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Pregnancy complicated by subarachnoid hemorrhage
COibEPLICATED
PRWHAHOY
A Report M. OARBER, M.D., F.A.C.S., (From
the Department
of
BRRAUB
BY SUBARACH#OID of Three Cases
AND R. R. MAIER, Obstetrics
and
Gynecology,
M.D., Mt.
CLEVELAND, %nai
OHIO
Hospital)
UBARACRNOID hemorrhage has been established as a definite, relatively common elins It rarely occurs, however, as a complication of pregical entity in the past sixty years. uancy, labor, or the puerperium. Moskowitz and Schneider, in 1938, reported three easee occurring during labor. They found t,hirteen cases reported up to that date. A recent search of the literature revealed only four additional occurrences: one reported in 1938 by Pancot and Galle, secondary t,o an intracerebral accident due to syphilis; and three reported by T. Dahle in 1946, in which toxemia of pregnancy was considered the causative factor. In the general consideration of subarachnoid hemorrhage, aside from its occurrence as a complication of pregnancy, a variety of diseases and conditions has been suggested aa Infections such as influenza, typhoid, smallpox, and syphilis; toxic conditions etiologie factors. including alcoholism, lead poisoning, and toxemias of pregnancy; and vascular lesions like arteriosclerosis and aneurysms have all been considered. The latter have been found most Two types of subarachnoid hemorrhage are distinguished: primary and secfrequently. ondary. In the first, the bleeding is into the subarachnoid space from a ruptured adjacent artery. This type is characterized by headache, delayed loss of consciousness, and late signs of paralysis. In the second type the bleeding is due to extension of intracerebral hemorrhage into the subarachnoid space, and is characterized by early signs of paralysis and rapid loss of consciousness. The latter occurs more often in the older age groups, and is usually on an arteriosclerotic basis. In the primary type the younger age groups are more commonly affected, and the cause is thought to he a rupture of a small ‘ ‘ berry ’ ’ type congenital aneurysm. Such aneurysms are frequently found at routine autopsies in which the incidence is reported Congenital aneurysms result from a local weakness or defect in the to bc 0.3 to I.0 per cent. media of the cerebral arteries and occur at the points of bifurcation in the region of the Circle of Willis where the vessels are essentially suspended in fluid with little oxternal support. These vessels may rupture easily under the impact of trauma from emotional strain, increased systolic pressure, or physical exertion. In the initial phase of the accident the striking symptoms of headache, vomiting, bradycardia, followed by stupor and coma, manifest themselves. If the patient does not succumb shortly after the accident the condition progresses with signs of meningeal irritation such as pain in the head, rigidity of the neck, a positive Kernig’s sign, leucocytosis and fever. Tile pathognomonio sign of subarachnoid hemorrhage is the finding of bloody spinal fluid under increased pressure.
Case Reports CASE 1.--l. R. ‘I’.. a 26-year-old Negro para 6, gravida ii, in her eighth month of gesta tion, was admitted to the hospital on Sept. 10, 1946, with painless vaginal bleeding of about At, the time of the onset of the vaginal bleeding she complained of t.en hours ’ durnt.ion. nausea, vomiting, and severe frontal and occipital headache, throbbing iu character. The past history was essentially negative except for a spontaneous three-month miscarriage in 1945, Her blood pressure was esentially negative. The uterus rvas enlarged to almost the size of a term pregnancy, and the fetal heart tones were heard. A catheterized urine specimen revealed a two plus albumin and hyaline casts. An x-ray examination of the abdomen with air insufflation of the bladder demonstrated a shadow suggestive of a low implantation of the placenta on the left posterior aspect of the uterus. A tentative diagnosis of partial placenta previa and toxemia of pregnancy was made, and it was decided to deliver the patient 1174
Volume
Number6
56
PREGNANCY
WITH
SUBARACHNOID
HEMORRHAGE
1175
