Management of pregnancy
associated with brain tumors
ROGER D. KEMPERS, M.D.
ROSS H. MILLER, M.D.
Rochester, Minnesota
T H E concurrence of tumors of the brain
and pregnancy is uncommon and few insti-
tutions have had experience with significant
numbers of cases of this type. In the man-
agement of these patients, judgments with
regard to the optimal time for neurologic
studies and operation, and mode of de-
livery or interruption of the pregnancy, are
frequently difficult and occasionally con-
troversial. Understandably, the literature on
this subject since the turn of the century
has consisted primarily of scattered case
reports. More recently, a number of authors
have incorporated an analysis of the litera-
ture in the reports of their cases with the
hope of achieving, from past experience,
some unanimity of opmwn regarding the
management of these women.
Divry ;md Bobon1 concluded, from re-
ported cases, that approximately 80 per cent
of women with brain tumors showed in-
creased severity of symptoms during preg-
nancy. The symptoms generally subsided
after deiivery, but in the remaining 20 per
cent there was an increase at delivery and
in the postpartum period.
Weyand and his associates 2 at the Mayo
Clinic, in 1951, observed that intracranial
meningiomas may first become symptomatic
during pregnancy. An acceleration in the
progression of symptoms during pregnancy
was assumed to be caused by an increased
accumulation of intracellular fluid, since
From the Mayo Clinic and Mayo
Foundation.
858
there was no detectable microscopic evi-
dence of accelerated growth of the tumors.
Likewise, Kloss 3 stated that increased
severity of symptoms, often first noted dur-
ing pregnancy, was related to increased
edema of the brain tissue during pregnancy
and seldom to increased rate of growth of
the brain tumor. He observed that the like-
lihood of conception in women with brain
tumors did not differ from that in normal
women. In general, he favored vaginal de-
livery and advocated interruption of preg-
nancy only if the mother's life or vision were
in balance.
In reviewing their cases, Rand and And-
ler4 found that headache was present to a
val-ying degree in all patients, nausea and
vomiting occurred frequently, and convul-
sions were rare. They believed that, in the
management of the pregnancy, both the lo-
cation and the type of the tumor should be
given consideration. Patients with gliomas
seemed most likely to have a rapid and fatal
course. Three patients with astrocytomas in
the pons, left frontal lobe, and left cerebellar
hemisphere, respectively, died with babies in
utero. Consequently, these authors thought
that prompt surgical intervention was in-
dicated in patients suspected of harboring
a glioma. Patients with benign tumors, they
believed, could safely await delivery and a
postpartum operation.
The most comprehensive review was
made by Tarnow, 5 who, in 1960, reported
an analysis of 97 cases obtained by com-
bining his own experience with many well-
Volume 87
~umber 7
documented cases from the literature. In
two thirds of this group, the patients sur-
vived pregnancy, delivery, and puerperium.
The tumors were generally supratentorial in
location and included meningiomas, astro-
cytomas, and oligodendrogliomas, and there
was no significant increase in intracranial
pressure. In addition, there were several ex-
amples of acoustic neuromas with uncom-
plicated pregnancy.
The remaining third of this group died
during pregnancy, delivery, or puerperium,
and, for the most part, represented cases of
operative deaths culled from the older
literature.
The deaths not caused by operation
usually were caused by acutely increased in-
tracranial pressure, particularly with tumors
located infratentorially. The patients who
died from supratentorially located tumors
were shown to have harbored glioblastoma
multiforme, abscesses, metastatic lesions, or
tumors situated either intraventricularly or
close to the ventricle. The most dangerous
complication of these tumors was the sudden
increase in intracranial pressure. It was
concluded that the prognosis of the preg-
nancy was good if the tumor was not
highly malignant and if it was not infraten-
torial.
Tarnow 5 further stated that, in patients
with supratentorial tumors which were not
highly malignant nor situated in close prox-
imity to the ventricles, pregnancy could be
managed by close observation, use of seda-
tion and diuretics, and delivery with the aid
of low forceps. The indicated neurologic
operation then could be performed in the
postpartum period. In instances of sudden
increase in intracranial pressure necessita-
ting immediate intracranial surgical inter-
vention, cesarean section was recommended.
Interruption of the pregnancy in early ges-
tation was recommended for patients with
seizures or with glioblastoma multiforme.
