Introduction
Materials and methods
Inclusion and exclusion criteria
Information sources and search strategy
Selection process
Data extraction
Results
Study selection
Study characteristics
Study | Study design | Single/multi center | Condition treated | Patients number | Fetus number | AC protocol | Primary sedation and analgesic |
---|---|---|---|---|---|---|---|
Abd-Elsayed et al. 2013 [39] | Retrospective | Single center | Tumor | 1 | 1 | NS | Anesthesia induction and maintenance: propofol/alfentanil (dose NS) |
Handlogten et al. 2015 [40] | Case study | Single center | Tumor | 1 | 1 | Awake-awake-awake | Local anesthesia: 0.25% bupivacaine with 1:200,000 epinephrine Sedation: initial infusion of 0.4 to 0.5 μg/kg/h of dexmedetomidine without a loading dose Intermittent boluses of propofol at 10–30 mg or fentanyl 25 μg administered as needed for stimulating events, such as urinary catheter placement |
Meng et al. 2016 [41] | Case study | Single center | Tumor | 1 | 2 | Awake-awake-awake | Local anesthesia: 1:1 mixture of 0.5% lidocaine and 0.25% bupivacaine Conscious sedation: propofol (25—60 mcg/kg/min) and remifentanil (0.04—0.14 mcg/kg/min) |
Hedayat et al. 2017 [42] | Case study | Single center | Pseudoaneurysm | 1 | 1 | Awake-awake-awake | Fentanyl and Diprivan (dose NS) |
Kamata et al. 2017 [44] | Case study | Single center | Tumor | 1 | 1 | Asleep-awake-asleep | Local anesthesia: 40 ml of 0.3% ropivacaine and 10 ml of 1% lidocaine with 0.01% epinephrine Induction: fentanyl 125 μg and thiopental 375 mg Maintenance: sevoflurane and remifentanil at 0.3 μg/kg/min Conscious sedation: dexmedetomidine started at 1.0 ug/kg/hr and continued at 0.7 μg/kg/hr after 20 min Surgical site closure: fentanyl 225 μg and droperidol 100 μg |
Al Mashani, 2018 [45] | Case study | Single center | Tumor | 1 | 1 | Awake-awake-awake | Local anesthesia: 0.25% bupivacaine and 1% lidocaine (1:1 mixture) Conscious sedation: low-dose propofol (50 mcg/kg/min), remifentanil (0.1 mcg/kg/min), and dexmedetomidine (0.5 mcg/kg/min). Propofol was stopped and dexmedetomidine was reduced before neurophysiologic testing (0.3 mcg/kg/min) |
Pawlik et al. 2018 [46] | Case study | Single center | Tumor | 1 | 1 | Awake-awake-awake | Local anesthesia: 15 ml of 1% ropivacaine and 15 ml of 1.0% lidocaine with 1:40,000 epinephrine Conscious sedation: dexmedetomidine at 0.4 to 0.7 mcg/kg/hr without a loading dose, and remifentanil of 1–2 ng/ml. Dexmedetomidine infusion was increased to 1.0 mcg/kg/hr and remifentanil to 3–4 ng/ml during mitigating events (such as scalp block infiltration, and head immobilization) |
Kumar et al. 2020 [47] | Case study | Single center | Tumor | 1 | 1 | Awake-awake-awake | NS |
Gunasekaran et al. 2022 [43] | Case study | Single center | Tumor | 1 | 1 | Awake-awake-awake | Local anesthesia: 2% lidocaine with 1:10,000 epinephrine and 0.5% ropivacaine mixed 1:1 Conscious sedation: remifentanil, dexmedetomidine, and propofol |
Medications
Study | Age (year) | Weight and height | Pathology | Presentation | Past medical history | Operation time | Surgical position | Follow-up |
---|---|---|---|---|---|---|---|---|
Abd-Elsayed et al. 2013 [39] | 40 | NS | Glioma | Seizure | NS | NS | NS | NS |
Handlogten et al. 2015 [40] | 27 | 70 kg, 172 cm | Anaplastic oligoastrocytoma (WHO grade III) | New onset seizure, mild receptive and expressive aphasia | NS | 8 h and 29 min | Supine with left uterine displacement | 30 months |
Meng et al. 2016 | 31 | NS | Anaplastic astrocytoma (WHO grade III) | Word finding difficulty, dysfluency, right upper extremity plegia, and right lower extremity paresis | Two general anesthesia tumor debulking during the same pregnancy at 16 weeks and 28 weeks gestation | NS | Right semilateral | NS |