by cesarean section. Lumbar puncture for spinal anesthesia showed a uniformly bloody spinal fluid, but its significance was overlooked. A low cervical section was done a,nd a premature viable male infant delivered. For three days postoperatively she ran a temperature of 100.5” F. She continued to complain of headache, but this was considered to be due to spinal anesthesia. On Sept. 16, 1946, her temperature rose to 102” F. She complained of severe headache and nuchal rigidity, but there was no nausea or vomiting. Examination on that date revealed no eye signs or pathologic reflexes, but definite evidence of meningeal irritation developed gradually in the form of a fine nystagmus, marked nuchal rigidity, absent upper reflexes, depressed lower reflexes, and a positive Eernig ‘s sign. A lumbar puncture on Sept. 20, 1946, revealed a grossly bloody fluid with an initial pressure of only 190 mm. of water and a four plus Pandy. The headache and nuchal rigidity gradually subsided. Spinal puncture on September 21 and September 23 demonstrated a gradual return to normal with the fluid on the latter date showing a xanthochromic color and only an occasional red blood cell and a one plus Pandy. The patient had a clear sensorium and was discharged from the hospital on Sept. 27, 1946, in good condition, The laboratory findings during her stay at the hospital were not remarkable. The urine which on admission had shown a two plus albumin became negative. On September 16 the white count rose to 10,650, but at other times was within normal range. Blood chemistry and serology were normal. A spinal fluid culture on September 21 showed no growth. In this case the accident, in all probability, occurred prior to her cesarean section as evidenced by her symptoms on admission and the bloody spinal fluid obtained at that time. It was overlooked due to the existence of a toxemia. CASE 2.-D. R., a 26.year-old white multipara, was admitted to the hospital on Nov. 20, 1946, in her thirty-fourth week of gestation, with a complaint of severe headache. Nine hours prior to admission the patient bent over and suddenly experienced a terrific pounding in the frontal region which subsequently became generalized and progressively more severe. She felt faint, did not lose consciousness, and within one and one-half hours developed marked nausea and projectile vomiting. Her family and past history was negative. She had had The blood pressure on admission one child and one abortion. She did not appear acutely ill. was 110/70 ; the pulse rate 66. Her pupils reacted to light and accommodation and the right fundus showed evidence of papilledema. There was moderate nuchal rigidity, but no A spinal puncture revealed a uniformly bloody fluid w-ith pathologic reflexes were present. an initial pressure of 280 mm. of water which dropped to 180 mm. upon slow withdrawal of the fluid. She was maintained at absolute bed rest, but in spite of that she apparently had a second episode of bleeding with an exacerbation of the headache. Examination at this time revealed well-established bilateral papilledema and absent patellar reflexes. Spinal puncture showed a xanthochromic fluid with pressures identical with those of the tap on admission. During the next several days, except for dizziness on movement of her head, the patient showed signs of improvement. She was allowed to be up on December 12, and the following day was found sprawled unconscious on the floor. Her breathing was stertorous. She vomited and urinated involuntarily. All superficial and deep reflexes were hyperactive; and bilateral positive Babinski and ankle clonus were present. She gradually became excited and incoherent. Her temperature for the first time rose to 100” F. A spinal puncture the following day again showed a grossly bloody fluid with an initial pressure of 560 mm, of water which was reduced to 260 mm. by withdrawal of fluid. On December 15 the patient appeared to be moribund. In view of the fact that the baby was viable, and that the additional trauma of labor was undesirable, it was decided to terminate the pregnancy by section before term. The lumbar puncture for spinal anesthesia still revealed a bloody fluid and an initial pressure of 450 A classical section was done, and a ‘i-pound viable female infant delivered. mm. of water. The patient regained consciousness promptly after the operation, and her improvement was uninterrupted and progressive. In a period of seven days spinal fluid pressure dropped from 600 mm. to 300 mm. of water. She showed evidence of eneephalopathy simulating schizophrenia. But within a week she manifested marked improvement, showed a return of considerable alertness, and was discharged from the hospital on Jan. 7, 1947, in good condition.
