Inr J Gynecol Obstet, 1992, 31: 271-274
International
Ventriculoperitoneal 0.A
271
Federation of Gynecology and Obstetrics
Olatunbosun,
shunt and pregnancy
E.O. Akande
and C.O. Adeoye
Department of Obstetrics and Gynecology, King Khalid University Hospital, PO Box 7805, Riyadh 11472 (Saudi Arabia)
(Received June 7th. 1991) (Accepted July 12th, 1991)
Abstract
A pregnancy in a patient with ventriculoperironeal (VP) shunt was recently managed at the authors’s institution. Review of the literature showed only six previous case reports. The management of this uncommon neurosurgical condition in pregnancy is presented along with a review of the literature. We conclude that pregnancy in a patient with a VP shunt for maternal hydrocephalus, generally has a normal outcome and that the function of the shunt is unaffected by pregnancy.
Keywords: Hydrocephalus,
triculoperitoneal
Pregnancy; Venshunt; Vaginal delivery.
Introduction
Patients with congenital hydrocephalus whose survival beyond infancy was not expected in the past, are now reaching childbearing age. Extracranial shunt techniques continue to improve, giving a new dimension to the problem of managing pregnant patients with congenital or acquired hydrocephalus, which has been, or needs to be corrected with a shunt. A patient with ventriculoperitoneal shunt 0020-7292/92/$05.00 0 1992 International Federation of Gynecology and Obstetrics Printed and Published in Ireland
for hydrocephalus was seen at the authors’ clinic during a recent pregnancy. Only six patients have been reported with this problem during pregnancy (Table 1). This report reviews and discusses the known information on this uncommon neurosurgical condition in pregnancy. Case report
NA is a 21-year-old Saudi woman, gravida 4, para 3, who was referred at 20 weeks of amenorrhea for consultation because of her past surgical history. She was diagnosed as having Arnold Chiari malformation with syringomyelia and hydrocephalus 1 year earlier. At that time she experienced severe headaches, blurring of vision, was unable to walk and had bilateral wasting of the hand muscles. Physical findings included normal intelligence, urinary incontinence, marked spastic paraparesis with weakness of the left upper extremity and bilateral optic atrophy. A computed axial tomography and magnetic resonance imaging of the brain showed massive hydrocephalus with Arnold Chiari malformation and a big syrinx extending from the upper cervical to the mid dorsal cord. She underwent a ventriculoperitoneal shunt and her postoperative course was uneventful. Post shunting her symptoms of headache, poor viCase Report
272
Olatunbosun et al.
Table 1.
Reports of ventriculoperitoneal
Source
Howard and Herrick [5] (1981) Howard and Herrick (51 (1981) Monfared et al. [7] (1979) Nugent and Hoshek [8] (1986) Hassan and Mouman ]41 (1988) Hassan and Mouman 141 (1988) Present case
Patient’s age (years)
shunts in pregnancy.
Time of shunt placement
Shunt complications
Mode of delivery
Comments
24
Pre-pregnancy
None
SVD”
No antibiotics during labor
25
12 weeks gestation
SVD
19
Pre-pregnancy
None
Low forceps delivery
Ampicillin/gentamicin prophylaxis during labor and delivery Penicillin during labor and delivery
30
7 weeks gestation
SVD
Extra-abdominal cyst formation
21
24 weeks gestation
Shunt displacement (extraabdominal) Abdominal pain
SVD
23
Pre-pregnancy
None
SVD
AmpicillirJgentamicin during labor and delivery Ampicillin/gentamicin during labor and delivery
21
Pre-pregnancy
None
SVD
Ampicillin/gentamicin during labor and delivery
“SVD = spontaneous vaginal delivery.
