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From the Department of Anesthesia, The Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.
Address correspondence to: Dr. Pirjo H. Manninen, Department of Anesthesia, The Toronto Western Hospital, 2 EC-046, 399 Bathurst Street, Toronto, Ontario M5T 2S8, Canada. Phone: 416-603-5118; Fax: 416-603-6494; E-mail: Pirjo.Manninen{at}uhn.on.ca
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Clinical features: A 33-yr-old woman presented at 28 weeks of gestation with rapidly deteriorating vision in her right eye. Neuroradiological investigations revealed a large suprasellar meningioma extending into the frontal lobe. She underwent a craniotomy for excision of the tumour at 28 weeks gestation because of the risk of irreversible blindness. Anesthetic management was tailored for pregnancy and an intracranial tumour. Intraoperative blood pressure was maintained within 10% of baseline and respiratory variables were stable. No fetal heart rate monitoring was used during the surgery, as there was no plan to perform an emergency Cesarean delivery even in the event of change in fetal monitoring. The aim was to treat the mother aggressively for any untoward events. She made a good neurological recovery after the procedure and had a spontaneous vaginal delivery at 40 weeks of gestation without any neonatal complications.
Conclusions: Anesthetic management of a brain tumour during pregnancy should be tailored to the individual patient according to the circumstances. It is possible to perform this type of procedure without fetal heart rate monitoring. The decision regarding fetal monitoring should be based on the consensus of the multidisciplinary care team and the mother.
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Case report |
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On examination, the patient’s cardiovascular and respiratory systems were normal and body mass was 64 kg. Neurological examination was also normal except for her right eye. Right eye visual acuity was 20/400 and left eye 20/20. She had loss of vision in the entire right hemifield and lower left field of the right eye. Fundoscopic examination showed disc swelling in the right eye. On obstetrical examination, uterine height and obstetrical ultrasound were normal for dates.
Brain magnetic resonance imaging (MRI) showed a suprasellar meningioma extending centrally and boring into the right frontal lobe. Tumour size was 2 cm x 1.7 cm x 2.6 cm. Patient was started on dexamethasone 8 mg four times a day to reduce brain edema. Following consultations among the neurosurgeon, obstetrician, neonatologist, anesthesiologist, and the patient, a decision was made to perform a craniotomy for tumour resection under general anesthesia. Also after considering the pros and cons of fetal monitoring and with the mother’s consent, it was decided not to perform intraoperative fetal monitoring. As well, no plans were made for emergency Cesarean delivery. Maternal optimization and resuscitation were considered the primary goal in the event of a crisis.
On the day of surgery, the patient received 30 mL sodium citrate half an hour prior to surgery as prophylaxis against aspiration. In the operating room, a wedge was placed under the right buttock to prevent aortocaval compression. Initial monitoring included electrocardiogram, noninvasive blood pressure, pulse oximeter and capnography. A modified rapid sequence induction with cricoid pressure was carried out using iv fentanyl 100 µg, lidocaine 80 mg, thiopentone sodium 200 mg and succinylcholine 120 mg to facilitate endotracheal intubation. Anesthesia was maintained with 60% O2 in air, isoflurane, intermittent fentanyl boluses and rocuronium. She received clindamycin 600 mg as an antimicrobial prophylaxis and dexamethasone 10 mg intravenously. Invasive monitoring included an intra-arterial catheter, central venous catheter in the right internal jugular vein, urinary catheter, esophageal temperature probe, peripheral nerve stimulation and somatosensory evoked potentials. Body temperature was kept normal with a warming blanket. Preoperative FHR monitoring had been performed with an ultrasound and was normal. Intraoperative FHR monitoring was not performed.
The surgical procedure was performed with the patient supine with 30° head up position. The MRI based guidance was used for accurate localization of the tumour. The tumour arose predominantly from the jugum sphenoidal area extending into the diaphragma sella enveloping the optic chiasma and both optic nerves and burrowing into the right frontal lobe. The entire tumour was excised without any vascular or neural damage.