1176
GARBER
AND
MAIER
Am. J. Obst. & Gynec. December, 1948
The laboratory findings were at no time remarkable. She had a moderate leucocytosis ranging from 9,100 to 11,550, but red counts, bleeding, and clotting times, prothrombin indices, blood chemistries, and serologies were all normal. Spinal fluid chemistries due to the admixture of blood were not reliable, and spinal fluid cultures, which revealed nothing on direct smear, showed a slight growth of gram positive cocci believed to be a contaminant. While the diagnosis in this case was relatively easy and definite, the treatment and management were uncert,ain. The main problem was the selection of the propitious time for the termination of pregnancy in view of the danger of precipitating another and perhaps fatal hemorrhage. Her apparently moribund state, however, forced the issue with, fortunately, a satisfactory outcome. CASE 3.-W. W., a N-year-old white primiparous female, was admitted to the hospiOa1 Examina,tion showed that she was almost ready on June 19, 1947, in active labor at term. for delivery. Under general anesthesia a term male infant was delivered with low forceps at ?:30 P.M. FolIowing delivery a tendency toward postpartum bleeding was noted and the patient received an ampule of infundin intramuscularly, an ampule of ergotrate, and a cubic centimeter of pitocin intravenously in the course of some twenty minutes. At 8:15 P.M. she The reacted from her anesthesia, became quite restless, and was given y* grain morphine. following day the patient appeared drowsy, but that was attributed to the effect of the anesthesia, On June 21, 3947, she complained of a marked headache. The next day the headache became more severe, and she had a stiffness of her neck with no apparent other signs. A spinal puncture was done and uniformly bloody fluid obtained with an initial pressure of 360 mm. of water, which on withdrawal of the fluid came down to 210 mm. By June 23 her temperature rose to 102” F., she beeameamarkedly lethargic, and complained of severe frontal and occipital headache. Examination disclosed marked nuchal rigidity, a positive Babinski, and resistance to straight leg raising, but her pupils and fundi remained normal. The blood pressure was 120/70 and the pulse rate fifty. The following day another spinal puncture again showed a grossly bloody fluid and an initial pressure of 332 mm. of water which was reduced to 162 mm, by withdrawal of fluid. She was treated expectantly with absolute bed rest and became more alert, her headaches gradually subsided, the pulse rate rose t.o seventy, and her nuchal rigidity and pathologic reflexes disappeared. She was allowed to be up July 2, and was discharged from the hospital the following day with no apparent residual signs. The laboratory findings were not remarkable. She ran a leucocytosis of from 11,100 to 14,050 with 86 per cent polymorphonuclears. Hemoglobins, red counts, blood ehemistries, and serology were normal. Spinal fluid examinations were grossly bloody and showed positive Pandys and high cell counts. This case is of interest in that it exemplifies th dangers inherent in the liberal use of oxytocics, because such drugs may give rise to just enough pressor action to precipitate rupture of a congenital aneurysm with resulting subarachnoid hemorrhage.
Discussion The cases here presented are all proved examples of subarachnoid hemorrhage complicatiug pregnancy, labor, and the puerperium. All occurred in young women of 24 and 26 years id age. Since none showed either early coma or residual paralysis they were probably ot +he primary variety and most likely secondary to congenital aneurysms of the Circle of Willis. Two of our cases presented similar patterns including normal blood pressures, moderate elevations of t,emperature, moderate leucocytosis, grossly bloody spinal fluid with markedly inrtcased pressure, and meningeal signs such as nuchal rigidity and pathologic reflexes several days following the original accident. The third case differed from the others in that the blood pressure was moderately elevated and the spinal fluid pressure was not unduly high. In two of our eases, as in those reported by Moskowitz and Schneider, toxemia was not a factor; but in one, as in the three cases reported by T. Dahle from Norway, toxemia may have played a role in the etiology. The diagnosis of eubarachnoid hemorrhage ctomplicating pretgnancy and delivery may be obscured by other conditions such as shock, anesthesia, and a prePPhmpSki. Dahle and others have emphasized the latter possibility and have pointed out that
Volume Number
56 6
PREGNANCY
WITH
SUBARACHNOID
1177
HEMORRHAGE
Still another factor without recourse to spinal puncture a mistaken diagnosis may be made. which may obscure the diagnosis is delivery under spinal anesthesia, since the manifestations of ‘ ‘ spinal headache, ’ ’ nuchal signs, and meningismus are frequently encountered following that type of anesthesia. In spite of the fact that lumbar puncture in the face of an increased intracranial pressure is considered by many as a dangerous procedure, all of these cases were subjected to repeated punctures. Removal of the irritating bloody fluids and lowering of the intracranial pressure apparently served to decrease the meningeal irritation and lessen the lethargy. The taps were done cautiously, the fluid removed slowly; and in the cases with increased pressure, the pressure was decreased by not more than half. The delivery of Case 2 by cesarean section was in accord with the conclusion of Moskowitz and Schneider that when the diagnosis has been established, cesarean section offers the least additional trauma. The emptying of the uterus in this case seems to have been a factor in her recovery. It is quite possible that eesarean section by decreasing abdominal pressure and allowing for stagnation in a dilated splanchnic vascular bed decreases the circulating blood volume, the venous pressure, and hence the intracranial pressure.
