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Meningiomas in pregnancy: timing of surgery and clinical outcomes as observed in 104 cases and establishment of a best management strategy

  • Review Article - Brain Tumors
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Abstract

Background

There is a strong correlation between the level of circulating female sex hormones and the parturient growth of meningiomas. As a result, rapid changes in meningioma size occur during pregnancy, putting both the mother and fetus at risk. Large, symptomatic meningiomas require surgical resection, regardless of the status of pregnancy. However, the preferred timing of such complex intervention is a matter of debate. The rarity of this clinical scenario and the absence of prospective trials make it difficult to reach evidence-based conclusions. The aim of this study was to create evidence-based management guidelines for timing of surgery for pregnancy-related intracranial meningiomas.

Method

The English literature from 1990 to 2016 was systematically reviewed according to PRISMA guidelines for all surgical cases of pregnancy–related intracranial meningiomas. Cases were divided into two groups: patients who have had surgery during pregnancy and delivered thereafter (group A) and patients who delivered first (group B). Groups were compared for demographic, clinical and radiological features, as well as for neurosurgical, obstetrical and neonatological outcomes. Statistical analysis was performed to assess differences.

Results

A total of 104 surgical cases were identified and reviewed, of which 86 were suitable for comparison and statistical analysis. Thirty-five patients (40%) underwent craniotomy for resection during pregnancy or at delivery (group A) and 51 patients (60%) underwent surgery after delivery (group B). Groups showed no significant differences in characteristics such as age at diagnosis, number of gestations, presenting symptoms, tumor site and tumor size. Despite a comparable distribution over the gestational trimesters, group A had significantly more patients diagnosed prior to the 27th gestational week (46 vs 17.5%, p = 0.0075). Group A was also associated with a significantly higher rate of both emergent craniotomies (40 vs 19.6%, p = 0.0048) and emergent Caesarian deliveries (47 vs 17.8%, p = 0.00481). The time from diagnosis to surgery was significantly longer in group B (11 weeks vs 1 week in group A, p = 0.0013). The rate of premature delivery was high but similar in both groups (∼70%). Risks of maternal mortality or fetal mortality were associated with group A (odds ratio = 14.7), but did not reach statistical significance.

Conclusions

While surgical resection of meningioma during pregnancy may be associated with increased maternal and fetal mortalities, the overall neurosurgical, obstetrical and neonatological outcomes, as well as many clinical characteristics, are similar to patients undergoing resection postpartum. We believe that fetal survival chances have a significant impact on decision-making, as patients diagnosed at a later stage in pregnancy (≥27th week of gestation) were more likely to undergo delivery first. This complicated clinical scenario requires the close cooperation of multiple disciplines. While the mother’s health and well-being should always be paramount in guiding management, we hope that the overall good outcomes observed by this systematic review will encourage colleagues to aim for term pregnancies whenever possible in order to reduce prematurity-related problems.

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References

  1. Bakar B, Sav A, Tekkok IH (2010) Giant chordoid meningioma symptomatic immediately after pregnancy: report of a rare case. Clin Neuropathol 29:163–168

    Article  PubMed  CAS  Google Scholar 

  2. Balki M, Manninen PH (2004) Craniotomy for suprasellar meningioma in a 28-week pregnant woman without fetal heart rate monitoring. Can J Anaesth 51:573–576. doi:10.1007/bf03018400

    Article  PubMed  Google Scholar 

  3. Baxter DS, Smith P, Stewart K, Murphy M (2009) Clear cell meningioma presenting as rapidly deteriorating visual field and acuity during pregnancy. J Clin Neurosci 16:1502–1504. doi:10.1016/j.jocn.2009.1502.1008

    Article  PubMed  CAS  Google Scholar 

  4. Bickerstaff ER, Small JM, Guest IA (1958) The relapsing course of certain meningiomas in relation to pregnancy and menstruation. J Neurol Neurosurg Psychiatry 21:89–91