sion and difficulty in walking totally resolved and neurological examination was normal. During her fourth pregnancy the patient initally was seen in the authors’ clinic at 20 weeks gestation. She gave a history of 3 previous normal vaginal deliveries, the last, 1 year prior to placement of the ventriculoperitoneal shunt. Evaluation by a neurosurgeon prior to consultation showed the patient to be neurologically normal without evidence of shunt malfunction. Fetal evaluation showed a normal fetal heart rate of 160 beats min and biometric per measurements on ultrasound at 24 weeks were consistent with the last menstrual period. The patient was seen regularly by the neurosurgeon for evaluation. There was no evidence of shunt malfunction. Her pregnancy progressed normally to term. At 39 weeks of gestation the patient went into spontaneous labor. She received ampicillin and gentamicin for antibiotic proInt J Gynecol Obstet 37
phylaxis during labor and after delivery. She delivered vaginally, a viable 33 10 g male infant with Apgar scores of 8 and 9 at 1 and 5 min respectively. The hospital courses of both mother and infant were unremarkable. Discussion Pregnancy associated with maternal hydrocephalus is a rare event, approximately only 10 cases with extracranial shunts having been reported [2,5-81. Surgical intervention with placement of extracranial shunts has made survival of women with hydrocephalus into the childbearing years possible. The shunt system most commonly used for CSF diversion is that in which the distal catheter is placed into the peritoneal cavity; ventriculoperitoneal (VP) shunt [ 11. Before contemplating pregnancy, the patient with a VP shunt should be evaluated neurologically for shunt malfunction. This
Venrriculoperitoneal shunt and pregnancy
will serve as a guide to the degree of risk pregnancy would entail. Patients should also be informed of the increased risk of congenital hydrocephalus in their offspring [2]. Serial fetal ultrasonography may be useful in the antenatal detection of this anomaly. It is noteworthy that none of the offsprings of the patients reported in the literature had congenital hydrocephalus. Diversion of the CSF into the peritoneal cavity may be accomplished with little risk to the pregnant patient [2,4,6-81. Three of the six patients reported in the literature had the initial shunting procedure during pregnancy at 7, 12 and 24 weeks without complications (Table 1). A contraindication to placement of a ventriculoperitoneal shunt is the presence of previous extensive intraabdominal operations. This will require the surgeon to chose an alternate site for shunt insertion. During the antepartum period, frequent neurological evaluation is essential to identify shunt malfunction and complications. Complications related to ventriculoperitoneal shunts are mostly often due to obstruction or infection. Nugent and Hoshek [8] reported retraction of the distal catheter out of the peritoneal cavity with formation of an extraabdominal cyst filled with CSF in a postpartum patient. They suggested longer intraabdominal catheter segments to prevent this complication in a pregnant patient. Mechanical obstruction of the catheter may also result from kinking or entrapment of the catheter tip by fibrosis and omental encaseand intestinal ment, colon perforation obstruction [ 11. Onset of shunt malfunction is associated with headache, ataxia, dysphasia, visual field abnormalities, and sensory loss or paralysis. When ventricular enlargement is computed axial demonstrated on tomographic scanning of the brain, revision of the VP shunt is indicated, and this can be safely carried out during pregnancy [2]. During the intrapartum period, patients with ventriculoperitoneal shunt are at a great risk of shunt infection. Colonization of the shunt leading to generalized bacteremia sep-
273
sis, ventriculitis, meningitis and occasional peritonitis is one of the most serious complications of this surgical procedure. Suspicion of shunt infection is prompted by a febrile illness associated with leucocytosis in a patient in whom a shunt has been placed. The bacterial organisms most frequently implicated in shunt infection are Staphylococcus epidermidis and Staphylococcus aureus [3]. Although George et al. reported the incidence of shunt infection to be as high as 30-40%, none has been reported during pregnancy. Almost all the patients reported in the literature received perioperative antibiotics for initial shunt placement and revisions, and during parturition, as for persons with valvular heart disease. All reported patients with ventriculoperitoneal had shunts vaginal deliveries. Most authors advocate delivery per vagina unless there are obstetrical contraindications. The use of elective outlet forceps, sedation and regional anesthesia with the aim of obviating straining during the second stage of labor has been supported by many authors [2,4-71. Vaginal delivery is safer than cesarean section which carries the risk of intraabdominal sepsis; it should be avoided in women with ventriculoperitoneal shunt. In conclusion, patients with ventriculoperitoneal shunts withstand pregnancy and delivery well, so long as the shunt functions adequately. No serious complications have been directly attributed to pregnancy itself. An organized perinatal team approach with obstetrician, neurosurgeon and neurologist is essential for the successful management of this problem. References Davidson RI: hydrocephalus.