Summary 1. Three
cases
of
proved
subarachnoid
hemorrhage
complicating
pregnancy
have
been
reported. 2. All three were apparently of the primary type and probably occurred at the sites of congenital aneurysms of the Circle of Willis. 3. Oxytocics should be used cautiously, particularly in cases with elevated blood pressure, a history of migraine, or any suggestive premonitory signs. 4. The use of repeated spinal puncture to relieve the symptoms of intracranial pressure and the employment of cesarean section to avoid the trauma of labor proved efficacious in the cases reported. 5. Subarachnoid bleeding may occur in milder forms, and be obscured by general anesthesia, shock, toxemia, or symptoms of “spinal headache.” 6. The more frequent employment of diagnostic lumbar puncture would obviate those sources of error since the finding of bloody spinal fluid under increased pressure is pathognomonic of subarachnoid hemorrhage.
R&f erences 1. Moskowitz, H. Leo, and Schneider, H.: AK J. 0~s~. & GYNEC. $ paz;t pd - Galle: Nord. med. Bull. 29:Sot. gynec. 1946. et d ‘obst. 27: 366,193s. 4: Evans: J:*P.: 5. Hirschfield, B. 1942. 6. Magee, C. G.: 7. German, Wm.
Ohio State A,, Tornay,
587, J. 36: 1086, 1940. M. A. S., and Yaskin, J.
Lancet 2: 497,1943. J.: Connecticut M.
J. 7: 88, 1943.
C.:
J.
36: 489, 1938.
M.
Sot.
New
Jersey
39:
494,
PRWHAHOY
A Report M. OARBER, M.D., F.A.C.S., (From
the Department
of
BRRAUB
BY SUBARACH#OID of Three Cases
AND R. R. MAIER, Obstetrics
and
Gynecology,
M.D., Mt.
CLEVELAND, %nai
OHIO
Hospital)
UBARACRNOID hemorrhage has been established as a definite, relatively common elins It rarely occurs, however, as a complication of pregical entity in the past sixty years. uancy, labor, or the puerperium. Moskowitz and Schneider, in 1938, reported three easee occurring during labor. They found t,hirteen cases reported up to that date. A recent search of the literature revealed only four additional occurrences: one reported in 1938 by Pancot and Galle, secondary t,o an intracerebral accident due to syphilis; and three reported by T. Dahle in 1946, in which toxemia of pregnancy was considered the causative factor. In the general consideration of subarachnoid hemorrhage, aside from its occurrence as a complication of pregnancy, a variety of diseases and conditions has been suggested aa Infections such as influenza, typhoid, smallpox, and syphilis; toxic conditions etiologie factors. including alcoholism, lead poisoning, and toxemias of pregnancy; and vascular lesions like arteriosclerosis and aneurysms have all been considered. The latter have been found most Two types of subarachnoid hemorrhage are distinguished: primary and secfrequently. ondary. In the first, the bleeding is into the subarachnoid space from a ruptured adjacent artery. This type is characterized by headache, delayed loss of consciousness, and late signs of paralysis. In the second type the bleeding is due to extension of intracerebral hemorrhage into the subarachnoid space, and is characterized by early signs of paralysis and rapid loss of consciousness. The latter occurs more often in the older age groups, and is usually on an arteriosclerotic basis. In the primary type the younger age groups are more commonly affected, and the cause is thought to he a rupture of a small ‘ ‘ berry ’ ’ type congenital aneurysm. Such aneurysms are frequently found at routine autopsies in which the incidence is reported Congenital aneurysms result from a local weakness or defect in the to bc 0.3 to I.0 per cent. media of the cerebral arteries and occur at the points of bifurcation in the region of the Circle of Willis where the vessels are essentially suspended in fluid with little oxternal support. These vessels may rupture easily under the impact of trauma from emotional strain, increased systolic pressure, or physical exertion. In the initial phase of the accident the striking symptoms of headache, vomiting, bradycardia, followed by stupor and coma, manifest themselves. If the patient does not succumb shortly after the accident the condition progresses with signs of meningeal irritation such as pain in the head, rigidity of the neck, a positive Kernig’s sign, leucocytosis and fever. Tile pathognomonio sign of subarachnoid hemorrhage is the finding of bloody spinal fluid under increased pressure.