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  5. Cahill DW, Bashirelahi N, Solomon LW, Dalton T, Salcman M, Ducker TB (1984) Estrogen and progesterone receptors in meningiomas. J Neurosurg 60:985–993. doi:10.3171/jns.1984.60.5.0985

    Article  PubMed  CAS  Google Scholar 

  6. Chacko JG, Miller JL, Angtuaco EJ (2010) Spontaneous postpartum resolution of vision loss caused by a progesterone receptor-positive tuberculum sellae meningioma. J Neuroophthalmol 30:132–134. doi:10.1097/WNO.1090b1013e3181da1099d1059

    Article  PubMed  Google Scholar 

  7. Claus EB, Black PM, Bondy ML, Calvocoressi L, Schildkraut JM, Wiemels JL, Wrensch M (2007) Exogenous hormone use and meningioma risk: what do we tell our patients? Cancer 110:471–476. doi:10.1002/cncr.22783

    Article  PubMed  Google Scholar 

  8. Cohen-Gadol AA, Friedman JA, Friedman JD, Tubbs RS, Munis JR, Meyer FB (2009) Neurosurgical management of intracranial lesions in the pregnant patient: a 36-year institutional experience and review of the literature. J Neurosurg 111:1150–1157. doi:10.3171/2009.1153.JNS081160

    Article  PubMed  Google Scholar 

  9. Cohen-Kerem R, Railton C, Oren D, Lishner M, Koren G (2005) Pregnancy outcome following non-obstetric surgical intervention. Am J Surg 190:467–473

    Article  PubMed  Google Scholar 

  10. Creanga AA, Bateman BT, Butwick AJ, Raleigh L, Maeda A, Kuklina E, Callaghan WM (2015) Morbidity associated with cesarean delivery in the United States: is placenta accreta an increasingly important contributor? Am J Obstet Gynecol 213:384.e1–384.e11. doi:10.1016/j.ajog.2015.1005.1002

    Article  Google Scholar 

  11. Ebner FH, Bornemann A, Wilhelm H, Ernemann U, Honegger J (2008) Tuberculum sellae meningioma symptomatic during pregnancy: pathophysiological considerations. Acta Neurochir (Wien) 150:189–193. doi:10.1007/s00701-00007-01417-00705, discussion 193

    Article  CAS  Google Scholar 

  12. Elwatidy S, Jamjoom Z, Elgamal E, Abdelwahab A (2011) Management strategies for acute brain lesions presenting during pregnancy: a case series. Br J Neurosurg 25:478–487. doi:10.3109/02688697.02682010.02550345

    Article  PubMed  Google Scholar 

  13. Felgenhauer K (1974) Protein size and cerebrospinal fluid composition. Klin Wochenschr 52:1158–1164

    Article  PubMed  CAS  Google Scholar 

  14. Gazzeri R, Galarza M, Gazzeri G (2007) Growth of a meningioma in a transsexual patient after estrogen-progestin therapy. N Engl J Med 357:2411–2412. doi:10.1056/NEJMc071938

    Article  PubMed  CAS  Google Scholar 

  15. Giannini A, Bricchi M (1999) Posterior fossa surgery in the sitting position in a pregnant patient with cerebellopontine angle meningioma. Br J Anaesth 82:941–944

    Article  PubMed  CAS  Google Scholar 

  16. Haas JF, Janisch W, Staneczek W (1986) Newly diagnosed primary intracranial neoplasms in pregnant women: a population-based assessment. J Neurol Neurosurg Psychiatry 49:874–880

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  17. Hatiboglu MA, Cosar M, Iplikcioglu AC, Ozcan D (2008) Sex steroid and epidermal growth factor profile of giant meningiomas associated with pregnancy. Surg Neurol 69:356–362. doi:10.1016/j.surneu.2007.03.013, discussion 362–353