Peritoneal Historical
bypass review
in the treatment of and abdominal com-
plications J Neurol Neurosurg Psychiatry 3Y: 640, 1976. Gast MJ, Grubb RL, Stickler RC: Maternal hydrocephalus and pregnancy. Obstet Gynecol 62: 29s. 1983. George R, Leibrock L, Epstein M: Long-term analysis of cerebrospinal fluid shunt infections: a 2%year experience. J Neurosurg 51’ 804, 1979. Case Report
214
4
5
6
7
Oiarunbosun er al
Hassan A, Moumani AW: Pregnancy and ventriculoperitoneal shunt; report of a case and literature review. Acta Obstet Gynecol Stand 67: 669, 1988. Howard TE, Herrick CN: Pregnancy in patients with ventriculoperitoneal shunts: report of two cases. Am J Obstet Gynecol 141: 99, 1981. Keucher TR, Mealey J: Long term results after ventriculoatrial and ventriculoperitoneal shunting for infantile hydrocephalus. J Neurosurg 50: 179, 1979. Monfared AH, Koh KS, Apuzzo MLJ et al: Obstetric management of pregnant women with extracranial shunts. CMA J 120: 562, 1979.
Int J Gynecol Obstet 37
8
Nugent P, Hoshek S: Large extraabdominal postpartum complication of peritoneal Neurosurg 64: 151, 1986.
Address for reprints: O.A. Olahmbosun Department of Obstetrics and Cynaecology King Khalid University Hospital Riyadh Saudi Arabia 11472
cyst as a shunt. J
International
Ventriculoperitoneal 0.A
271
Federation of Gynecology and Obstetrics
Olatunbosun,
shunt and pregnancy
E.O. Akande
and C.O. Adeoye
Department of Obstetrics and Gynecology, King Khalid University Hospital, PO Box 7805, Riyadh 11472 (Saudi Arabia)
(Received June 7th. 1991) (Accepted July 12th, 1991)
Abstract
A pregnancy in a patient with ventriculoperironeal (VP) shunt was recently managed at the authors’s institution. Review of the literature showed only six previous case reports. The management of this uncommon neurosurgical condition in pregnancy is presented along with a review of the literature. We conclude that pregnancy in a patient with a VP shunt for maternal hydrocephalus, generally has a normal outcome and that the function of the shunt is unaffected by pregnancy.
Keywords: Hydrocephalus,
triculoperitoneal
Pregnancy; Venshunt; Vaginal delivery.
Introduction
Patients with congenital hydrocephalus whose survival beyond infancy was not expected in the past, are now reaching childbearing age. Extracranial shunt techniques continue to improve, giving a new dimension to the problem of managing pregnant patients with congenital or acquired hydrocephalus, which has been, or needs to be corrected with a shunt. A patient with ventriculoperitoneal shunt 0020-7292/92/$05.00 0 1992 International Federation of Gynecology and Obstetrics Printed and Published in Ireland
for hydrocephalus was seen at the authors’ clinic during a recent pregnancy. Only six patients have been reported with this problem during pregnancy (Table 1). This report reviews and discusses the known information on this uncommon neurosurgical condition in pregnancy. Case report
NA is a 21-year-old Saudi woman, gravida 4, para 3, who was referred at 20 weeks of amenorrhea for consultation because of her past surgical history. She was diagnosed as having Arnold Chiari malformation with syringomyelia and hydrocephalus 1 year earlier. At that time she experienced severe headaches, blurring of vision, was unable to walk and had bilateral wasting of the hand muscles. Physical findings included normal intelligence, urinary incontinence, marked spastic paraparesis with weakness of the left upper extremity and bilateral optic atrophy. A computed axial tomography and magnetic resonance imaging of the brain showed massive hydrocephalus with Arnold Chiari malformation and a big syrinx extending from the upper cervical to the mid dorsal cord. She underwent a ventriculoperitoneal shunt and her postoperative course was uneventful. Post shunting her symptoms of headache, poor viCase Report
272
Olatunbosun et al.