Case Reports CASE 1.--l. R. ‘I’.. a 26-year-old Negro para 6, gravida ii, in her eighth month of gesta tion, was admitted to the hospital on Sept. 10, 1946, with painless vaginal bleeding of about At, the time of the onset of the vaginal bleeding she complained of t.en hours ’ durnt.ion. nausea, vomiting, and severe frontal and occipital headache, throbbing iu character. The past history was essentially negative except for a spontaneous three-month miscarriage in 1945, Her blood pressure was esentially negative. The uterus rvas enlarged to almost the size of a term pregnancy, and the fetal heart tones were heard. A catheterized urine specimen revealed a two plus albumin and hyaline casts. An x-ray examination of the abdomen with air insufflation of the bladder demonstrated a shadow suggestive of a low implantation of the placenta on the left posterior aspect of the uterus. A tentative diagnosis of partial placenta previa and toxemia of pregnancy was made, and it was decided to deliver the patient 1174
Volume
Number6
56
PREGNANCY
WITH
SUBARACHNOID
HEMORRHAGE
1175
by cesarean section. Lumbar puncture for spinal anesthesia showed a uniformly bloody spinal fluid, but its significance was overlooked. A low cervical section was done a,nd a premature viable male infant delivered. For three days postoperatively she ran a temperature of 100.5” F. She continued to complain of headache, but this was considered to be due to spinal anesthesia. On Sept. 16, 1946, her temperature rose to 102” F. She complained of severe headache and nuchal rigidity, but there was no nausea or vomiting. Examination on that date revealed no eye signs or pathologic reflexes, but definite evidence of meningeal irritation developed gradually in the form of a fine nystagmus, marked nuchal rigidity, absent upper reflexes, depressed lower reflexes, and a positive Eernig ‘s sign. A lumbar puncture on Sept. 20, 1946, revealed a grossly bloody fluid with an initial pressure of only 190 mm. of water and a four plus Pandy. The headache and nuchal rigidity gradually subsided. Spinal puncture on September 21 and September 23 demonstrated a gradual return to normal with the fluid on the latter date showing a xanthochromic color and only an occasional red blood cell and a one plus Pandy. The patient had a clear sensorium and was discharged from the hospital on Sept. 27, 1946, in good condition, The laboratory findings during her stay at the hospital were not remarkable. The urine which on admission had shown a two plus albumin became negative. On September 16 the white count rose to 10,650, but at other times was within normal range. Blood chemistry and serology were normal. A spinal fluid culture on September 21 showed no growth. In this case the accident, in all probability, occurred prior to her cesarean section as evidenced by her symptoms on admission and the bloody spinal fluid obtained at that time. It was overlooked due to the existence of a toxemia. CASE 2.-D. R., a 26.year-old white multipara, was admitted to the hospital on Nov. 20, 1946, in her thirty-fourth week of gestation, with a complaint of severe headache. Nine hours prior to admission the patient bent over and suddenly experienced a terrific pounding in the frontal region which subsequently became generalized and progressively more severe. She felt faint, did not lose consciousness, and within one and one-half hours developed marked nausea and projectile vomiting. Her family and past history was negative. She had had The blood pressure on admission one child and one abortion. She did not appear acutely ill. was 110/70 ; the pulse rate 66. Her pupils reacted to light and accommodation and the right fundus showed evidence of papilledema. There was moderate nuchal rigidity, but no A spinal puncture revealed a uniformly bloody fluid w-ith pathologic reflexes were present. an initial pressure of 280 mm. of water which dropped to 180 mm. upon slow withdrawal of the fluid. She was maintained at absolute bed rest, but in spite of that she apparently had a second episode of bleeding with an exacerbation of the headache. Examination at this time revealed well-established bilateral papilledema and absent patellar reflexes. Spinal puncture showed a xanthochromic fluid with pressures identical with those of the tap on admission. During the next several days, except for dizziness on movement of her head, the patient showed signs of improvement. She was allowed to be up on December 12, and the following day was found sprawled unconscious on the floor. Her breathing was stertorous. She vomited