Can a patient with a history of Arnold Chiari malformation, who underwent craniotomy and grafting, have a safe vaginal delivery during pregnancy?

Management of Vaginal Delivery in a Patient with Arnold-Chiari Malformation

Vaginal delivery is the preferred mode of delivery for a patient with a history of surgically corrected Arnold-Chiari malformation, provided there are no current neurological symptoms or complications. 1

Risk Assessment and Delivery Planning

• Patients with surgically corrected Arnold-Chiari malformation without current symptoms can generally undergo vaginal delivery with appropriate precautions 2
• A multidisciplinary team approach involving obstetricians, neurologists, and anesthesiologists is essential for safe delivery planning 1, 3
• Pre-delivery assessment should include evaluation of current neurological symptoms, imaging if indicated, and anesthesia consultation 2
• Delivery should take place in a tertiary center with specialist multidisciplinary team care for high-risk cases 1

Mode of Delivery Recommendations

• Vaginal delivery is associated with less blood loss, lower infection risk, and decreased risk of venous thrombosis compared to cesarean delivery 1
• For patients with surgically corrected Arnold-Chiari malformation without current symptoms, management of labor and delivery can be similar to that for normal pregnant women 1
• Cesarean delivery should generally be reserved for obstetric indications rather than performed solely due to history of Arnold-Chiari malformation 1, 4

Special Considerations for Vaginal Delivery

• Limiting maternal Valsalva efforts during the second stage of labor is recommended to avoid increased intracranial pressure 2, 5
• Assisted vaginal delivery (forceps or vacuum) under neuraxial anesthesia can be considered to minimize pushing efforts 2, 5
• An individualized delivery plan should be created that specifies timing of delivery, method of induction if needed, analgesia/anesthesia approach, and level of monitoring required 1

Anesthesia Considerations

• Epidural anesthesia is reasonable with precautions to avoid hypotension 1, 5
• Careful placement of neuraxial anesthesia by experienced providers is important to minimize risk of complications 2, 6
• General anesthesia may be necessary in some cases, particularly if there are concerns about increased intracranial pressure or if neuraxial anesthesia is contraindicated 6

Monitoring During Labor and Delivery

• Continuous monitoring of maternal vital signs, including blood pressure and heart rate, is essential 1
• Pulse oximetry and continuous ECG monitoring should be utilized as required 1
• Close monitoring for neurological symptoms during labor is important 2, 3

Potential Complications to Watch For

• Increased intracranial pressure during labor contractions is a theoretical concern that could potentially lead to brainstem herniation 2
• Neurological deterioration, including worsening headaches, visual disturbances, or extremity weakness/numbness 2, 3
• Complications related to anesthesia, particularly with neuraxial techniques 6

Postpartum Care

• Close monitoring for neurological symptoms in the immediate postpartum period 3
• Early mobilization and thromboprophylaxis to reduce risk of venous thromboembolism 7
• Follow-up neurological evaluation may be warranted, particularly if new symptoms develop 3

Despite theoretical concerns, the available evidence suggests that vaginal delivery can be safely performed in patients with surgically corrected Arnold-Chiari malformation who are currently asymptomatic, with appropriate precautions to minimize increases in intracranial pressure during delivery 2, 5.