2022 Volume 10 Issue 4 Pages 117-120
We experienced three cases of intracranial hemorrhage in pregnant women with hypertensive disorders of pregnancy (HDP). Case 1 showed progression of chronic hypertension to superimposed preeclampsia, Case 2 was diagnosed with preeclampsia, and Case 3 was diagnosed with gestational hypertension. Intracranial hemorrhage developed at home in Cases 1 and 2, and during cesarean section in Case 3. Cases 1 and 2 were treated by hematoma removal and aneurysm clipping after cesarean section, while Case 3 elected conservative treatment. Case 1 had hypertension from the first trimester but was not diagnosed with chronic hypertension. She later developed severe hypertension but was managed as a normal pregnancy. Case 2, despite having preeclampsia, was not placed under stringent blood pressure control. Case 3, despite persistent high blood pressure during anesthesia, did not receive appropriate blood pressure control with antihypertensives. Appropriate management, including antihypertensive therapy for HDP, may reduce the risk of intracranial hemorrhage.
While stroke during pregnancy is relatively rare (2–8 cases/10,000 births), it is associated with a high mortality rate (3–38%).1,2) In Japan, stroke was the second most common cause of maternal deaths after critical obstetric bleeding between 2010 and 2020, accounting for 15% of all maternal deaths.3)
The rate of bleeding in pregnant Japanese patients due to intracranial hemorrhage, such as subarachnoid hemorrhage, intracerebral hemorrhage, and intraventricular hemorrhage, is higher than that of ischemia.3) Hemorrhagic strokes in Japan have been reported to be due to HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets) (33%), arteriovenous malformation (AVM) (18%), subarachnoid hemorrhage (22%), moyamoya disease (6%), and unknown reasons (18%).4) The mortality rate for maternal cerebral hemorrhage is reportedly 25%; 26% of cerebral hemorrhages and 57% of deaths from cerebral hemorrhage in pregnant women are associated with hypertensive disorders of pregnancy (HDP).4) Cerebral hemorrhage occurs at various stages, with 62% occurring during pregnancy, 13% during delivery, and 25% during the puerperium.5) Eclampsia associated with severe hypertension is the most common cause of intracranial hemorrhage in pregnant women with HDP. Both Western and Japanese guidelines recommend appropriate management, including antihypertensive treatment, for pregnant women with HDP.6,7,8,9)
From among the 2024 deliveries from January 2016 to December 2020 in our hospital, we report on our experiences with three pregnant women with cerebral hemorrhage and HDP who were not properly managed, as well as lessons learned from these experiences.
Case 1 was a 41-year-old woman (gravida 1, para 1). Although her office systolic blood pressure often exceeded 140 mmHg during routine prenatal checkups since early pregnancy, she had not been diagnosed with hypertension by her previous doctor. While systolic blood pressure was in the 190 mmHg range at the routine prenatal checkup at 35 weeks of gestation, it fell within the normal range after re-examination and was in the 130 mmHg range at home.
At 36 weeks and 1 day of gestation, she was found lying down at home and was brought to our hospital in an ambulance. Although she was conscious on arrival and had no complaints of motor paralysis, she could not hold a conversation. Given her systolic blood pressure of >200 mmHg on arrival and proteinuria, she was diagnosed with preeclampsia (PE). A computed tomography (CT) scan, performed because of her complaints of severe headache, revealed a subarachnoid hemorrhage and an existing cerebral aneurysm. Fetal heart rate pattern was reassuring on cardiotocogram (CTG), and no obvious fetal abnormalities were found by screening ultrasonography (USG).
The patient was administered an antihypertensive after hospitalization, but since her blood pressure control was poor, an emergency cesarean section was performed with general anesthesia. The delivered infant had the following parameters: 2,542 g, Apgar score (APS): 6 points at 1 minute/9 points at 5 minutes, umbilical arterial blood pH: 7.27, and Base Excess (BE): −4.8. After the cesarean section, the mother underwent craniotomy clipping surgery. Postoperative blood pressure control was satisfactory with appropriate antihypertensive management. She was subsequently transferred to the neurosurgery department, underwent rehabilitation, and was discharged 25 days after brain surgery. After discharge, she experienced mild motor paralysis in the right half of the body, but it did not impact her daily life.