and urinated involuntarily. All superficial and deep reflexes were hyperactive; and bilateral positive Babinski and ankle clonus were present. She gradually became excited and incoherent. Her temperature for the first time rose to 100” F. A spinal puncture the following day again showed a grossly bloody fluid with an initial pressure of 560 mm, of water which was reduced to 260 mm. by withdrawal of fluid. On December 15 the patient appeared to be moribund. In view of the fact that the baby was viable, and that the additional trauma of labor was undesirable, it was decided to terminate the pregnancy by section before term. The lumbar puncture for spinal anesthesia still revealed a bloody fluid and an initial pressure of 450 A classical section was done, and a ‘i-pound viable female infant delivered. mm. of water. The patient regained consciousness promptly after the operation, and her improvement was uninterrupted and progressive. In a period of seven days spinal fluid pressure dropped from 600 mm. to 300 mm. of water. She showed evidence of eneephalopathy simulating schizophrenia. But within a week she manifested marked improvement, showed a return of considerable alertness, and was discharged from the hospital on Jan. 7, 1947, in good condition.
1176
GARBER
AND
MAIER
Am. J. Obst. & Gynec. December, 1948
The laboratory findings were at no time remarkable. She had a moderate leucocytosis ranging from 9,100 to 11,550, but red counts, bleeding, and clotting times, prothrombin indices, blood chemistries, and serologies were all normal. Spinal fluid chemistries due to the admixture of blood were not reliable, and spinal fluid cultures, which revealed nothing on direct smear, showed a slight growth of gram positive cocci believed to be a contaminant. While the diagnosis in this case was relatively easy and definite, the treatment and management were uncert,ain. The main problem was the selection of the propitious time for the termination of pregnancy in view of the danger of precipitating another and perhaps fatal hemorrhage. Her apparently moribund state, however, forced the issue with, fortunately, a satisfactory outcome. CASE 3.-W. W., a N-year-old white primiparous female, was admitted to the hospiOa1 Examina,tion showed that she was almost ready on June 19, 1947, in active labor at term. for delivery. Under general anesthesia a term male infant was delivered with low forceps at ?:30 P.M. FolIowing delivery a tendency toward postpartum bleeding was noted and the patient received an ampule of infundin intramuscularly, an ampule of ergotrate, and a cubic centimeter of pitocin intravenously in the course of some twenty minutes. At 8:15 P.M. she The reacted from her anesthesia, became quite restless, and was given y* grain morphine. following day the patient appeared drowsy, but that was attributed to the effect of the anesthesia, On June 21, 3947, she complained of a marked headache. The next day the headache became more severe, and she had a stiffness of her neck with no apparent other signs. A spinal puncture was done and uniformly bloody fluid obtained with an initial pressure of 360 mm. of water, which on withdrawal of the fluid came down to 210 mm. By June 23 her temperature rose to 102” F., she beeameamarkedly lethargic, and complained of severe frontal and occipital headache. Examination disclosed marked nuchal rigidity, a positive Babinski, and resistance to straight leg raising, but her pupils and fundi remained normal. The blood pressure was 120/70 and the pulse rate fifty. The following day another spinal puncture again showed a grossly bloody fluid and an initial pressure of 332 mm. of water which was reduced to 162 mm, by withdrawal of fluid. She was treated expectantly with absolute bed rest and became more alert, her headaches gradually subsided, the pulse rate rose t.o seventy, and her nuchal rigidity and pathologic reflexes disappeared. She was allowed to be up July 2, and was discharged from the hospital the following day with no apparent residual signs. The laboratory findings were not remarkable. She ran a leucocytosis of from 11,100 to 14,050 with 86 per cent polymorphonuclears. Hemoglobins, red counts, blood ehemistries, and serology were normal. Spinal fluid examinations were grossly bloody and showed positive Pandys and high cell counts. This case is of interest in that it exemplifies th dangers inherent in the liberal use of oxytocics, because such drugs may give rise to just enough pressor action to precipitate rupture of a congenital aneurysm with resulting subarachnoid hemorrhage.
