preconception [Neurosurgery Wiki]

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### **Preconception Considerations in Neurosurgery**
In neurosurgery, **preconception care** is critical for women with pre-existing neurological conditions or those who have undergone neurosurgical procedures. The goal is to optimize maternal and fetal outcomes by managing neurological conditions before pregnancy.

#### **Key Preconception Considerations in Neurosurgery:**

1. **Epilepsy and Seizure Disorders**  
   - Ensure seizure control before pregnancy.  
   - Adjust **antiepileptic drugs (AEDs)** to minimize teratogenic risks (e.g., valproate is associated with neural tube defects).  
   - Monitor drug levels, as pregnancy can alter AED metabolism.  
   - Consider folic acid supplementation (≥4 mg/day) due to increased risk of neural tube defects.

2. **Hydrocephalus and Shunted Patients**  
   - Evaluate **ventriculoperitoneal (VP) shunts** for functionality before pregnancy.  
   - Be aware that increased intra-abdominal pressure during pregnancy may affect shunt function.  
   - Consider alternative CSF diversion strategies if necessary.

3. **Brain and Spinal Tumors**  
   - Assess tumor status and potential pregnancy-related growth stimulation (e.g., **meningiomas** can grow due to hormonal influence).  
   - Delay pregnancy if surgical intervention or adjuvant therapy (radiotherapy, chemotherapy) is needed.  
   - Consider MRI monitoring during pregnancy (preferably without contrast).

4. **Spinal Disorders and Previous Spinal Surgery**  
   - Women with prior spinal fusions or instrumentation should be evaluated for potential **pelvic and lumbar spine stress** during pregnancy.  
   - Assess risks for worsening spinal stenosis or herniation due to increased lumbar lordosis.  
   - Consult anesthesia for **epidural feasibility** if prior spinal surgery exists.

5. **Stroke and Cerebrovascular Conditions**  
   - **Arteriovenous malformations (AVMs)** and **intracranial aneurysms** require preconception risk assessment due to increased rupture risk during pregnancy.  
   - **Carotid or vertebral artery dissections** require control of hypertension and anticoagulation planning.  
   - Pregnancy-related **hypercoagulability** increases stroke risk in certain conditions.

6. **Chiari Malformation and Syringomyelia**  
   - Evaluate for worsening symptoms (headache, myelopathy) with increased **intracranial pressure (ICP)** due to pregnancy-related fluid shifts.  
   - Discuss **vaginal vs. cesarean delivery** based on neurological status.

7. **Multiple Sclerosis and Neuroimmunological Disorders**  
   - Consider disease-modifying therapy (DMT) adjustments, as some are teratogenic.  
   - Pregnancy often reduces MS relapse rates, but postpartum relapse risk increases.  
   - Evaluate neurosurgical implications if there is severe disability.

8. **Neurosurgical Medications and Pregnancy**  
   - **Avoid teratogenic drugs** such as valproate, methotrexate, and certain immunosuppressants.  
   - Adjust corticosteroid use if needed for neurological inflammation.  
   - Consider thromboprophylaxis in patients at high risk of **venous thromboembolism (VTE)** due to immobilization.

### **Conclusion**
Women with neurological conditions planning pregnancy should undergo **preconception counseling with a multidisciplinary team**, including **a neurosurgeon, neurologist, obstetrician, and anesthesiologist**. Optimizing neurological health before conception improves both maternal and fetal outcomes.

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