Treat first, deliver second: management of aneurysmal subarachnoid haemorrhage in late pregnancy

Abstract

Introduction: Subarachnoid haemorrhage (SAH) occurs in approximately 1 in 10,000 pregnancies and may be more common in the third trimester.1 Management at advanced gestation is challenging and requires complex multidisciplinary team (MDT) decision-making balancing maternal and fetal risks. The literature is limited, with most cases describing delivery prior to definitive SAH treatment.2 We report a case in which endovascular treatment of aneurysmal SAH was undertaken prior to Caesarean section, resulting in good maternal and neonatal outcomes. Case report: A 33-year-old nulliparous woman presented at 36 + 5 weeks' gestation with sudden-onset severe headache. Past medical history was unremarkable except for a strong family history of SAH. Neurological examination demonstrated a Glasgow Coma Scale (GCS) of 15. CT imaging revealed a Fisher grade 3 SAH with mild hydrocephalus secondary to an aneurysm. She was transferred to our centre, which provides obstetric, neonatal and neurosurgical services on a single site. Following urgent MDT discussion, the decision was made to secure the aneurysm via endovascular coiling under general anaesthesia prior to delivery, as Caesarean section with an unsecured aneurysm posed an increased risk of neurological deterioration. General anaesthesia was maintained with total intravenous anaesthesia and meticulous haemodynamic control. Aortocaval compression was minimised using lateral displacement. Endovascular coiling was completed successfully, after which the patient was transferred directly, for immediate Caesarean section. The procedure was uncomplicated. The neonate required overnight ventilatory support, but was discharged home on day five in good condition. The patient was extubated postoperatively with a GCS of 15. She later developed cerebral vasospasm requiring further endovascular intervention but was discharged home after 25 days with mild word-finding difficulty and neck stiffness. Discussion(s): Optimal management of SAH in pregnancy remains poorly defined. Delivery prior to securing an aneurysm risks neurological eterioration from airway manipulation and haemodynamic fluctuation, particularly when neuraxial anaesthesia is contraindicated. Conversely, prioritising neurointervention exposes the fetus to prolonged general anaesthesia and flat positioning and maternal heparinasation. In this case, MDT decision-making enabled definitive treatment prior to delivery with favourable maternal and neonatal outcomes. [Formula presented] Copyright © 2026