Discussion The cases here presented are all proved examples of subarachnoid hemorrhage complicatiug pregnancy, labor, and the puerperium. All occurred in young women of 24 and 26 years id age. Since none showed either early coma or residual paralysis they were probably ot +he primary variety and most likely secondary to congenital aneurysms of the Circle of Willis. Two of our cases presented similar patterns including normal blood pressures, moderate elevations of t,emperature, moderate leucocytosis, grossly bloody spinal fluid with markedly inrtcased pressure, and meningeal signs such as nuchal rigidity and pathologic reflexes several days following the original accident. The third case differed from the others in that the blood pressure was moderately elevated and the spinal fluid pressure was not unduly high. In two of our eases, as in those reported by Moskowitz and Schneider, toxemia was not a factor; but in one, as in the three cases reported by T. Dahle from Norway, toxemia may have played a role in the etiology. The diagnosis of eubarachnoid hemorrhage ctomplicating pretgnancy and delivery may be obscured by other conditions such as shock, anesthesia, and a prePPhmpSki. Dahle and others have emphasized the latter possibility and have pointed out that
Volume Number
56 6
PREGNANCY
WITH
SUBARACHNOID
1177
HEMORRHAGE
Still another factor without recourse to spinal puncture a mistaken diagnosis may be made. which may obscure the diagnosis is delivery under spinal anesthesia, since the manifestations of ‘ ‘ spinal headache, ’ ’ nuchal signs, and meningismus are frequently encountered following that type of anesthesia. In spite of the fact that lumbar puncture in the face of an increased intracranial pressure is considered by many as a dangerous procedure, all of these cases were subjected to repeated punctures. Removal of the irritating bloody fluids and lowering of the intracranial pressure apparently served to decrease the meningeal irritation and lessen the lethargy. The taps were done cautiously, the fluid removed slowly; and in the cases with increased pressure, the pressure was decreased by not more than half. The delivery of Case 2 by cesarean section was in accord with the conclusion of Moskowitz and Schneider that when the diagnosis has been established, cesarean section offers the least additional trauma. The emptying of the uterus in this case seems to have been a factor in her recovery. It is quite possible that eesarean section by decreasing abdominal pressure and allowing for stagnation in a dilated splanchnic vascular bed decreases the circulating blood volume, the venous pressure, and hence the intracranial pressure.
Summary 1. Three
cases
of
proved
subarachnoid
hemorrhage
complicating
pregnancy
have
been
reported. 2. All three were apparently of the primary type and probably occurred at the sites of congenital aneurysms of the Circle of Willis. 3. Oxytocics should be used cautiously, particularly in cases with elevated blood pressure, a history of migraine, or any suggestive premonitory signs. 4. The use of repeated spinal puncture to relieve the symptoms of intracranial pressure and the employment of cesarean section to avoid the trauma of labor proved efficacious in the cases reported. 5. Subarachnoid bleeding may occur in milder forms, and be obscured by general anesthesia, shock, toxemia, or symptoms of “spinal headache.” 6. The more frequent employment of diagnostic lumbar puncture would obviate those sources of error since the finding of bloody spinal fluid under increased pressure is pathognomonic of subarachnoid hemorrhage.
R&f erences 1. Moskowitz, H. Leo, and Schneider, H.: AK J. 0~s~. & GYNEC. $ paz;t pd - Galle: Nord. med. Bull. 29:Sot. gynec. 1946. et d ‘obst. 27: 366,193s. 4: Evans: J:*P.: 5. Hirschfield, B. 1942. 6. Magee, C. G.: 7. German, Wm.
Ohio State A,, Tornay,
587, J. 36: 1086, 1940. M. A. S., and Yaskin, J.
Lancet 2: 497,1943. J.: Connecticut M.
J. 7: 88, 1943.
C.:
J.
36: 489, 1938.
M.
Sot.
New
Jersey
39:
494,