Asia-Oceania J . Obstet. Gynaecol. Vol. 16, No. 2: 111-113 1990
Case Report: Pregnant Woman with a Ventriculoperitoneal Shunt to Treat Hydrocephalus
Atsuhiko Okagaki,’) Hideharu I(anzaki,l) Kouzo Moritake,2) and Takahide Moril) I ) Department of Obstetrics and Gynecology, Kyoto University, Faculty of Medicine, Kyoto, Japan 2) Department of Neurosurgery, Kyoto University, Faculty of Medicine, Kyoto, Japan
Abstract A pregnant woman with hydrocephalus who required multiple revisions of a ventriculoperitoneal shunt is discussed. Her symptoms improved after the replacement of the ventriculoperitoneal (VP) shunt with a ventriculoatrial (VA) shunt, suggesting the benefits of ventriculoatrial shunting during pregnancy.
Key words: complicated pregnancy, ventriculoatrial (VA) shunt, ventriculoperitoneal (VP) shunt, hydrocephalus
Introduction The clinical results of extracranial shunting in patients with hydrocephalus have markedly improved, and women with such shunts have been able to carry pregnancies to term with successful deliveries. Since the first report of Monfared et al.” in 1979, 15 pregnancies involving extracranial shunts have been reported in the English literature.1-8) Shunt malfunction during pregnancy was noted in 7 pregnancies, and in 2 of them shunt revision was required. The following report is on a woman who required multiple revision of a ventriculoperitoneal shunt during the third trimester.
Case Report A 25-year-old pregnant woman, gravida 0,
was referred to our hospital for headaches and memory disturbances at 24 weeks’ gestation. (She had undergone her first operation for VP shunting at age 22, due to a diagnosis of aqueductal stenosis, and had subsequently undergone 3 additional shunt revisions within the following 12 months due to malfunctions.) At 24 weeks’ gestation, C T scan findings and palpation of the shunt reservoir suggested a shunt malfunction caused by occlusion of the distal tube, and the shunt was replaced with another VP shunt system. She was then asymptomatic until she began to complain of severe headaches and became drowsy at 31 weeks’ gestation, at which time a shunt malfunction was again suspected. As the symptoms did not improve when the flushing device was pumped, the VP shunt was replaced and direct drainage of the left ventricle was per-
Received: Feb. 28, 1990
Reprint request to: Dr. Atsnhiko Okagaki, Department of Gynecology and Obstetrics, Kyoto University, Faculty of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto 606, Japan 111
A. OKAGAKI ET AL.
formed. Following the VP shunt revision, her consciousness improved deteriorating again at 34 weeks’ gestation. Replacement of the left-VP shunt and direct drainage of the right ventricle were then performed, but her symptoms did not completely disappear. Therefore, delivery was induced with metreurysis and oxytocin infusion. Nine hours later, a female infant weighing 1,800 g was delivered, her Apgar scores were 8 and 9 at 1 and 5 min respectively. The patient’s symptoms gradually improved after delivery, but she had a seizure and became unconscious on the 20th postpartum day, when the VP shunt with a low pressure valve was replaced by a VA shunt with a medium pressure valve. Her condition then improved, and she was discharged 3 months after delivery without symptoms or abnormal computed tomography findings. There were no complications with the infant except for slight hyperbilirubinemia, which was for 2 days treated with phototherapy.
Discussion There is some controversy surrounding the treatment of shunting for pregnant women..
Table 1 summarizes the 15 reported pregnancies with extracranial shunts.1-8) I t is generally accepted that the severity of complications involved with VA shunts exceeds that of VP ~hunt.S-1~)Thus, some authors recommend VP shunts due to their lower rate of complications.7) However, 6 of 11 patients with VP shunts experienced neurological symptoms during pregnancy. Four of them were successfully treated by tapping and pumping the cerebrospinal fluid (CSF) reservoir of the shunt system. The remaining 2 pregnancies were treated by replacing the old VP shunt with a new one. During pregnancy, the expanding uterus may cause an increase in intraperitoneal pressure. An increase in the distal lumen to the shunt system causes a decrease in the pressure gradient between the ventricle and peritoneal cavity, resulting in decreased shunt flow. The flow of the shunt can neither be too small nor too large, otherwise the pressure gradient decreases and results in a decreased shunt flow. The repeated VP shunt malfunctions in the present case seem to derive from a combination of the narrow optimal range of the shunting pressure, the patient’s high shuntdependency due to her aqueductal stenosis,
Table 1. Reported pregnancies with extracranial shunts
No.