    Article  PubMed  Google Scholar 

  18. Idowu OE, Shokunbi MT, Amanor-Boadu SD, Roberts OA, Eyo C (2004) Surgical management of tuberculum sellae meningioma in a patient with a twin pregnancy: case report. Surg Neurol 62:60–63. doi:10.1016/j.surneu.2003.07.007

    Article  PubMed  CAS  Google Scholar 

  19. Isla A, Alvarez F, Gonzalez A, Garcia-Grande A, Perez-Alvarez M, Garcia-Blazquez M (1997) Brain tumor and pregnancy. Obstet Gynecol 89:19–23

    Article  PubMed  CAS  Google Scholar 

  20. Ismail K, Coakham HB, Walters FJ (1998) Intracranial meningioma with progesterone positive receptors presenting in late pregnancy. Eur J Anaesthesiol 15:106–109

    Article  PubMed  CAS  Google Scholar 

  21. Jhawar BS, Ranger A, Steven D, Del Maestro RF (2003) Risk factors for intracranial hemorrhage among full-term infants: a case–control study. Neurosurgery 52:581–590, discussion 588–590

    Article  PubMed  Google Scholar 

  22. Johnson N, Sermer M, Lausman A, Maxwell C (2009) Obstetric outcomes of women with intracranial neoplasms. Int J Gynaecol Obstet 105:56–59. doi:10.1016/j.ijgo.2008.1011.1037

    Article  PubMed  Google Scholar 

  23. Kanaan I, Jallu A, Kanaan H (2003) Management strategy for meningioma in pregnancy: a clinical study. Skull Base 13:197–203. doi:10.1055/s-2004-817695

    Article  PubMed  PubMed Central  Google Scholar 

  24. Kasper EM, Hess PE, Silasi M, Lim KH, Gray J, Reddy H, Gilmore L, Kasper B (2010) A pregnant female with a large intracranial mass: reviewing the evidence to obtain management guidelines for intracranial meningiomas during pregnancy. Surg Neurol Int 1:95. doi:10.4103/2152-7806.74242

    Article  PubMed  PubMed Central  Google Scholar 

  25. Kerschbaumer J, Freyschlag CF, Stockhammer G, Taucher S, Maier H, Thome C, Seiz-Rosenhagen M (2015) Hormone-dependent shrinkage of a sphenoid wing meningioma after pregnancy: case report. J Neurosurg 124:137-140. doi:10.3171/2014.12.jns142112

  26. Khong SY, Leach J, Greenwood C (2007) Meningioma mimicking puerperal psychosis. Obstet Gynecol 109:515–516

    Article  PubMed  Google Scholar 

  27. Krovvidi H, Sharma S, Danks J (2008) Postpartum neurologic deficit: an intracranial cause. Int J Obstet Anesth 17:378–379. doi:10.1016/j.ijoa.2008.1006.1002

    Article  PubMed  Google Scholar 

  28. Kumar S, Gupta V, Khandelwal N (2013) Hemorrhage in meningioma: an unwanted outcome of pregnancy. Neurol India 61:329–330. doi:10.4103/0028-3886.115098

    Article  PubMed  Google Scholar 

  29. Kurdoglu Z, Cetin O, Gulsen I, Dirik D, Bulut MD (2014) Intracranial meningioma diagnosed during pregnancy caused maternal death. Case Rep Med 158326:10

    Google Scholar 

  30. Laviv Y, Ohla V, Kasper EM (2016) Unique features of pregnancy-related meningiomas: lessons learned from 148 reported cases and theoretical implications of a prolactin modulated pathogenesis. Neurosurg Rev 16:16

    Google Scholar 

  31. Lee E, Grutsch J, Persky V, Glick R, Mendes J, Davis F (2006) Association of meningioma with reproductive factors. Int J Cancer 119:1152–1157. doi:10.1002/ijc.21950