Pituitary tumors were thought not to in-
fluence gestation; but, because of possible
permanent damage to the optic nerves,
operation on the tumor was often indicated,
and the management of the pregnancy
Pregnancy and brain tumors 859
would depend upon the stage of gestation
at that time. In patients with tumors of
infratentorial location, including tumors at
the cerebellopontine angle, spontaneous de~
livery was awaited only if there were no
general signs of increased intracranial pres-
sure. If signifi.cant symptoms were present
early in gestation, interruption was advised.
Occasionally, toward the end of gestation, a
Torkildsen procedure was done to relieve
intracranial pressure and allow time for the
fetus to attain viability.
Report of cases
A review was made of gravid patients,
seen at the Mayo Clinic from 1950 to 1963,
who had associated brain tumors. Sixteen
were found who had undergone complete
diagnostic investigation, and the majority
also had had definitive treatment here. The
obstetric aspects of these cases are summar-
ized in Table I. The clinical histories and
neurologic aspects are given in the con-
densed summaries which follow.
Case 1. At age 22 and para 0, the patient
had been blind in the left eye for 8 years and
had blurred vision in the right eye during the
last month of pregnancy. A meningioma of the
tuberculum of the sella was diagnosed on a skull
roentgenogram but operation was refused.
This patient was seen again at age 23, para i,
with blurred vision in the right eye and right
frontoparietal headaches. The previous diagnosis
was confirmed by carotid angiography during
the pregnancy but operation was refused until
3 months post partum. Subtotal removal of the
meningioma surrounding the optic nerves and
extending along the base of the skull was per-
formed. The patient refused postoperative x-ray
therapy.
During the third pregnancy, at age 24, the
patient was almost totally blind. Total blindness
ensued two and one-half years post partum.
Case 2. This patient, aged 24 and para i, was
seen in the thirty-fourth week of the second
pregnancy. There had been progressive loss of
vision for two and one-half years. The right eye
had been affected in the first pregnancy and
both eyes for 5 months of the present pregnancy.
Meningioma of the tuberculum of the sella was
diagnosed by carotid angiography during the
pregnancy and immediate craniotomy was
860 Kempers and Miller
urged. At operation, 3 days post partum, the
meningioma of the tuberculum of the sella was
completely removed. Vision was restored com-
pletely in the left eye but the right was totally
blind.
Case 3. This 39-year-old patient, para vii, had
had temporary partial blindness of the right eye
during the last 2 months of the previous preg-
nancy. She was seen ncar term in the current
pregnancy and had been totally blind in the
right eye and partially blind in the left since
early in the pregnancy. A meningioma of the
tuberculum of the sella was suspected, but was
not confirmed since spontaneous onset of de-
livery ensued, at 40 weeks' gestation. Postpartum
neurologic surgery was refused. Her vision was
poor two and one-half years later.
Case 4. The patient, 37 years old and para
iii, was seen at 3 months' gestation with the
chief complaint of total blindness in the right
eye and progressive loss of vision in the left.
Subtotal removal of a right basofrontal menin-
gioma had been performed one and one-half
years previously. Carotid angiography revealed
recurrent clinoid meningioma which was treated
by irradiation with cobalt-60. Interruption of the
pregnancy was recommended but was refused.
Her vision had remained unchanged three and
one-half years later.
Case 5. When first seen at 35 weeks' gestation,
this patient (37 years old, para vii) had paraly-
sis of the left hand of recent onset and seizures
of the left side of the body which had started in
the fifth month and were uncontrolled by medi-
cation. After delivery, pneumoencephalography
and carotid angiography were performed but
results were normal. Paralysis regressed but
seizures continued.
This patient was seen again 6 years later at
10 weeks' gestation. The paralysis in the left
hand had recurred since conception and there
wPre focal seizures twice a month. A mass, which
proved to be a meningioma, was detected in the
right frontoparietal region by pneumoencephal-
ography and was removed by craniotomy during
the first trimester. Seizures ceased and paralysis
re!'ressed.
Case 6. This 25-year-old patient, para iii, was
at 4 weeks' gestation when seen here. There
were frequent focal seizures of the left side
during the present and previous pregnancies. A
meningioma had been removed from the right
parasagittal region at 12 years of age. Recur-
rence of this lesion was suggested by a skull
roentgenogram and at craniotomy, during the
December 1, 1963
Aru. J. Obst. & Gyncc,
first trimester, a large osteoma and a recurrent
meningioma involving the scalp were removed.
A pedicle skin graft covered the defect, and the
second stage of the procedure, removing the
parasagittal growth, was done 3 months later.
Radiation therapy with cobalt-60 was applied
postoperatively. The patient was known to be
living 21 months later.