Intraoperative hemodynamic and respiratory variables were stable throughout the procedure with systolic blood pressure between 110 to 120 mmHg, heart rate 60 to 70 beats•min–1 , SpO2 of 99%, ETCO2 30 to 35 mmHg, central venous pressure 10 to 12 mmHg and temperature 36 to 37°C. Arterial blood gases revealed pH 7.43, PaO2 260 mmHg, PaCO2 35 mmHg, HCO3 28 mEq•L–1 and hemoglobin 116 g•L–1. Blood glucose was checked every two hours and remained within normal limits. Estimated blood loss was 400 mL and intra-operative fluid administration consisted of 4000 mL crystalloid. The surgical procedure lasted for six hours. At the end of the procedure, iv dimenhydrinate 50 mg was administered for preventing postoperative nausea and vomiting. Neuromuscular blockade was reversed using neostigmine and glycopyrrolate. The patient was extubated fully awake and neurologically intact in the operating room and then transferred to the intensive care unit. Postoperative FHR monitoring was normal. She recovered without any complications and was discharged from the hospital after a week.
At the three week postoperative visit, the patient’s vision had improved significantly, with right eye visual acuity at 20/30 and visual fields had returned to normal. She delivered a healthy baby weighing 3 kg with Apgar scores of 9 at one minute and 9 at five minutes, at 40 weeks of gestation by spontaneous vaginal delivery.
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The signs and symptoms of a meningioma may initially appear during the second or third trimester of pregnancy and then subside in the postpartum period. As with this patient, the most frequent symptoms of a brain tumour such as headache, visual disturbance, nausea and vomiting are often attributed to pregnancy itself and hence the diagnosis may be delayed. It is believed that the presence of hormone receptors, mainly progesterone receptors are responsible for the worsening symptoms of meningioma.1,2,5 The fluctuations in the hormonal milieu of pregnancy as a result of increase in the blood volume, redistribution of body water between intracellular and extracellular fluid compartments and the influence of steroid hormones may increase the tumour size and peritumour edema.
Anesthetic considerations for surgery during pregnancy involve the safety of two patients, the mother and the fetus.6–8 Alterations in the maternal anatomy and physiology have clinical anesthetic implications and in addition an intracranial mass presents the problems of potential increased intracranial pressure (ICP) and preservation of cerebral perfusion. Rapid sequence induction has been advocated for all pregnant patients beyond 20 weeks gestation, but needs modification to decrease the stimulation of laryngoscopy and intubation with agents such as lidocaine when an intracranial mass is present. Controversy exists for the intraoperative management of ICP in a pregnant patient. Hyperventilation may adversely affect the fetus by reducing cardiac output due to reduced venous return, thus decreasing uterine blood flow, producing hypocapnic induced uterine/umbilical artery vasoconstriction, and by producing alkalosis induced shift of the O2 - hemoglobin dissociation curve to the left, thus reducing O2 delivery to the fetus.4,9 Animal and human studies suggest that the use of an osmotic diuretic, such as mannitol, may cause redistribution of water from the fetus to the mother leading to fetal hypovolemia and dehydration.7 Maternal hydration should be maintained to prevent fetal hypovolemia. Furosemide may be a better alternative to mannitol. The use of steroids in the pregnant neurosurgical patient has two effects; reduction of peritumoural edema and the acceleration of fetal lung maturity by increasing the production of surfactant.1,5 Hemodynamic stability is important for maintaining maternal cerebral perfusion as well as prevention of uterine hypoperfusion and fetal hypoxia.
Intraoperative fetal asphyxia may be caused by a number of events such as decreased uterine blood flow, maternal hypotension, hypoxia and depression of the fetal cardiovascular system from anesthetic agents.8 To prevent intraoperative fetal catastrophes, close monitoring of maternal blood pressure, intravascular volume and respiratory variables is essential. Since fetal distress would most likely occur because of maternal compromise, optimizing maternal conditions should be the first priority in such situations.
