Outcomes of hospitalization in pregnant women with CNS neoplasms: a population-based study

Anna Terry

Fred Barker

Lisa Leffert

Brian Bateman

Irene Souter

Scott Plotkin

Supplementary Material

Supplementary Data:

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Neurosurgical Service (A.R.T., F.G.B.); Department of Anesthesia, Critical Care, and Pain Medicine (L.L., B.T.B.); Department of Obstetrics and Gynecology (I.S.); and Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts (S.R.P.)

Corresponding Author: Anna R. Terry, MD, MPH, Neurosurgical Service, White 502, Massachusetts General Hospital, Boston, MA 02114 (moc.liamg@7791yrretra).

Received 2011 Dec 20; Accepted 2012 Feb 23.

Abstract

Managing a CNS neoplasm during pregnancy presents complex challenges, and population-based studies are lacking. We designed a retrospective cohort study using the Nationwide Inpatient Sample (NIS) to investigate pregnancy outcomes in women with CNS neoplasms. We constructed a logistic regression model for maternal mortality, preterm labor, intrauterine growth restriction (IUGR), and Caesarean delivery, controlling for age, comorbidities, and demographic characteristics. We identified 379 malignant brain tumors, 437 benign brain tumors, and 44 spine tumors among 19 million pregnancy-related admissions from 1988 through 2009. Malignant brain tumors were associated with maternal mortality (odds ratio [OR], 143), preterm labor (OR, 3.4), and IUGR (OR, 2.9). Benign brain tumors were associated with preterm labor (OR, 2.3). A diagnosis of hyperemesis gravidarum was more common in malignant (OR, 2.2) and benign (OR, 2.8) brain tumors. Compared with the general population, Caesarean delivery was more frequent for malignant (OR, 6.4) and benign (OR, 2.8) brain tumors and spine tumors (OR, 3.9). Admission without delivery was more common for malignant (OR, 8.6) and benign (OR, 4.3) brain tumors and spine tumors (OR, 3.8; P < .05 for all outcomes). Thirty-three percent of all hospitalizations involved neurosurgical procedures, but pregnancy complications were not significantly more likely to occur in surgical patients. In conclusion, malignant brain tumors were associated with adverse pregnancy outcomes, and CNS neoplasms were associated with higher rates of Caesarean delivery. Additional research is needed to improve understanding of obstetric risk in these patients and to assist with treatment, counseling, and monitoring during delivery.

Keywords: brain tumors, epidemiology, outcome research, pregnancy, spine tumors

Abstract

Primary intracranial neoplasms are the fifth leading cause of cancer-related death in women aged 20–39 years.¹ Among young adults aged 20–34 years, gliomas are the most common histology (34%), followed by pituitary tumors (27%) and meningiomas (14%).² Although pregnancy is not considered to be a risk factor for developing a CNS neoplasm and there is no evidence that primary brain tumors occur at greater frequency during pregnancy compared with nonpregnant women of the same age,³,⁴ physiologic changes during pregnancy may exacerbate tumor-related symptoms or affect the growth of lesions with steroid hormone receptors, such as meningiomas.⁵,⁶ Because peritumoral edema can worsen as the result of fluid shifts during the second and third trimesters,¹,⁷ pre-existing lesions may become symptomatic for the first time during pregnancy.⁸ Although less common than brain tumors, spinal neoplasms may pose risks during the process of labor and delivery, given the frequent need for spinal or epidural anesthesia.⁹–¹¹

As with other cancers, treatment of CNS tumors during pregnancy depends on the site, biology, and aggressiveness of the tumor and on balancing the complex and interconnected needs of mother and fetus.¹² This is particularly true in the case of malignant brain tumors, for which the accepted treatment standard includes radiation therapy, which is usually contraindicated during pregnancy, especially in its early stages. In addition, the stress of surgery and anesthesia during pregnancy has been associated with preterm labor and other complications.¹³

Although several authors have attempted to clarify pregnancy outcomes in women with CNS tumors, population-based studies addressing this scenario are lacking. Most of the previous work on this topic consists of single case reports or small series.⁸,¹³–²² Although neurosurgical procedures performed during pregnancy have not been shown to worsen maternal or neonatal outcomes, prior studies were not adequately powered to draw statistically significant conclusions. Similarly, although some women experienced fetal loss, preterm labor, and other complications related to their CNS neoplasms, it was not possible to quantify their risk for such complications.

We address this clinical question by using a nationally representative administrative dataset to identify hospitalized pregnant women with CNS tumors, thus maximizing sample size and statistical power and illuminating areas of future research to clarify diagnostic and treatment strategies in these patients. We hypothesized that pregnant women with CNS neoplasms, particularly malignant brain tumors, would have an elevated risk of adverse pregnancy outcomes and a higher rate of Caesarean delivery because of more conservative management of their delivery process.

Abbreviations: MBT, malignant brain tumors; BBT, benign brain tumors; ST, spine tumors.

^{Per HCUP policy, exact number and frequency cannot be reported when cell size <10.}

^P < .0001.

Abbreviations: MBT, malignant brain tumors; BBT, benign brain tumors; ST, spine tumors; IUGR, intrauterine growth restriction.

Outcomes are not reported for subgroups with zero events. ORs are univariate unless otherwise noted.

^{Adjusted for age, pre-eclampsia, chronic and gestational diabetes, chronic and gestational hypertension, renal disease, multiple gestation, race, and socioeconomic status.}

^{Adjusted for pre-eclampsia, multiple gestation, and race.}

^{Adjusted for age, year, previous Caesarean delivery, pre-eclampsia, chronic and gestational diabetes, chronic and gestational hypertension, multiple gestation, and insurance payor.}

^{Adjusted for pre-eclampsia, chronic diabetes, multiple gestation, and race.}

^{Adjusted for age, year, previous Caesarean delivery, pre-eclampsia, chronic and gestational diabetes, chronic and gestational hypertension, multiple gestation, renal disease, insurance payor, socioeconomic status, and hospital type.}

^{Adjusted for chronic diabetes and race.}

^P < .0001

^{According to HCUP policy, exact number and frequency cannot be reported when cell size <10.}

Abbreviations: MBT, malignant brain tumors; BBT, benign brain tumors.

Outcomes are not reported for subgroups with zero events. ORs are univariate unless otherwise noted.

^{Adjusted for gestational diabetes and socioeconomic status.}

^{Adjusted for age, hypertension, race, and socioeconomic status.}

^P < .0001

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Acknowledgments

We thank Dr. Robert Martuza and the MGH Neurosurgical Service for generous financial support of relevant coursework at the Harvard School of Public Health. A preliminary version of this work was presented as a poster at the annual Society for Neuro-Oncology meeting in Orange County, CA, November 2011.

Conflict of interest statement. None declared.

Acknowledgments

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