Case 7. The 37-year-old patient (para m,
abortion i) was seen in the thirty-first week of
the fifth pregnancy. There had been seizures
which were focal at onset but had become
generalized. A meningioma in the right parasa-
gittal region was detected by carotid angi-
ography. Following brief observation, the patient
was delivered at 32Y2 weeks' gestation. At crani-
otomy, 3 days later, the tumor was removed.
She was well at last report, 10 months later.
Case 8. This 21-year-old patient was seen at
6 weeks' gestation of the second pregnancy and
had been followed for 2 years because of loss of
memory and a convulsive disorder. Fractional
pneumoencephalography, 4 months previously,
had suggested a mass in the right parietooccipi-
tal region but none was found at craniotomy.
Radiation therapy with cobalt-60 was applied
postoperatively. Since the onset of the current
pregnancy, there had been weakness of the left
side and the left hand was almost useless.
Therapeutic abortion was performed. There was
some symptomatic improvement one year later.
Case 9. This 20-year-old primigravid patient
had noted the onset of disturbances in vision in
the fourth month of pregnancy. Examination
elsewhere at that time disclosed bitemporal
hemianopsia and an enlarged sella turcica, and
roentgen ray therapy had been given for a su-
spected pituitary tumor. When this patient was
seen here, at 31 weeks' gestation, there had been
slight progression of loss of vision. After obser-
vation for four and one-half weeks, cesarean
section was done when a change was noted in
the visual fields. At 3 days post partum, crani-
otomy was performed and a Rathke pouch cystic
adamantinoma, which was grooving the right
optic nerve, was removed. With substitutional
hormone therapy for hypopituitarism, she has
been well for 4 years.
Case 10. The patient, 30 years old and para
i, was seen at 8 weeks' gestation. For the previ-
ous 2 years a tumor in the right parietotemporal
region had been suspected although it had not
been verified at craniotomy. There had been
impairment of memory, homonymous hemian-
opsia of the left lower quadrant, and partial
Volume 87
Pregnancy and brain tumors 861
Number 7

palsy of the right third cranial nerve. No pro-
gression was noted on examination here and
pregnancy was not disturbed. No follow-up in-
(ormation is available.
Case 11. This 38-year-old patient, para v, was
seen here at 37~ weeks' gestation because
of a sudden generalized convulsion followed by
slight weakness in the left side. Two weeks
later, several focal seizures were noted on the
left side. Several days after delivery pneumo-
encephalography and carotid angiography were
performed but results were negative. In the en-

Table !. Tumor diagnosis, method of delivery, and outcome 1n pregnancy associated \vith
brain tumor

Age
Case (yr.) Tumor diagnosis Delivery Outcome
22 0 Meningioma, tuberculum Cesarean, 40 wk. Vision improved slightly; baby liv-
sella ing
23 Same Cesarean, 36 wk. Vision decreasing; baby living
24 ii Same Cesarean, 38 wk.; tubes Vision lost completely 2 J/2 yr.
ligated later; baby living
24 Meningioma, tuberculum Amniotomy, 34J/2 wk.; Vision restored left eye, lost com-
sella spontaneous delivery pletely in right eye; baby living
39 vii Meningioma, tuberculum Spontaneous, 40 wk. Vision improved slightly post par-
seiia (suspected) tum, poor 2 Y2 yr. iater; baby
living
4 37 iii Meningioma, clinoid Interruption refused. Vision poor left eye, lost com-
Cesarean, 31 wk. else- pletely right eye 3 J/2 yr. later;
where*; sterilization baby premature, died
5 37 vu None Amniotomy, 35 wk.; Paralysis regressed, seizures con-
spontaneous delivery tinued; baby living
43 vm Meningioma, right fron- At 40 wk. elsewhere Paralysis regressed, seizures ceased;
toparietal region baby living
6 25 iii Meningioma, right para- At 40 wk. elsewhere Living 21 mo. later; baby living
sagittal region
7 37 m Meningioma, right para- Amniotomy, 32 ~ wk.; Well 10 mo. later; baby living
sagittal region outlet forceps
8 21 Meningioma, right para- Pregnancy interrupted, Some symptomatic improvement
sagittal (suspected) 6 wk.