Hedayat et al. 2017 [42] | NS | NS | Cortical pseudoaneurysm of the distal right middle cerebral artery under previous craniotomy site | Intermittent headaches, dizziness, and tingling of hands | Previous craniotomy due to superficially penetrating gunshot wound with complete neurological recovery | NS | NS | NS |
Kamata et al. 2017 [44] | 30 | 61.4 kg, 162 cm | Anaplastic astrocytoma (WHO grade III) | Generalized convulsive seizures that were poorly controlled with anti-convulsive therapy | NS | 241 min (surgery), 291 min (anesthesia) | Supine with a wedge placed under the right buttock to prevent aortocaval compression | 17 months |
Al Mashani, 2018 [45] | 26 | NS | NS | Recurrent seizures for one week | NS | NS | Left lateral position | NS |
Pawlik et al. 2018 [46] | 31 | NS | Astrocytoma (Grade II/III) | Word finding difficulty | NS | 4 h and 40 min* | Semilateral | NS |
Kumar et al. 2020 [47] | 29 | 53 kg, 153 cm | Meningioma | Left eye blurred vision | Non-significant | 4 h | NS | 1 week |
Gunasekaran et al. 2022 [43] | 24 | NS | Giant cell glioblastoma (WHO grade IV) | Generalized tonic–clonic seizure, frequent headaches, right leg numbness and weakness, and difficulty with memory and cognition | Systemic lupus erythematosus (1, 100%) | 2 h | Left lateral decubitus | 1 year |
Study | Lesion hemisphere | Lesion location | AC indication | Eloquent area lesion and mapping (n, %) | Intraoperative fetal monitoring | Pre-operative localization | AC extent of resection (n, %) |
---|---|---|---|---|---|---|---|
Abd-Elsayed et al. 2013 | Left (1, 100%) | Frontal lobe (1, 100%) | NS | NS | Yes- Heart rate | NS (2.4 × 2.2 cm) | NS |
Handlogten et al. 2015 [40] | Left (1, 100%) | Temporal lobe (1, 100%) | Eloquent language area (Wernicke’s area) lesion | Motor and speech (1, 100%) | Yes- Heart rate and movement | MRI (4.5 × 3.2 × 3.5 cm intracranial mass) | Total/near total (1, 100%) |
Meng et al. 2016 [41] | Left (1, 100%) | Frontoparietal white matter (1, 100%) | Avoiding fetus and patient exposure to harmful anesthestic medication, and frontoparietal lesion | Language and sensorimotor (1, 100%) | Yes- Heart rate | MRI (7 × 6 × 5 cm anterior– posterior transverse cranio–caudal) | Subtotal (1, 100%) |
Hedayat et al. 2017 [42] | Right (1, 100%) | NS | Cortical lesion | NS | Yes- Heart rate | CT and cerebral angiography | NS |
Kamata et al. 2017 [44] | Left (1, 100%) | Frontal lobe (1, 100%) | Avoiding fetus and patient exposure to harmful anesthestic medication, and facilitating full-term birth | Motor (1, 100%) | Yes- Heart rate | MRI (6 cm) | Total/near total (1, 100%) |
Al Mashani, 2018 [45] | Right (1, 100%) | Frontoparietal region (1, 100%) | Avoiding fetus and patient exposure to harmful anesthestic medication, and eloquent area (frontoparietal close to motor area) lesion | Motor and speech (1, 100%) | Yes- Tococardiography | MRI (8.2 × 4.5 × 4.6 cm) | NS |
Pawlik et al. 2018 [46] | Left (1, 100%) | Parietal lobe (1, 100%) | Eloquent area lesion | Speech (1, 100%) | Yes- NS | MRI (NS) | NS |
Kumar et al. 2020 [47] | Right (1, 100%) | Frontal lobe (1, 100%) | Avoiding fetus exposure to harmful anesthestic medication and enhancing recovery | Motor (1, 100%) | Yes- NS | MRI (extra-axial- NS) | Total (1, 100%) |
Gunasekaran et al. 2022 [43] | Left (1, 100%) | Frontal lobe (1, 100%) | Eloquent motor area | Motor (1, 100%) | Yes- Heart rate using Doppler | MRI (2.0 × 1.5 × 1.5 cm intracranial mass at the level of the coronal suture) | Total (1, 100%) |
Pre-, intra-, and post-operative monitoring of the fetus