    Article  PubMed  CAS  Google Scholar 

  32. Lee KH, Lall RR, Chandler JP, Bigio EH, Mao Q (2013) Pineal chordoid meningioma complicated by repetitive hemorrhage during pregnancy: case report and literature review. Neuropathology 33:192–198. doi:10.1111/j.1440-1789.2012.01337.x

    Article  PubMed  Google Scholar 

  33. Locatelli A, Consonni S, Ghidini A (2015) Preterm labor: approach to decreasing complications of prematurity. Obstet Gynecol Clin N Am 42:255–274. doi:10.1016/j.ogc.2015.1001.1004

    Article  Google Scholar 

  34. Lusis EA, Scheithauer BW, Yachnis AT, Fischer BR, Chicoine MR, Paulus W, Perry A (2012) Meningiomas in pregnancy: a clinicopathologic study of 17 cases. Neurosurgery 71:951–961. doi:10.1227/NEU.0b013e31826adf65

    Article  PubMed  Google Scholar 

  35. Macarthur A (2004) Craniotomy for suprasellar meningioma during pregnancy: role of fetal monitoring. Can J Anaesth 51:535–538

    Article  PubMed  Google Scholar 

  36. Mazze RI, Kallen B (1989) Reproductive outcome after anesthesia and operation during pregnancy: a registry study of 5405 cases. Am J Obstet Gynecol 161:1178–1185

    Article  PubMed  CAS  Google Scholar 

  37. Mealey J Jr, Carter JE (1968) Spinal cord tumor during pregnancy. Obstet Gynecol 32:204–209

    PubMed  Google Scholar 

  38. Michelsen JJ, New PF (1969) Brain tumour and pregnancy. J Neurol Neurosurg Psychiatry 32:305–307

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  39. Moscovici S, Fraifeld S, Cohen JE, Dotan S, Elchalal U, Shoshan Y, Spektor S (2014) Parasellar meningiomas in pregnancy: surgical results and visual outcomes. World Neurosurg 82:e503–e512. doi:10.1016/j.wneu.2013.06.019

    Article  PubMed  Google Scholar 

  40. Nakamura M, Samii M (2003) Surgical management of a meningioma in the retrosellar region. Acta Neurochir (Wien) 145:215–219. doi:10.1007/s00701-002-1053-z, discussion 219–220

    Article  CAS  Google Scholar 

  41. Narayansingh GV, Ramsewak S, Cross JN, Adam RU, Kissoon W (1992) Worsening neurological status in late pregnancy: consider meningioma. Postgrad Med J 68:486

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  42. Nishio S, Morioka T, Suzuki S, Takeshita I, Ikezaki K, Fukui M, Nakano H (1996) Primary brain tumours manifesting during pregnancy: presentation of six cases and a review of the literature. J Clin Neurosci 3:334–337

    Article  PubMed  CAS  Google Scholar 

  43. ACOG Committee on Obstetric Practice (2011) ACOG Committee Opinion No. 474: nonobstetric surgery during pregnancy. Obstet Gynecol 117:420–421. doi:10.1097/AOG.1090b1013e31820eede31829

    Article  Google Scholar 

  44. Nossek E, Ekstein M, Barkay G, Shahar T, Gonen L, Rimon E, Kesler A, Margalit N (2015) Visual deterioration during pregnancy due to skull base tumors compressing the optic apparatus. Neurosurg Rev 38:473–479. doi:10.1007/s10143-10015-10608-10144, discussion 479

    Article  PubMed  Google Scholar 

  45. Nossek E, Ekstein M, Rimon E, Kupferminc MJ, Ram Z (2011) Neurosurgery and pregnancy. Acta Neurochir (Wien) 153:1727–1735. doi:10.1007/s00701-00011-01061-y