Continuous intraoperative as well as postoperative FHR monitoring has been advocated during maternal surgery after 16 weeks of gestation.6–8,10 This can be achieved by using electronic fetal monitoring, Doppler, external abdominal ultrasound, transabdominal ultrasound transducer or even by a transesophageal echocardiography probe placed directly on the uterus. Technical problems such as obesity may limit the use of continuous fetal monitoring. However, there is considerable controversy to the usefulness of intraoperative FHR monitoring.10,11 Fetal heart variability, which typically is a good indicator of fetal well being, is present by 25 to 27 weeks’ gestation. Maternal anesthesia may decrease the baseline FHR and beat-to-beat variability but does not usually cause spontaneous decelerations. Misinterpretations of FHR monitoring can lead to unsafe interventions.11 Intraoperative FHR monitoring requires the presence of additional trained operating room personnel. In addition, there should be a plan regarding how to proceed in the event of persistent fetal distress, including whether to perform an emergency Cesarean delivery. Also intervention and therefore continued FHR monitoring will depend upon availability of appropriate personnel and facilities to care for a preterm infant. Many obstetricians feel that FHR monitoring during surgery is not useful because derangements in maternal physiologic variables can be assessed and treated without reference to FHR analysis.6,12 No fetal hypoxic mortality or morbidity has been documented without the occurrence of maternal hypoxic complication regardless of the use of FHR monitoring or whether alterations of the FHR occurred.10 In a survey from United States hospitals in 1995; it was found that only 60% of hospitals routinely used some form of fetal or uterine monitoring during maternal non-obstetric surgery.12 With the patient presented here, it was the strong opinion of both the obstetrician and neonatologist that FHR monitoring was not of any benefit as there was no plan to intervene should a change in the FHR occur. The aim was to treat the mother aggressively for any untoward event. This issue was clearly discussed with the mother and she was agreeable to this plan of action.
The surgical options for this patient were to continue the pregnancy till term and operate after delivery while closely monitoring visual function and neurological status; to operate now with possible Cesarean delivery; or to operate now and continue the pregnancy till term. Fetal viability begins at 24 weeks of gestation but the neonatal outcome in terms of survival and long term neurological development improves with increasing gestational age. Every attempt is, usually, made to bring the fetus to term. Maternal morbidity and fetal loss increase when maternal disease is advanced. The patient had rapidly escalating symptoms with a risk of irreversible blindness and a risk of increase in ICP due to intracranial extension of the tumour. Waiting until term may have increased the risks of emergency craniotomy and possibly a worse outcome for both the mother and the fetus. Hence it was decided to operate immediately without interrupting the pregnancy.
The management of a pregnant patient with a brain tumour must be individualized and the final decision should be based on the intracranial pathology, gestational age and the mother’s wishes after full consultation with all members of the team. A multidisciplinary and cooperative approach of the neurosurgeon, anesthesiologist, obstetrician and neonatologist are required to ensure a successful outcome.
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Footnotes |
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2 Ismail K, Coakham HB, Walters FJ. Intracranial meningioma with progesterone positive receptors presenting in late pregnancy. Eur J Anaesthesiol 1998; 15: 106–9.[Medline]
3 Giannini A, Bricchi M. Posterior fossa surgery in the sitting position in a pregnant patient with cerebellopontine angle meningioma. Br J Anaesth 1999; 82: 941–4.
4 Beni-Adani L, Pomeranz S, Flores I, et al. Huge acoustic neurinomas presenting in the late stage of pregnancy. Treatment options and review of literature. Acta Obstet Gynecol Scand 2001; 80: 179–84.[Medline]
5 Swensen R, Kirsch W. Brain neoplasms in women: a review. Clin Obstet Gynecol 2002; 45: 904–27.[Medline]
6 Goodman S. Anesthesia for nonobstetric surgery in the pregnant patient. Semin Perinatol 2002; 26: 136–45.[Medline]
7 Gianopoulos JG. Establishing the criteria for anesthesia and other precautions for surgery during pregnancy. Surg Clin North Am 1995; 75: 33–45.[Medline]
8 Rosen MA. Management of anesthesia for the pregnant surgical patient. Anesthesiology 1999; 91: 1159–63.[Medline]
9 Johnson MD, Zavisca FG. Intracranial and spinal cord lesions. In: Gambling DR, Douglas MJ (Eds). Obstetric Anesthesia and Uncommon Disorders. Pennsylvania: W.B. Saunders Inc.; 1998: 219–37.
10 Horrigan TJ, Villarreal R, Weinstein L. Are obstetrical personnel required for intraoperative fetal monitoring during nonobstetric surgery? J Perinatol 1999; 19: 124–6.[Medline]
11 Immer-Bansi A, Immer FF, Henle S, Spörri S, Petersen-Felix S. Unnecessary emergency caesarean section due to silent CTG during anaesthesia? Br J Anaesth 2001; 87: 791–3.
12 Kendrick JM, Woodard CB, Cross SB. Surveyed use of fetal and uterine monitoring during maternal surgery. AORN J 1995; 62: 386–92.[Medline]
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