Table 1.
Reports of ventriculoperitoneal
Source
Howard and Herrick [5] (1981) Howard and Herrick (51 (1981) Monfared et al. [7] (1979) Nugent and Hoshek [8] (1986) Hassan and Mouman ]41 (1988) Hassan and Mouman 141 (1988) Present case
Patient’s age (years)
shunts in pregnancy.
Time of shunt placement
Shunt complications
Mode of delivery
Comments
24
Pre-pregnancy
None
SVD”
No antibiotics during labor
25
12 weeks gestation
SVD
19
Pre-pregnancy
None
Low forceps delivery
Ampicillin/gentamicin prophylaxis during labor and delivery Penicillin during labor and delivery
30
7 weeks gestation
SVD
Extra-abdominal cyst formation
21
24 weeks gestation
Shunt displacement (extraabdominal) Abdominal pain
SVD
23
Pre-pregnancy
None
SVD
AmpicillirJgentamicin during labor and delivery Ampicillin/gentamicin during labor and delivery
21
Pre-pregnancy
None
SVD
Ampicillin/gentamicin during labor and delivery
“SVD = spontaneous vaginal delivery.
sion and difficulty in walking totally resolved and neurological examination was normal. During her fourth pregnancy the patient initally was seen in the authors’ clinic at 20 weeks gestation. She gave a history of 3 previous normal vaginal deliveries, the last, 1 year prior to placement of the ventriculoperitoneal shunt. Evaluation by a neurosurgeon prior to consultation showed the patient to be neurologically normal without evidence of shunt malfunction. Fetal evaluation showed a normal fetal heart rate of 160 beats min and biometric per measurements on ultrasound at 24 weeks were consistent with the last menstrual period. The patient was seen regularly by the neurosurgeon for evaluation. There was no evidence of shunt malfunction. Her pregnancy progressed normally to term. At 39 weeks of gestation the patient went into spontaneous labor. She received ampicillin and gentamicin for antibiotic proInt J Gynecol Obstet 37
phylaxis during labor and after delivery. She delivered vaginally, a viable 33 10 g male infant with Apgar scores of 8 and 9 at 1 and 5 min respectively. The hospital courses of both mother and infant were unremarkable. Discussion Pregnancy associated with maternal hydrocephalus is a rare event, approximately only 10 cases with extracranial shunts having been reported [2,5-81. Surgical intervention with placement of extracranial shunts has made survival of women with hydrocephalus into the childbearing years possible. The shunt system most commonly used for CSF diversion is that in which the distal catheter is placed into the peritoneal cavity; ventriculoperitoneal (VP) shunt [ 11. Before contemplating pregnancy, the patient with a VP shunt should be evaluated neurologically for shunt malfunction. This
Venrriculoperitoneal shunt and pregnancy
will serve as a guide to the degree of risk pregnancy would entail. Patients should also be informed of the increased risk of congenital hydrocephalus in their offspring [2]. Serial fetal ultrasonography may be useful in the antenatal detection of this anomaly. It is noteworthy that none of the offsprings of the patients reported in the literature had congenital hydrocephalus. Diversion of the CSF into the peritoneal cavity may be accomplished with little risk to the pregnant patient [2,4,6-81. Three of the six patients reported in the literature had the initial shunting procedure during pregnancy at 7, 12 and 24 weeks without complications (Table 1). A contraindication to placement of a ventriculoperitoneal shunt is the presence of previous extensive intraabdominal operations. This will require the surgeon to chose an alternate site for shunt insertion. During the antepartum period, frequent neurological evaluation is essential to identify shunt malfunction and complications. Complications related to ventriculoperitoneal shunts are mostly often due to obstruction or infection. Nugent and Hoshek [8] reported