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BRAIN TUMORS The incidence of brain neoplasms does not increase during pregnancy and
the types of tumors are similar to those seen in nonpregnant women of the same age. Low-grade
and high-grade gliomas and meningiomas each represent about one-third of cases. No particular
systemic neoplasm with brain metastases is associated with pregnancy with the exception of
choriocarcinoma, in which approximately 3 to 20 percent of patients have brain metastases at the
time of diagnosis [72]. Meningiomas, vestibular schwannomas (acoustic neuromas), and
pituitary tumors may enlarge during pregnancy and become symptomatic.
The changes that occur during pregnancy can have a significant effect on symptoms and tumor
growth [72-74]. Fluid retention, for example, can increase tumor edema and enlarge vascular
tumors such as meningiomas and vestibular schwannomas [74]. In addition, both meningiomas
and vestibular schwannomas have sex hormone receptors, which may play a role in accelerating
tumor growth during gestation [75]. A study of 12 pregnancies in 11 women with grade II
gliomas, found significant radiologic expansion of the tumor during pregnancy as compared to
prepregnancy and post-delivery time periods [76]. In another small case series of eight patients
with a glioma, pregnancy appeared to be associated with adverse effects (clinical and/or
radiographic worsening) in six [77].
Clinical manifestations Although nausea and vomiting is a common symptom of both
pregnancy and cerebral neoplasms, pregnancy-related nausea and vomiting occurs very early in
pregnancy and tends to improve across gestation, while tumor-related nausea and vomiting is
more likely to arise late in gestation, gradually worsens, and may be accompanied by headache.
New onset of seizures can be a symptom of eclampsia or associated with a brain tumor.
Eclamptic seizures are typically generalized. Tumor-related seizures may be focal and associated
with focal neurologic findings. However, secondary generalization may occur rapidly, and the
focal onset therefore may be unapparent to observers. In one case series, increased seizure
frequency was noted in 5 of 12 pregnancies in women who harbored grade II gliomas [76]. An
overview of the clinical manifestations and diagnosis of brain tumors can be found separately.
(See "Clinical presentation and diagnosis of brain tumors".)
Management The treatment and prognosis of brain neoplasms seen during pregnancy is
highly dependent upon the particular cell type involved, as well as the clinical manifestations and
the stage of pregnancy [78]. Magnetic resonance imaging (MRI), which does not involve
radiation, can be safely performed in the pregnant patient, but gadolinium is typically not
recommended. (See "Diagnostic imaging procedures during pregnancy".)
Surgery during pregnancy is indicated in patients with malignant tumors or tumors causing
severe symptoms [78]. Brain irradiation when indicated may be performed during pregnancy.

Symptomatic treatment with anticonvulsants or corticosteroids may be necessary and should be


used with appropriate caution. Neither should be used prophylactically in this setting. Treatment
of seizures during pregnancy is discussed separately (see "Management of epilepsy and
pregnancy"). Considerations regarding the use of corticosteroids in pregnancy are also discussed
separately. (See "Use of antiinflammatory and immunosuppressive drugs in rheumatic diseases
during pregnancy and lactation", section on 'Glucocorticoids'.)
Maternal blood pressure and fluids should be monitored closely. Antihypertensive medication
should be given sparingly to avoid hypotension, which could result in cerebral hypoperfusion.
Excessive hydration, which could worsen cerebral edema, should also be avoided [79]. (See
"Management of vasogenic edema in patients with primary and metastatic brain tumors".)
A potential problem can occur in patients with brain tumors during the second stage of labor.
Increased cerebrospinal fluid pressures have been observed in normal women during painful
uterine contractions [80]. This could potentially lead to neurologic compromise in a woman who
already has a baseline elevation in intracranial pressure. Thus, careful consideration should be
given to the type of delivery. Depending upon the location and size of the mass, a cesarean
delivery under general anesthesia may be warranted [81]. There are insufficient data to assess
risk and make a general recommendation; advice of subspecialists in neurology and neurosurgery
is advised in each case.
Pituitary adenoma Pregnancy also promotes the growth of lactotroph adenomas
(prolactinomas). Neurologic symptoms most often develop in patients with macroadenomas (13
to 36 percent) but also occur in a few patients (less than 2 percent) with microadenomas (defined
as less than 10 mm in diameter). Pregnant women with known pituitary adenomas may present
with new onset headache or visual changes that can be difficult to differentiate from migraines
and other headache disorders. Magnetic resonance imaging (MRI) can be used when necessary
during all trimesters of pregnancy to rule out growth of the adenoma or pituitary apoplexy from
ischemia or hemorrhage [82]. (See "Diagnostic imaging procedures during pregnancy", section
on 'Magnetic resonance imaging'.)
It is preferable to reduce tumor size with a dopamine agonist and/or surgery prior to pregnancy in
women with a macroadenoma. (See "Management of lactotroph adenoma (prolactinoma) during
pregnancy".)

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