Author
Shunt
1 2 3 4 5 6 7 8 9 10 11
Monfared
VAa) VPb’ VP VP VP VP VA VA VA VP VP
12 13 14 15 16
Howard Kleinman Gast
Hanakita Nugent Frolich Samuels Okagaki ~~
VP VP VP VP VP
Problem
No No No No Shunt pumping Yes 29Wc: Shunt pumping Yes 2 9 W No No Shunt revision Yes 2 M Shunt revision Yes 32W Shunt placement Yes 7 W 3 W aft. del. Extra abdominal cyst operation Elective C/Sql No No CSFe) drainage C/S Yes 37W Yes 34W CSF drainage C/S Shunt revision etc. Yes 24W-
~
a) : ventriculoatrial shunt, b) : ventriculoperitoneal shunt, e) : cerebrospinal fluid
112
Therapy
c) : pregnancy 29 weeks,
d ) : cesarian section,
PREGNANT WOMEN WITH V P SHUNT
and the increase of pressure in the intraperitoneal cavity which causes a reverse pressure gradient in the shunt system. On the other hand, the function of a VA shunt is not affected by an enlarged uterus and increased intraperitoneal pressure as suggested by Samuels et aLs) The 4 reported pregnancies involving VA shunts had no malfunctions during the third trimester.lp4) In our case, VA shunt replacement seemed to be indicated. However, since , VA shunt replacement involves fetal risks caused by infection, and induction delivery is safer than VA shunt replacement after lung maturation, we elected against a VA shunt replacement during pregnancy. And, as shunt drainage cannot be maintain longer than one week, and the VA shunt replacement could be done anytime after delivery, as the patient became unconsciousness, we choose VA shunt replacement after delivery. The successful treatment of our case by installation of a VA shunt after repeated VP shunt malfunctions shows the benefits of VA shunts during pregnancy. We recommend VA shunt placement for all young woman with hydrocephalus who have any possibility of becoming pregnant.
References 1. Monfared AH, Koh KS, Apuzzo MLJ, CoIlea JV. Obstetric management of pregnant women with extracranial shunts. Can Med Assoc J 1979; 120: 562-563 2. Howard TE, Herrick CN. Pregnancy in patients with ventriculoperitoneal shunts : Report of two cases. A m J Obstet Gynecol 1981;141: 99-101
3.
4.
5.
6.
7.
8.
9.
10.
11.
Kleinman G, Sutherling W, Martinez M, Tabsh K. Malfunction of ventriculoperitoneal shunts during pregnancy. Obstet GynecoZl983; 61 : 753-754 Gast MJ, Grubb RL, Stricker RC. Maternal hydrocephalus and pregnancy. Obstet GynecoZl983; 62: 315-317 Hanakita J, Suzuki T , Yamamoto Y, et al. Ventriculoperitoneal shunt malfunction during pregnancy. J Neurosurg 1985; 63: 45 9-460 Nugent P, Sylvio H. Large extra-abdominal cyst of a postpartum complication of peritoneal shunt. J Neurosurg 1986; 64: 151-152 Frolich EP, Russel JM, VanGelderen CJ. Pregnancy in patients with ventriculoperitoneal shunts: Report of two cases. S Afr Med J 1986; 70: 358-360 Samuels P, Driscoll DA, London MB, et al. Cerebrospinal fluid shunts in pregnancy: Report of two cases and review of the literature. A m J Perinatol 1988; 5: 22-25 Ignelzi RJ, Kirsch WM. Follow-up analysis of ventriculoperitoneal and ventriculoatrial shunts for hydrocephalus. J Neurosurg 1975; 42: 679-682 Keucher TE, Mealey JJ. Long term results after ventriculoatrial and ventriculoperitoneal shunting for infantile hydrocephalus. J Neurosurg 1979; 50: 179186 Sekhar LN, Mossy J, Guthkelch AN. Malfunctioning ventriculoperitoneal shunts : Clinical and pathological features, J Neurosurg 1982; 56: 411-416
113
Case Report: Pregnant Woman with a Ventriculoperitoneal Shunt to Treat Hydrocephalus
Atsuhiko Okagaki,’) Hideharu I(anzaki,l) Kouzo Moritake,2) and Takahide Moril) I ) Department of Obstetrics and Gynecology, Kyoto University, Faculty of Medicine, Kyoto, Japan 2) Department of Neurosurgery, Kyoto University, Faculty of Medicine, Kyoto, Japan
Abstract A pregnant woman with hydrocephalus who required multiple revisions of a ventriculoperitoneal shunt is discussed. Her symptoms improved after the replacement of the ventriculoperitoneal (VP) shunt with a ventriculoatrial (VA) shunt, suggesting the benefits of ventriculoatrial shunting during pregnancy.