In this case, chronic hypertension (CH) progressed to superimposed preeclampsia (SPE) and likely led to cerebral hemorrhage.
Case 2Case 2 was a 34-year-old woman (gravida 1, para 0). She had proteinuria from 37 weeks of gestation and a diastolic blood pressure that exceeded 90 mmHg, but her pregnancy was managed by her previous doctor in a normal outpatient setting. She visited her previous doctor with complaints of severe headache at 39 weeks and 1 day of gestation; her systolic blood pressure was >150 mmHg. She was transferred to our hospital by ambulance as her headache did not go away.
She was alert on arrival and showed no motor or sensory disturbances in the upper and lower limbs. Blood pressure was 154/99 mmHg and 2+ on dipstick for urinary protein. CT performed because of her complaints of headache revealed a subarachnoid hemorrhage, with blood present in the right ventricle. Fetal heart rate pattern was reassuring on CTG, and screening USG showed no apparent fetal abnormalities. She underwent an emergency cesarean section under general anesthesia. The delivered male infant had the following parameters: 2,664 g, APS: 8 points at 1 minute/10 points at 5 minutes, umbilical arterial blood pH: 7.29, and BE: −3.6. After delivery, the patient underwent craniotomy hematoma removal. She had a good postoperative course and was discharged on postoperative day 20.
The patient did not have paralysis but had an epileptic seizure three months postoperatively and was transported to our emergency department. She was diagnosed with symptomatic epilepsy and is currently on antiepileptic drugs. In this case, PE likely led to cerebral hemorrhage.
Case 3Case 3 was a 32-year-old woman (gravida 2, para 1). She had undergone a cesarean section in her previous pregnancy. She was referred to our hospital with a diagnosis of gestational diabetes mellitus (GDM) at 32 weeks of gestation by a nearby doctor.
GDM was managed by dietary control at our hospital. She was hospitalized on 37 weeks and 2 days of gestation and was scheduled to undergo cesarean section on 37 weeks and 3 days of gestation. Blood pressure was ≥140/90 mmHg on admission but was within the normal range at rest, and she did not have proteinuria. Systolic blood pressure ≥160 mmHg persisted during spinal induction of anesthesia (Figure 1). Maternal tonic-clonic convulsions appeared after delivery, and she was switched to general anesthesia. This event occurred 56 minutes after lumbar anesthesia was initiated, and the operation was completed 116 minutes after the start of lumbar anesthesia. The delivered male infant had the following parameters: 2,840 g, APS: 6 points at 1 minute / 8 points at 5 minutes, umbilical arterial blood pH: 7.32, and BE: −3.2.
Changes in blood pressure and heart rate during the perioperative period.
Closed circle, opened circle, and cross mark represent systolic blood pressure, diastolic blood pressure, and heart rate, respectively.
Postoperative uterine contractions were poor, and bleeding continued. She had a systolic blood pressure in the 60 mmHg range and an Hb of 6.9 g/dl. Hemodynamics and uterine contractions improved with continuous administration of oxytocin and blood transfusion. Since hypertension persisted, continuous infusions of a calcium blocker and magnesium sulfate were initiated. No particular abnormality was found on brain magnetic resonance imaging (MRI) immediately after the operation, but Hb was 5.3 g/dl on the first day after birth. The possibility of bleeding in the abdominal cavity was suspected because the presence of ascitic effusion was demonstrated by USG, but a general CT scan examination found no intraperitoneal bleeding. However, a subarachnoid hemorrhage was found. Given the lack of abnormal neurological findings, she did not undergo surgery but was instead followed up. She was discharged 25 days after surgery. She stopped visiting the hospital afterwards and we lost contact. Thus, her current condition is unknown.
In this case, pregnancy with gestational hypertension (GH) with persistent severe hypertension during induction of spinal anesthesia likely led to eclampsia and concomitant cerebral hemorrhage.