retraction of the distal catheter out of the peritoneal cavity with formation of an extraabdominal cyst filled with CSF in a postpartum patient. They suggested longer intraabdominal catheter segments to prevent this complication in a pregnant patient. Mechanical obstruction of the catheter may also result from kinking or entrapment of the catheter tip by fibrosis and omental encaseand intestinal ment, colon perforation obstruction [ 11. Onset of shunt malfunction is associated with headache, ataxia, dysphasia, visual field abnormalities, and sensory loss or paralysis. When ventricular enlargement is computed axial demonstrated on tomographic scanning of the brain, revision of the VP shunt is indicated, and this can be safely carried out during pregnancy [2]. During the intrapartum period, patients with ventriculoperitoneal shunt are at a great risk of shunt infection. Colonization of the shunt leading to generalized bacteremia sep-
273
sis, ventriculitis, meningitis and occasional peritonitis is one of the most serious complications of this surgical procedure. Suspicion of shunt infection is prompted by a febrile illness associated with leucocytosis in a patient in whom a shunt has been placed. The bacterial organisms most frequently implicated in shunt infection are Staphylococcus epidermidis and Staphylococcus aureus [3]. Although George et al. reported the incidence of shunt infection to be as high as 30-40%, none has been reported during pregnancy. Almost all the patients reported in the literature received perioperative antibiotics for initial shunt placement and revisions, and during parturition, as for persons with valvular heart disease. All reported patients with ventriculoperitoneal had shunts vaginal deliveries. Most authors advocate delivery per vagina unless there are obstetrical contraindications. The use of elective outlet forceps, sedation and regional anesthesia with the aim of obviating straining during the second stage of labor has been supported by many authors [2,4-71. Vaginal delivery is safer than cesarean section which carries the risk of intraabdominal sepsis; it should be avoided in women with ventriculoperitoneal shunt. In conclusion, patients with ventriculoperitoneal shunts withstand pregnancy and delivery well, so long as the shunt functions adequately. No serious complications have been directly attributed to pregnancy itself. An organized perinatal team approach with obstetrician, neurosurgeon and neurologist is essential for the successful management of this problem. References Davidson RI: hydrocephalus.
Peritoneal Historical
bypass review
in the treatment of and abdominal com-
plications J Neurol Neurosurg Psychiatry 3Y: 640, 1976. Gast MJ, Grubb RL, Stickler RC: Maternal hydrocephalus and pregnancy. Obstet Gynecol 62: 29s. 1983. George R, Leibrock L, Epstein M: Long-term analysis of cerebrospinal fluid shunt infections: a 2%year experience. J Neurosurg 51’ 804, 1979. Case Report
214
4
5
6
7
Oiarunbosun er al
Hassan A, Moumani AW: Pregnancy and ventriculoperitoneal shunt; report of a case and literature review. Acta Obstet Gynecol Stand 67: 669, 1988. Howard TE, Herrick CN: Pregnancy in patients with ventriculoperitoneal shunts: report of two cases. Am J Obstet Gynecol 141: 99, 1981. Keucher TR, Mealey J: Long term results after ventriculoatrial and ventriculoperitoneal shunting for infantile hydrocephalus. J Neurosurg 50: 179, 1979. Monfared AH, Koh KS, Apuzzo MLJ et al: Obstetric management of pregnant women with extracranial shunts. CMA J 120: 562, 1979.
Int J Gynecol Obstet 37
8
Nugent P, Hoshek S: Large extraabdominal postpartum complication of peritoneal Neurosurg 64: 151, 1986.
Address for reprints: O.A. Olahmbosun Department of Obstetrics and Cynaecology King Khalid University Hospital Riyadh Saudi Arabia 11472
cyst as a shunt. J