Key words: complicated pregnancy, ventriculoatrial (VA) shunt, ventriculoperitoneal (VP) shunt, hydrocephalus
Introduction The clinical results of extracranial shunting in patients with hydrocephalus have markedly improved, and women with such shunts have been able to carry pregnancies to term with successful deliveries. Since the first report of Monfared et al.” in 1979, 15 pregnancies involving extracranial shunts have been reported in the English literature.1-8) Shunt malfunction during pregnancy was noted in 7 pregnancies, and in 2 of them shunt revision was required. The following report is on a woman who required multiple revision of a ventriculoperitoneal shunt during the third trimester.
Case Report A 25-year-old pregnant woman, gravida 0,
was referred to our hospital for headaches and memory disturbances at 24 weeks’ gestation. (She had undergone her first operation for VP shunting at age 22, due to a diagnosis of aqueductal stenosis, and had subsequently undergone 3 additional shunt revisions within the following 12 months due to malfunctions.) At 24 weeks’ gestation, C T scan findings and palpation of the shunt reservoir suggested a shunt malfunction caused by occlusion of the distal tube, and the shunt was replaced with another VP shunt system. She was then asymptomatic until she began to complain of severe headaches and became drowsy at 31 weeks’ gestation, at which time a shunt malfunction was again suspected. As the symptoms did not improve when the flushing device was pumped, the VP shunt was replaced and direct drainage of the left ventricle was per-
Received: Feb. 28, 1990
Reprint request to: Dr. Atsnhiko Okagaki, Department of Gynecology and Obstetrics, Kyoto University, Faculty of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto 606, Japan 111
A. OKAGAKI ET AL.
formed. Following the VP shunt revision, her consciousness improved deteriorating again at 34 weeks’ gestation. Replacement of the left-VP shunt and direct drainage of the right ventricle were then performed, but her symptoms did not completely disappear. Therefore, delivery was induced with metreurysis and oxytocin infusion. Nine hours later, a female infant weighing 1,800 g was delivered, her Apgar scores were 8 and 9 at 1 and 5 min respectively. The patient’s symptoms gradually improved after delivery, but she had a seizure and became unconscious on the 20th postpartum day, when the VP shunt with a low pressure valve was replaced by a VA shunt with a medium pressure valve. Her condition then improved, and she was discharged 3 months after delivery without symptoms or abnormal computed tomography findings. There were no complications with the infant except for slight hyperbilirubinemia, which was for 2 days treated with phototherapy.
Discussion There is some controversy surrounding the treatment of shunting for pregnant women..
Table 1 summarizes the 15 reported pregnancies with extracranial shunts.1-8) I t is generally accepted that the severity of complications involved with VA shunts exceeds that of VP ~hunt.S-1~)Thus, some authors recommend VP shunts due to their lower rate of complications.7) However, 6 of 11 patients with VP shunts experienced neurological symptoms during pregnancy. Four of them were successfully treated by tapping and pumping the cerebrospinal fluid (CSF) reservoir of the shunt system. The remaining 2 pregnancies were treated by replacing the old VP shunt with a new one. During pregnancy, the expanding uterus may cause an increase in intraperitoneal pressure. An increase in the distal lumen to the shunt system causes a decrease in the pressure gradient between the ventricle and peritoneal cavity, resulting in decreased shunt flow. The flow of the shunt can neither be too small nor too large, otherwise the pressure gradient decreases and results in a decreased shunt flow. The repeated VP shunt malfunctions in the present case seem to derive from a combination of the narrow optimal range of the shunting pressure, the patient’s high shuntdependency due to her aqueductal stenosis,
Table 1. Reported pregnancies with extracranial shunts
No.