    Article  Google Scholar 

  46. Otton GR, Giles W, Walters WA (1997) Large meningioma complicating pregnancy. Aust N Z J Obstet Gynaecol 37:466–469

    Article  PubMed  CAS  Google Scholar 

  47. Patel S, Sharan V (2010) Meningioma in pregnancy. J Obstet Gynaecol 30:56–57. doi:10.3109/01443610903267465

    Article  PubMed  CAS  Google Scholar 

  48. Perry A, Stafford SL, Scheithauer BW, Suman VJ, Lohse CM (1997) Meningioma grading: an analysis of histologic parameters. Am J Surg Pathol 21:1455–1465

    Article  PubMed  CAS  Google Scholar 

  49. Pettorini BL, Park YS, Caldarelli M, Massimi L, Tamburrini G, Di Rocco C (2008) Radiation-induced brain tumours after central nervous system irradiation in childhood: a review. Childs Nerv Syst 24:793–805. doi:10.1007/s00381-008-0631-7

    Article  PubMed  Google Scholar 

  50. Pimperl LC (2005) Radiation as a nervous system toxin. Neurol Clin 23:571–597

    Article  PubMed  Google Scholar 

  51. Pliskow S, Herbst SJ, Saiontz HA, Cove H, Ackerman RT (1995) Intracranial meningioma with positive progesterone receptors. A case report. J Reprod Med 40:154–156

    PubMed  CAS  Google Scholar 

  52. Rand CW, Andler M (1950) Tumors of the brain complicating pregnancy. Arch Neurol Psychiatr 63:1–41, illust

    Article  CAS  Google Scholar 

  53. Reedy MB, Kallen B, Kuehl TJ (1997) Laparoscopy during pregnancy: a study of five fetal outcome parameters with use of the Swedish Health Registry. Am J Obstet Gynecol 177:673–679

    Article  PubMed  CAS  Google Scholar 

  54. Rodriguez-Porcel F, Hughes I, Anderson D, Lee J, Biller J (2013) Foster Kennedy Syndrome due to meningioma growth during pregnancy. Front Neurol 4:183

  55. Roelvink NC, Kamphorst W, van Alphen HA, Rao BR (1987) Pregnancy-related primary brain and spinal tumors. Arch Neurol 44:209–215

    Article  PubMed  CAS  Google Scholar 

  56. Rosen MA (1999) Management of anesthesia for the pregnant surgical patient. Anesthesiology 91:1159–1163

    Article  PubMed  CAS  Google Scholar 

  57. Sadetzki S, Flint-Richter P, Ben-Tal T, Nass D (2002) Radiation-induced meningioma: a descriptive study of 253 cases. J Neurosurg 97:1078–1082. doi:10.3171/jns.2002.97.5.1078

    Article  PubMed  Google Scholar 

  58. Sahu S, Lata I, Gupta D (2010) Management of pregnant female with meningioma for craniotomy. J Neurosci Rural Pract 1:35–37. doi:10.4103/0976-3147.63101

    Article  PubMed  PubMed Central  Google Scholar 

  59. Sayres WG Jr (2010) Preterm labor. Am Fam Physician 81:477–484

    PubMed  Google Scholar 

  60. Schwartz AC, Afejuku A, Garlow SJ (2013) Bifrontal meningioma presenting as postpartum depression with psychotic features. Psychosomatics 54:187–191. doi:10.1016/j.psym.2012.1001.1011

    Article  PubMed  Google Scholar 

  61. Scott A, Sharkawi E, Micallef C, Johns P, Grant L (2008) Chordoid meningioma presenting as painful orbital apex syndrome in pregnancy. Int Ophthalmol 28:355–357

    Article  PubMed  Google Scholar 

  62. Shitara S, Nitta N, Fukami T, Nozaki K (2012) Tuberculum sellae meningioma causing progressive visual impairment during pregnancy. Case report. Neurol Med Chir (Tokyo) 52:607–611

