Surgical or endovascular treatment of ruptured aneurysms during pregnancy may be associated with improved maternal-fetal outcomes. Benefits are less clear with AVMs. A decision to deliver or continue pregnancy is best coordinated with specialty team.

Blood Pressure Control

Hemorrhagic Stroke

A set of AHA/ASA guideline recommendations (Class C) have been published for nonpregnant patients with hemorrhagic stroke.¹⁹ If the patient also has pre-eclampsia/eclampsia (which should be assumed after 20 weeks of pregnancy), the exact targets may need to be coordinated with neurology, neurosurgery, and OB consultants. Also, magnesium sulfate should be used prophylactically to prevent seizures in pre-eclampsia/eclampsia, which can exacerbate the severity of hemorrhagic stroke and elevated blood pressures.

Drug treatment for pre-eclampsia/eclampsia is usually reserved for patients with BP greater than 160 systolic and greater than 110 diastolic. Avoid lowering blood pressure below 140/90 because of the possible untoward consequence of uterine hypoperfusion.²⁰

Ischemic Stroke

In the pregnant patient, a significantly elevated BP may be detrimental to the pregnancy, especially when associated with pre-eclampsia. This condition requires treatment with magnesium sulfate, which promotes vasodilation and prevents seizures. Symptomatic hypoxic neurologic injury associated with ischemic brain pathology caused by occlusive vasospasm of pre-eclampsia (and demonstrated on MRI) is frequently completely reversed by conservative management that includes the use of magnesium sulfate, expedited delivery of the fetus and placenta, and management of any additional complications associated with pre-eclampsia.

Blood Pressure Drugs

Optimal drugs have not been well studied in pregnant patients. Strongly consider pre-eclampsia when significant hypertension is present. A consulting team can help select the best option. Labetalol drip, commonly recommended in pre-eclampsia, is a widely used option.

Limited experience with nicardipine has shown it to be an effective antihypertensive agent in severe pre-eclampsia and in pregnant women with autonomic hyperreflexia. So far, nicardipine has not been shown to have any deleterious effect on neonatal outcomes, even when an overdose was accidentally given to one patient. To avoid undesired precipitous drops in BP, consider an initial dose of 2.5 mg/hour without a bolus and the use of an arterial line for continuous BP monitoring. Close clinical surveillance in the postpartum period is mandatory because of a possible increased risk for uterine atony after treatment with nicardipine.²¹

One study showed patients treated with nicardipine were more likely to reach a physician-specified systolic BP target range within 30 minutes versus those treated with labetalol.²²

Antiepileptics

Assume seizures are caused by eclampsia (after 20 weeks of pregnancy)²³ even if BP is not elevated. Also assume there is risk for seizures with the diagnosis of pre-eclampsia and progressive hypertension or other neurologic symptoms. In either case, initiate magnesium sulfate therapy to decrease risk of new or recurrent seizures, according to the following protocol:

• Give a 4- to 6-g IV loading dose over 15-20 minutes.
• Give a maintenance infusion at 2 g/hour.
• Check DTRs, urine output, and respiratory rate hourly. For depressed DTRs or oliguria, stop infusion and check serum magnesium level. For magnesium overdose, administer 1 g of calcium gluconate via a slow IV push.
• Treat a breakthrough seizure with a 2-g bolus over 3 minutes. If ineffective, consider sodium amobarbital 250 mg IV over 3-5 minutes, lorazepam 1-2 mg/min IV up to 10 mg, or diazepam 2 mg/min up to 20 mg. Lorazepam has a longer duration of action. These drugs, especially in combination with magnesium, may result in substantial maternal and neonatal respiratory depression.
• Consider RSI as necessary.

Benzodiazepines are used as in nonpregnant patients for terminating acute seizures. These drugs may affect fetal heart rate variability. Initial stabilization with a fosphenytoin loading dose or benzodiazepine drip are acceptable options. Refractory cases can be treated with propofol.^24,25