Study | Gestational age at diagnosis (week) | Gestational age at craniotomy (week) | Pregnancy term | Delivery method | Hospitalization length | Intraoperative complications | Neonatal outcome |
---|---|---|---|---|---|---|---|
Abd-Elsayed et al. 2013 [39] | 18 | 22 | No | NS | NS | None | Viable infant with normal Apgar score |
Handlogten et al. 2015 [40] | 16 | 20 | Yes | Vaginal | NS | None | Healthy baby delivered vaginally at term |
Meng et al. 2016 [41] | NS | 30 | No- 31 weeks | Under spinal anesthesia on post-operative day 4 | NS | NS | Two babies were uneventfully delivered |
Hedayat et al. 2017 [42] | 2 | 23 | Yes | NS | NS | Unsuccessful primary reconstruction of vessel and aneurysmorrhaphy. Unsuccessful end-to-end bypass | The fetus was delivered at term with no obstetric or neurological complications. Pre, intra, and post-operative monitoring of the fetus's heart rate showed no abnormalities or variabilities |
Kamata et al. 2017 [44] | 21 | 27 | No- 35 weeks and 2 days | NS | NS | No complications | Healthy baby of 2,137 g delivered. The baby did not show any evidence of medical or developmental concern at 17 months follow-up |
Al Mashani, 2018 [45] | 10 | 10 | NS | NS | NS | None | NS regarding delivery, did mention that post-operative the fetal status was satisfactory |
Pawlik et al. 2018 [46] | 22 | 22 | NS | NS | NS | None | No changes in fetal status were observed post-operatively. No fetus or intrauterine volume abnormalities were discovered in ultrasound a day following AC |
Kumar et al. 2020 [47] | 13 | 13 | NS | NS | 3 days | NS | No changes in fetal status post-operatively. Viable heart sounds were heard post-operatively indicating the fetus's viability |
Gunasekaran et al. 2022 [43] | 7 | 9 | No- the baby was delivered at 34 weeks gestation | Cesarean section | 1 day | None | No change in fetal status was observed post-operatively. Doppler monitoring was completed and demonstrated a normal fetal heart rate. The baby was born via cesarian section at 34 weeks gestation due to preterm premature rupture of membranes and concerning fetal monitoring findings (NS). The baby was 5 months old and healthy when the article was written |
Study | Conversion to GA | Pre-operative neurological symptoms | Post-operative complications | Post-operative neurological deficits resolved | Post-operative treatment | Main outcome |
---|---|---|---|---|---|---|
Abd-Elsayed et al. 2013 [39] | No | NS | Patient deceased 16 months after craniotomy | NS | NS | AC caused no intra or post-operative complications. The baby was delivered with normal Apgar scores. The patient deceased 16 months after the craniotomy |
Handlogten et al. 2015 [40] | No | Seizure, expressive & receptive aphafasia | No new neurological deficits | NS | NS | Use of dexmedetomidine and mannitol during AC in a pregnant patient did not lead to notable maternal and fetal adverse effects. There were no intra operative or post-operative complications or newly developed post-operative neurological deficits. The use of mannitol did lead to a transient 30% reduction in internal uterine volume but had no overt maternal or fetal/neonatal adverse effects. A healthy baby was delivered uneventfully at term |
Meng et al. 2016 [41] | No | Dysfluency, word-finding difficulty, right upper extremity paralysis, right lower extremities weakness | No immediate post-operative deficits. Receiving hospice care 12 months post-AC. Walking impairment, comprehensible but slurred speech | Significant improvement in fluency with naming and speech comprehension post-operative day 1, but with impaired repetition. The strength of the right arm and leg returned to baseline except for a weak hand grip | Partial course of external beam radiotherapy and chemotherapy | The patient showed significant post-operative day 1 improvement in naming and comprehension, and the strength of the right arm and leg returned to baseline apart from a weak hand grip. No intra operative complications were seen. Two babies (twin) were delivered uneventfully on post-operative day 4 under spinal anesthesia. 12 months post-operative patient is receiving hospice care, with progressive worsening of right leg weakness and slurred speech |