    Article  Google Scholar 

  63. Smith JS, Quinones-Hinojosa A, Harmon-Smith M, Bollen AW, McDermott MW (2005) Sex steroid and growth factor profile of a meningioma associated with pregnancy. Can J Neurol Sci 32:122–127

    Article  PubMed  Google Scholar 

  64. Starke RM, Przybylowski CJ, Sugoto M, Fezeu F, Awad AJ, Ding D, Nguyen JH, Sheehan JP (2015) Gamma knife radiosurgery of large skull base meningiomas. J Neurosurg 122:363–372. doi:10.3171/2014.3110.JNS14198

    Article  PubMed  Google Scholar 

  65. Stevenson CB, Thompson RC (2005) The clinical management of intracranial neoplasms in pregnancy. Clin Obstet Gynecol 48:24–37

    Article  PubMed  Google Scholar 

  66. Terry AR, Barker FG II, Leffert L, Bateman BT, Souter I, Plotkin SR (2012) Outcomes of hospitalization in pregnant women with CNS neoplasms: a population-based study. Neuro-Oncology 14:768–776. doi:10.1093/neuonc/nos1078

    Article  PubMed  PubMed Central  Google Scholar 

  67. Tyson JE, Parikh NA, Langer J, Green C, Higgins RD (2008) Intensive care for extreme prematurity—moving beyond gestational age. N Engl J Med 358:1672–1681. doi:10.1056/NEJMoa073059.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  68. Verheecke M, Halaska MJ, Lok CA, Ottevanger PB, Fruscio R, Dahl-Steffensen K, Kolawa W, Gziri MM, Han SN, Van Calsteren K et al (2014) Primary brain tumours, meningiomas and brain metastases in pregnancy: report on 27 cases and review of literature. Eur J Cancer 50:1462–1471. doi:10.1016/j.ejca.2014.1402.1018

    Article  PubMed  Google Scholar 

  69. Wahab M, Al-Azzawi F (2003) Meningioma and hormonal influences. Climacteric 6:285–292

    Article  PubMed  CAS  Google Scholar 

  70. Wigertz A, Lonn S, Mathiesen T, Ahlbom A, Hall P, Feychting M, Swedish Interphone Study G (2006) Risk of brain tumors associated with exposure to exogenous female sex hormones. Am J Epidemiol 164:629–636. doi:10.1093/aje/kwj254

    Article  PubMed  Google Scholar 

  71. Wrensch M, Minn Y, Chew T, Bondy M, Berger MS (2002) Epidemiology of primary brain tumors: current concepts and review of the literature. Neuro-Oncology 4:278–299

    Article  PubMed  PubMed Central  Google Scholar 

  72. Zoli M, Faustini-Fustini M, Mazzatenta D, Pasquini E, Frank G (2012) Tuberculum sellae meningioma growing during pregnancy: a difficult decision-making process. J Clin Endocrinol Metab 97:1418–1419. doi:10.1210/jc.2012-1155

    Article  PubMed  CAS  Google Scholar 

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Authors and Affiliations

  1. Department of Surgery, Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA

    Yosef Laviv, Ahmed Bayoumi & Ekkehard M. Kasper

  2. Department of Neurosurgery, Medical Park Goztepe Hospital, Bahcesehir University School of Medicine, Istanbul, Turkey

    Ahmed Bayoumi

  3. Department of Radiation Oncology, Department of Radiology/Division of Neuroradiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA

    Anand Mahadevan

  4. Department of Obstetrics and Fetal Maternal Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA

    Brett Young

  5. Department of Anesthesia, Pain and Critical Care Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA

    Myles Boone

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  1. Yosef Laviv
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  2. Ahmed Bayoumi
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  3. Anand Mahadevan
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  6. Ekkehard M. Kasper
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Correspondence to Ekkehard M. Kasper.

