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While obstetric causes of maternal mortality have declined, non-obstetric causes of maternal morbidity and mortality have increased.1 Among the leading non-obstetric causes are neurosurgical pathologies. Although a pregnant woman is essentially no more susceptible to developing a neurosurgical problem than a non-pregnant one, because of physiological and anatomical changes associated with pregnancy, there are certain diseases that are of particular concern to the neurosurgeon. These are subarachnoid haemorrhage (most commonly caused by cerebral aneurysms and arteriovenous malformations), intracranial tumours, and lower back pain and disc herniation.
The epidemiology, pathophysiology, presentation, investigation and management of each of these neurosurgical problems will be discussed, focusing particularly on how the pregnant state influences each of these factors. Furthermore, brief consideration will be given to the management of ventriculoperitoneal shunts during pregnancy, and some general cautions regarding standard neurosurgical practices in the pregnant woman will also be highlighted.
Evidently, the care of a pregnant woman with a neurosurgical condition requires coherent teamwork between the obstetrician, neurosurgeon and neuroanaesthetist. As will be demonstrated, complex decisions will often need to be made with a significant lack in class 1, or even 2, evidence. Constant communication and discussion between this medical team and the patient is absolutely necessary to achieve optimal care.
SUBARACHNOID HAEMORRHAGE (SAH)
Spontaneous SAH occurs in 10–20 women per 100 000 pregnancies.2 Although uncommon, this phenomenon has devastating consequences. It is the third most common cause of “indirect death” in pregnant women, accounting for approximately 5% of all maternal deaths,3 and has a substantial maternal mortality of 35–83%.2
There is some indication that the incidence of SAH increases during pregnancy,2 and with maternal age and parity.4 Increased plasma volumes and pregnancy induced hypertension are hypothesised to account for this.2
SAH in pregnancy presents as in the non-pregnant. Clinical features include:
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