Hedayat et al. 2017 [42] | No | Intermittent headaches, dizziness, and hand tingling | No post-operative neurological deficits | NS | NS | AC for management of a pseudoaneurysm in a pregnant female at 23-week gestation was successfully done without any post-operative neurological complications. Pre- and post-operative fetal heart rate monitoring showed no variabilities or abnormalities. The baby was successfully delivered at term. No neurological complications were observed in follow-up visits |
Kamata et al. 2017 [44] | No | Generalized convulsive seizures | None | NS | Radiotherapy and chemotherapy 2 months post-delivery | AC for removal of high-grade glioma in a pregnant patient at 27-week gestation was successfully conducted with full tumor resection. No intra operative or post-operative complications were seen. The patient delivered a healthy baby at 35 weeks gestation. At the 17-month follow-up, there was no evidence of tumor recurrence in the patient and no developmental or medical concerns for the child |
Al Mashani, 2018 [45] | No | Seizures- unspecified type | None | NS | NS | AC for tumor removal in a pregnant patient at 10-week gestation was completed with no intra operative or post-operative complications. The fetal status was satisfactory intra operatively and post-operatively, there was no information provided regarding the pregnancy |
Pawlik et al. 2018 [46] | No | Word finding difficulty | NS | NS | NS | AC for tumor removal in a pregnant patient at 22-week gestation was successfully completed with no intra operative complications. Obstetric abdominal ultrasound was done before, immediately after, and the next day after surgery and all showed no fetal or intrauterine volume abnormalities. AC has neuroprotective effects for the patient and is feasible during pregnancy |
Kumar et al. 2020 [47] | No | Left eye blurred vision | NS | Complete resolution of symptoms post-operatively | NS | AC for tumor removal in a pregnant patient at 13-week gestation was successfully completed with complete resolution of symptoms at one-week follow-up. Extensive pre-op psychological preparation was done as part of anesthetic management. Post-operative obstetric review showed fetus viability as evident by fetal heart rate sounds. AC facilitates intraoperative neurological monitoring and provides hemodynamic stability with improved fetal-maternal outcomes |
Gunasekaran et al. 2022 [43] | No | Generalized convulsive seizures, subjective right leg numbness and weakness, and difficulty with concentration and memory | NS | NS | Fractionated radiotherapy alone over 40 days. The patient opted out of adjuvant temozolomide treatment | AC for glioblastoma resection in a 24-year-old patient who was pregnant in her first trimester was successfully completed with gross total resection of the tumor. There were no intra operative complications, and after interdisciplinary care with adjuvant radiotherapy, one-year follow-up showed no further disease. There were no post-operative fetal complications, and a healthy baby was born at 34 weeks gestation. At the time the article was written, the baby was 5 months old and in good health. AC is a safe and effective process for resectioning glioblastoma in pregnancy |