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Comments

The authors aimed to perform a meta-analysis of the literature on surgery for intracranial meningiomas during pregnancy, with the ultimate objective of suggesting guidelines for the management of patients in this situation. This is an admirable objective, given the relatively limited data published and complexity of decision-making in this situation. Unfortunately, the published reports are widely diverse, complicating the task. In particular, they lack almost any information about late maternal-child outcomes, the ultimate determinant of whether a given management approach has been successful. The authors nevertheless present a management algorithm for intracranial meningioma during pregnancy (Fig. 1) that looks reasonable, with the caveat that the range between gestational week (GW) 27 and 36 is too wide. There is a vast difference in neonatal outcomes at the two ends of this spectrum, and there is also a fairly rapid increase in risk to the mother for surgery after about GW 28–30. We addressed these issues in some depth in our paper, and they are reviewed elsewhere [1–3]. Based on these issues, we do not feel the current literature is sufficiently robust or homogenous to support the development of evidence-based guidelines.

The central issue in this clinical situation is balancing the well-being of mother and fetus. The authors encourage delaying surgery until after delivery as a general rule, raising the point that Caesarian section is also associated with some risk. In their conclusion, they urge their colleagues to aim for late or term deliveries whenever possible to reduce problems from prematurity. We wish to question this broad recommendation. First, while it is well known that later delivery improves neonatal outcomes, we lack data in this specific situation to support substantial morbidity or mortality for these children. More importantly, this recommendation obviously contradicts our current ethical premise that the mother’s well-being takes first place for caregivers [1, 2].

We are concerned that following a general approach of delaying surgery may in fact increase risks for both mother and baby. In fact, the authors found significant differences in the rates or urgent/emergent craniotomy as well as Caesarian section in cases where craniotomy was performed during Pregnancy. In addition, the two maternal deaths occurred in cases where surgery had been delayed; they were not a direct result of the neurosurgical intervention itself. It is certainly possible that in some cases when tumor growth increases pressure on critical neuroanatomy, delaying surgery can lead to irreparable neurological damage or even herniation. For this reason, we have found that issues relating to the risks of craniotomy during pregnancy versus delay, and decisions regarding how long to allow the pregnancy to continue must be carefully examined in each situation, and we shy away from any broad rule of thumb. Of course we want to do what is possible to allow normal fetal/child development. Surely when possible we should try to get past the gestational week GW 27 hurdle, and then the week GW 30 hurdle, and further, when we feel it can be done safely for the mother.

Another important issue is the central role of the patient. It is not enough to present information to the patient. In fact, the ultimate decision rests with her. In our experience, these women are concerned not only for themselves but also for one or more living children. Given the current ethical premise that protecting the life and well-being of the mother is our highest priority, we feel that only she and her family have the right to choose a significant delay in surgery when she faces the risk of serious impairment or even death.

Sergey Spektor

Jerusalem, Israel

References

1. American College of Obstetricians and Gynecolists (ACOG), Committee on Obstetric Practice. (2011, Reaffirmed 2015) Nonobstetric surgery during pregnancy. Committee Opinion #474. https://www.acog.org/-/media/Committee-Opinions/Committee-on-Obstetric-Practice/co474.pdf?dmc=1&ts=20170305T2217422111. Accessed March 6, 2017

2. Lynch JC, Gouvea F, Emmerich JC, Kokinovrachos G, Pereira C, Welling L, Kislanov S (2011) Management strategy for brain tumour diagnosed during pregnancy. Br J Neurosurg 25:225–230

3. Moscovici S, Fraifeld S, Cohen JE, Dotan S, Elchalal U, Shoshan Y, Spektor S (2014) Parasellar meningiomas in pregnancy: surgical results and visual outcomes. World Neurosurg 82:e503-e512

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Laviv, Y., Bayoumi, A., Mahadevan, A. et al. Meningiomas in pregnancy: timing of surgery and clinical outcomes as observed in 104 cases and establishment of a best management strategy. Acta Neurochir 160, 1521–1529 (2018). https://doi.org/10.1007/s00701-017-3146-8

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