Author
Shunt
1 2 3 4 5 6 7 8 9 10 11
Monfared
VAa) VPb’ VP VP VP VP VA VA VA VP VP
12 13 14 15 16
Howard Kleinman Gast
Hanakita Nugent Frolich Samuels Okagaki ~~
VP VP VP VP VP
Problem
No No No No Shunt pumping Yes 29Wc: Shunt pumping Yes 2 9 W No No Shunt revision Yes 2 M Shunt revision Yes 32W Shunt placement Yes 7 W 3 W aft. del. Extra abdominal cyst operation Elective C/Sql No No CSFe) drainage C/S Yes 37W Yes 34W CSF drainage C/S Shunt revision etc. Yes 24W-
~
a) : ventriculoatrial shunt, b) : ventriculoperitoneal shunt, e) : cerebrospinal fluid
112
Therapy
c) : pregnancy 29 weeks,
d ) : cesarian section,
PREGNANT WOMEN WITH V P SHUNT
and the increase of pressure in the intraperitoneal cavity which causes a reverse pressure gradient in the shunt system. On the other hand, the function of a VA shunt is not affected by an enlarged uterus and increased intraperitoneal pressure as suggested by Samuels et aLs) The 4 reported pregnancies involving VA shunts had no malfunctions during the third trimester.lp4) In our case, VA shunt replacement seemed to be indicated. However, since , VA shunt replacement involves fetal risks caused by infection, and induction delivery is safer than VA shunt replacement after lung maturation, we elected against a VA shunt replacement during pregnancy. And, as shunt drainage cannot be maintain longer than one week, and the VA shunt replacement could be done anytime after delivery, as the patient became unconsciousness, we choose VA shunt replacement after delivery. The successful treatment of our case by installation of a VA shunt after repeated VP shunt malfunctions shows the benefits of VA shunts during pregnancy. We recommend VA shunt placement for all young woman with hydrocephalus who have any possibility of becoming pregnant.
References 1. Monfared AH, Koh KS, Apuzzo MLJ, CoIlea JV. Obstetric management of pregnant women with extracranial shunts. Can Med Assoc J 1979; 120: 562-563 2. Howard TE, Herrick CN. Pregnancy in patients with ventriculoperitoneal shunts : Report of two cases. A m J Obstet Gynecol 1981;141: 99-101
3.
4.
5.
6.
7.
8.
9.
10.
11.
Kleinman G, Sutherling W, Martinez M, Tabsh K. Malfunction of ventriculoperitoneal shunts during pregnancy. Obstet GynecoZl983; 61 : 753-754 Gast MJ, Grubb RL, Stricker RC. Maternal hydrocephalus and pregnancy. Obstet GynecoZl983; 62: 315-317 Hanakita J, Suzuki T , Yamamoto Y, et al. Ventriculoperitoneal shunt malfunction during pregnancy. J Neurosurg 1985; 63: 45 9-460 Nugent P, Sylvio H. Large extra-abdominal cyst of a postpartum complication of peritoneal shunt. J Neurosurg 1986; 64: 151-152 Frolich EP, Russel JM, VanGelderen CJ. Pregnancy in patients with ventriculoperitoneal shunts: Report of two cases. S Afr Med J 1986; 70: 358-360 Samuels P, Driscoll DA, London MB, et al. Cerebrospinal fluid shunts in pregnancy: Report of two cases and review of the literature. A m J Perinatol 1988; 5: 22-25 Ignelzi RJ, Kirsch WM. Follow-up analysis of ventriculoperitoneal and ventriculoatrial shunts for hydrocephalus. J Neurosurg 1975; 42: 679-682 Keucher TE, Mealey JJ. Long term results after ventriculoatrial and ventriculoperitoneal shunting for infantile hydrocephalus. J Neurosurg 1979; 50: 179186 Sekhar LN, Mossy J, Guthkelch AN. Malfunctioning ventriculoperitoneal shunts : Clinical and pathological features, J Neurosurg 1982; 56: 411-416
113