Cerebral hemorrhage is one of the three leading causes of maternal death, with a mortality rate of about 10%.1) It poses serious risks to both the mother and child.1,2) Severe hypertension associated with HDP is a risk factor for eclampsia and concomitant cerebral hemorrhage. Here, we described our experiences with three cases of cerebral hemorrhage in pregnant women with HDP.
Case 1 exhibited hypertension, as reflected by her office blood pressure, early on in pregnancy. She should have been diagnosed with CH but was not diagnosed as such and thus was managed normally. There are two reasons for why the patient was not diagnosed with hypertension. First, when office blood pressure suggested hypertension, her blood pressure was measured several times until it returned to the normal range. Second, although systolic blood pressure was in the 190 mmHg range at 35 weeks of gestation, it returned to the normal range when re-examined and was in the 130 mmHg range at home. At 36 weeks of gestation, the patient suffered a brain hemorrhage at home and was admitted to our hospital with a systolic blood pressure of 200 mmHg (severe hypertension) and proteinuria. Even if home blood pressure is in the normal range and office blood pressure returns to normal after re-examination, once a patient exhibits severe hypertension, she should be placed under strict maternal management, including hospitalization. Recently, more obstetricians are recommending home blood pressure monitoring in general obstetric practice. However, as reflected in this case, normal home blood pressure readings do not negate office hypertension. Rather, the management of hypertension should be based on a comprehensive and appropriate evaluation of office and home blood pressure values. If blood pressure is high when the patient arrives at the hospital, hospitalization should be considered if necessary, and daily blood pressure fluctuations should be investigated. Based on the events described above, CH was thought to have progressed to SPE. The ISSHP guideline recommends strict control of blood pressure because up to 25% of CH cases progress to SPE.7) Cerebral hemorrhage might have been prevented in Case 1 by an early CH diagnosis, strict control of HDP, and blood pressure control.
Case 2 was being managed as a normal pregnancy, despite a diagnosis of PE based on the presence of hypertension and proteinuria at 37 weeks of gestation. Japan’s Best Practice Guide 2021 for the Diagnosis and Management of Hypertensive Disorders of Pregnancy (HDP) recommends, in principle, pregnant women with PE to be hospitalized for management.6) This is because the condition of pregnant women with PE is likely to deteriorate rapidly. Yet, Case 2 did not receive hospitalized management. The Practice Guide also recommends that pregnant women with PE should be planned for delivery after 37 weeks of gestation. Since the fundamental treatment for PE is delivery, Case 2 should have been managed in a different manner than that for normal pregnant women. Cerebral hemorrhage may have been prevented by hospitalized management and strict control of HDP, including dietary guidance such as salt restriction and lifestyle modification, as well as blood pressure control and timing the delivery appropriately.
Case 3 was managed appropriately for GH and GDM, but during anesthesia for a scheduled cesarean section, severe hypertension persisted, resulting in eclampsia and concomitant cerebral hemorrhage. The patient was also highly obese, which made spinal subarachnoid anesthesia difficult, and it took a long time to begin the cesarean section. Although a systolic blood pressure ≥160 mmHg persisted during induction of spinal anesthesia, the anesthesiologist did not provide antihypertensives. As a result, she developed eclampsia during the cesarean section, which was complicated by a cerebral hemorrhage. Anesthesiologists were not fully aware of eclampsia and associated cerebral hemorrhage due to severe hypertension, highlighting the importance of blood pressure control during anesthesia as well. The risk of eclampsia and cerebral hemorrhage due to severe hypertension in patients with HDP should be discussed with anesthesiologists on a daily basis so that appropriate antihypertensive measures can be taken.
We experienced three cases of cerebral hemorrhage in pregnant women with HDP who were not properly managed. Eclampsia and subsequent cerebral hemorrhage can also occur if severe hypertension is sustained during anesthesia. Appropriate management of HDP in accordance with relevant guidelines, as well as blood pressure control during anesthesia, may reduce the risk of eclampsia and cerebral hemorrhage.
It is necessary that more sampling of cases containing of the course of hypertension severity and the course of management for further study.
The authors thank the pregnant women and doctors who cooperated with the preparation of this report.
The authors declare no conflicts of interest associated with this manuscript.
