Meningiomas in pregnancy: timing of surgery and clinical outcomes as observed in 104 cases and establishment of a best management strategy
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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.
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.
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.
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.
KeywordsMeningioma Pregnancy Craniotomy Caesarian delivery
Compliance with ethical standards
No funding was received for this research.
Conflict of interest
For this type of study formal consent is not required. This article does not contain any studies with human participants performed by any of the authors.
- 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 CrossRefPubMedGoogle 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 CrossRefGoogle 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 CrossRefPubMedPubMedCentralGoogle 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
- 29.Kurdoglu Z, Cetin O, Gulsen I, Dirik D, Bulut MD (2014) Intracranial meningioma diagnosed during pregnancy caused maternal death. Case Rep Med 158326:10Google 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 16:16Google 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 4:183Google 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 CrossRefPubMedGoogle Scholar