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Anaesthetic challenges in complicated labour: unruptured intracranial aneurysm
Intracranial aneurysms are uncommon during pregnancy. Haemodynamic stress during pregnancy is a key factor in the multifactorial pathogenesis of cerebral aneurysm, contributing to the risk of aneurysm formation, progression and rupture. Successful management requires multidisciplinary care; anaesthetists require knowledge of obstetric anaesthesia, neuroanaesthesia and critical care. The incidence of subarachnoid haemorrhage in pregnancy is 0.01–0.05%, with a maternal mortality rate of 11% in treated cases and a fetal mortality rate of 5% in treated cases (Allen et al. Anesthetic management of the pregnant patient for endovascular coiling of an unruptured intracranial aneurysm. Neurocrit Care 2006;4:18–20). Definitive treatment involves either open neurosurgical clipping or endovascular therapy, maintaining stable transmural pressure in the aneurysm to prevent rupture. Very few cases have been reported in the literature, and guidelines for the management of intracranial aneurysm during pregnancy and evidence-based recommendations for obstetric anaesthesia in patients with unruptured intracranial aneurysm during labour do not exist. A review of the literature reveals varying results, differing on a case-by-case basis, for treatment of intracranial aneurysms during pregnancy and labour. Reducing risks associated with intracranial aneurysm must focus on both mother and child. This review encourages the establishment of formal guidelines for an algorithmic approach to managing intracranial aneurysm during pregnancy and labour.