Management of Idiopathic Intracranial Hypertension in Pregnancy

Rosa A Tang, MD, MPH


Idiopathic intracranial hypertension (IIH) is a syndrome of increased intracranial pressure without hydrocephalus or mass lesion with elevated cerebrospinal fluid (CSF) pressure but otherwise normal CSF composition (Modified Dandy's criteria).[1] Pregnancy occurs in IIH at about the same rate as in the general population and can occur in any trimester of pregnancy. Affected patients have the same spontaneous abortion rate as that of the general population, and the visual outcome is the same as for nonpregnant patients with IIH.[2,3] In this issue of Medscape General Medicine, Bagga and colleagues[4] report on 3 women with IIH during pregnancy and review choices for therapy and mode of delivery.

Although the general recommendation is that pregnant patients with IIH be managed and treated the same way as any other patient with IIH, the 2 groups should be managed differently with regard to the use of imaging and drug contraindications. Treatment should be administered with 2 major goals in mind: preservation of vision and symptom resolution. Medical therapy includes weight control, nonketotic diet, serial lumbar punctures, diuretics, steroids, and certain analgesics.[5] When medical therapy aimed at salvaging vision fails, surgical procedures need to be considered. The 2 main procedures are optic nerve sheath fenestration and lumbo-peritoneal (LP) shunt.

The proper method and use of anesthesia during delivery, especially when surgery has been performed, is a valid concern raised by Bagga and colleagues.[2] Spinal anesthesia has been shown to be safe and effective in a patient with IIH without a prior LP shunt.[6,7] In pregnant patients with a preexisting LP shunt, general anesthesia for cesarean section has been recommended over epidural anesthesia because of the potential damage to the shunt during epidural placement.[6] It should be noted, however, that the evidence is only anecdotal. In addition, general anesthesia in pregnant patients, particularly those who are obese - ie, the typical patient with IIH -- carries multiple risks, including aspiration and airway problems, and it is thus generally best avoided if possible.[7]

Case reports indicate that in pregnant patients with preexisting CSF shunts, proper management can lead to normal pregnancy, and decisions regarding the mode of delivery, anesthesia, and analgesia should be based only on obstetric concerns.[7] The use of outlet forceps has been suggested to prevent prolonged second-stage labor in patients with IIH, but it is not established that a prolonged second stage of labor is a cause for concern. A cesarean section is not required, nor is sterilization. Therapeutic abortion to limit progression of disease is not indicated, and subsequent pregnancies do not increase the risk of recurrence of IIH.[7]


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