progressive symptoms, it seemed wise not to wait several weeks (10 weeks to full-term) but to remove the lesion electively as the intrapartum complications can be fatal to the patient and the baby.[29
Risks to the mother included general endotracheal anesthesia during pregnancy, which is complicated by weight gain, water retention, venous engorgement, upper airway mucosal edema, increased propensity for reflux and aspiration and a decreased functional residual capacity. Furthermore, under general anesthesia, the neurological status can no longer be assessed, which could complicate the evaluation of the patient after emergence. From an anesthesia perspective, the concerns focused around positioning, possible induction of labour, avoiding rapid extremes of blood pressure, which are common during delivery, and also treatment of post-partum hemorrhage during anesthesia in such high-risk pregnancy.[8
Particular maternal risk in this scenario however lies in neurological compromise since the tumor may progressively enlarge, cause seizures or a stroke and even herniation. However, the use of diuretics (mannitol or lasix) is not advocated in pregnancy as a sudden decrease in the plasma volume might compromise uteroplacental perfusion and may put the fetus at an unpredictable risk during brain surgery. Conversely, the lack of brain relaxation makes intracranial surgery significantly more difficult. Furthermore, if surgery is needed to be performed, excessive blood loss and subsequent hypotension, hypovolemia and hypoxia are all risk factors for possible harm to the fetus and intrauterine demise.
The set of risks to the fetus included stillbirth, birth defects (more in earlier stages of pregnancy), premature labour, premature delivery and fetal asphyxia. From a fetal perspective, the neonatologist mentioned that the risk for the baby quo ad vitam at this point was about 4–5%, whereas at 31 weeks it would still be 2–3%. Lung maturation had been drug induced with the use of betametasone. For that reason, it was argued that little reduction of fetal risk would be gained by delaying delivery.
Because brain surgery may induce labour, or lead to fetal complications intraoperatively, the consensus was in favor of taking care of the baby first. From an obstetrical perspective, an elective caesarean section, which has a low morbidity/mortality (e.g., blood loss of 500–1000 cc), if performed under epidural anesthesia, could be performed at any time and seemed to be the procedure of choice. Epidural anesthesia would provide the advantage of maintaining stable blood pressure parameters and allowing neurological status assessment during surgery.[1
] It was indicated that due to a significantly raised intracranial pressure, fluid resuscitation had to be isotonic at all times.
It was decided to proceed with this elective caesarean delivery of the premature fetus as it was felt that an elective premature delivery is preferred over sentinel delivery concurrently with brain surgery. It was assumed that after delivery, the patient could undergo full imaging to complete the pre-operative assessment of the brain and to have the second surgery electively shortly thereafter with significantly reduced risk to the mother.