Individual research recommendation details

Recommendation ID

NG121/1

Question

Does caesarean section protect against cerebral haemorrhage in women with a history of subarachnoid haemorrhage or cerebrovascular malformation?

Any explanatory notes
(if applicable)

Why the committee made the recommendations

Although the available evidence showed that there were no maternal or neonatal deaths or morbidities related to maternal cerebrovascular malformation or a history of intracranial bleeding, the committee agreed that there was not enough evidence to justify changing practice for women at high risk of an intracranial bleed. Current practice is to manage the bleeding risk as conservatively as possible.

Although vaginal birth is an option for women at low risk of intracranial bleeding, the committee acknowledged that some women would choose a caesarean section because of the theoretical risk of a bleed. The committee agreed that mode of birth should be based on the woman's preference as well as obstetric indications.

In women at high risk, or unknown risk (for example, because they have presented in labour with no antenatal care), the committee decided that in theory a caesarean section reduces the risk of intracranial bleeding because it should reduce the risks of raised intracranial pressure. This theoretical reduction in risk justified caesarean section for this group. The committee added that if a woman at high risk wanted to go into labour, the benefits and risks of an assisted second stage of labour compared with active pushing alone should be explained to the woman to ensure that steps are taken to reduce the risk of intracranial bleeding.

The committee knew that there was sometimes a reluctance to offer regional analgesia and anaesthesia to women with a history of subarachnoid haemorrhage or arteriovenous malformation of the brain because of the possibility of provoking a bleed. They discussed that this was extremely unlikely unless there was a genetic predisposition to multiple cerebrovascular malformations or unknown genetic history. They agreed that most women should be able to choose regional analgesia if they wished.

The committee was aware that cerebrovascular malformations affect more than 3% of the population and that women with cerebrovascular malformations or a previous subarachnoid haemorrhage are at risk of a potentially life-threatening cerebral haemorrhage. In current practice, many women with cerebrovascular malformations will be offered a caesarean section. However, it is uncertain whether vaginal birth increases the risk of cerebral haemorrhage in these women and the committee agreed to make a research recommendation to inform future guidance.

How the recommendations might affect practice

The recommendations are in line with current practice for women at high risk, but many healthcare professionals would currently offer an elective caesarean section to women at low risk. So these recommendations could lead to a major change in practice for these women, with fewer caesarean sections. This assumes that their obstetric indications and personal preferences are similar to those of the general population of women.

Source guidance details

Comes from guidance

Intrapartum care for women with existing medical conditions or obstetric complications and their babies

Number

NG121

Date issued

March 2019

Other details