9 20 0 Adamantinoma, pituitary Cesarean, 35J/2 wk. Well 4 yr. later, hormone therapy;
baby living
10 30 Suspected, right temporo- Pregnancy continued; Unknown
parietal region delivery elsewhere
11 38 0 Mixed glioma, right post- Amniotomy, 40 wk.; Seizures continued, died 10 mo.
hemisphere (necropsy) spontaneous delivery post partum elsewhere; baby
living
12 35 m Astrocytoma, right tem- Pregnancy interrupted, No significant change 6 mo. later
poroparietal region 6 wk.; sterilization
13 42 v Suspected mixed-type Pregnancy continued; Living 6 yr. later; fetal outcome
adenocarcinoma delivery elsewhere unknown
14 40 vii Malignant pontine glioma Spontaneous, 40 wk.; Died 6 mo. post partum; baby
low forceps living
15 24 0 !~ eurofibroma,
cerebello- Cesarean, 35 Y2 wk. Died i6 mo. postpartum, massive
pontine angle tumor recurrence; baby living
16 37 Vascular hemangioma, Cesarean, 40 wk.; steril- Died 15 mo. postpartum; baby
pineal region ization living
*Interruption of pregnancy had been advised here but had been refused.
862 Kempers and Miller
suing months, the focal seizures continued and
the patient became mentally confused. She died
during neurologic investigation elsewhere ( 10
months post partum) and necropsy revealed a
mixed glioma in the right posterior hemisphere.
Case 12. This patient, 35 years old and para
iii, was seen at 6 weeks' gestation. Two years
previously subtotal removal of an infiltrating
astrocytoma in the right temporoparietal region
with postoperative radiation therapy was per-
formed. Focal seizures of the left side and,
rarely, grand mal seizures had continued with
increased frequency, in spite of sedation, since
conception. Therapeutic abortion and steriliza-
tion were done here. No significant change in
her condition was noted 6 months later.
Case 13. When seen in the fifth month of the
eighth pregnancy, this patient ( 42 years old,
para v) complained of blurred vision and ver-
tigo of 5 years' duration but with no recent
progression. The findings were of the bulbar type
and a hard mass behind the right side of the
soft palate was thought to be mixed-type adeno-
carcinoma extending into the right posterior
fossa. Roentgen ray therapy was given, the preg-
nancy was not disturbed, and she is alive 6 years
latPr.
Case 14. The patient, 40 years old and para
vii, was seen at 8 months' gestation. There was
bilateral cerebellar ataxia, and progressive loss
of -;ense of touch and pain over the right side of
the face. The tentative diagnosis was tumor of
the pons, and roentgen ray therapy was applied
to the brain stem. Symptoms subsided and she
was delivered at term. However, at re-examina-
tion 3 months later, signs of increasing intra-
cranial pressure were seen and craniotomy re-
vealed an inoperable malignant pontine glioma.
ThP. patient died 3 months after this operation.
Case 15. This 24-year-old patient (para 0,
abortion i) had noted progressive postural diz-
ziness, deafness, and tinnitus of the left ear since
conception. She was very anxious for a happy
outcome for the pregnancy and neurologic sur-
gery was delayed until after cesarean section at
35~;2 weeks' gestation. At operation, a large
neurofibroma of the cerebellopontine angle was
removed. This recurred in massive size and re-
section was attempted again 15 months later.
ShP died 5 weeks later.
Case 16. This 37-year-old patient (para i,
abortion vi) had been treated for a suspected
pinealoma with associated subarachnoid hemor-
rhages by means of a Torkildsen procedure
(right lateral ventricle to cisterna magna) and
December 1, 1963
Am. J, Obst. & Gynec.
roentgen ray therapy, and, subsequently, by sub-
total removal of a vascular hemangioma in the
pineal region. The patient returned a year later,
very near to term in her eighth pregnancy, be-
cause of difficulty in walking. Delivery was ac-
complished by cesarean section, because of a
difficult first delivery which included ocular
hemorrhages, and sterilization was performed
by tubal ligation. Her condition deteriorated
gradually and she died 15 months later.
Comment
It is apparent, from reviewing the litera-
ture and from analyzing our experience,
that the management of the pregnancy must
be somewhat flexible because of differences
in type and location of the tumors, differ-
ences in symptoms, differences in parity and
length of gestation, and differences in the
patients' personal wishes.
All infants of mothers who were cared
for here in the last trimester of their preg-
nancy survived. There were no maternal
deaths during pregnancy, delivery, or in the
immediate postpartum period.
It is of interest that one fourth of the
brain tumors, those in the last 4 cases sum-
marized, were infratentorial in location. In
one of these cases, the tumor was metastatic
in origin. In the other 3, the patients were
gravely ill and death occurred from 6 to 16
months post partum. The gravity of the
course in these patients probably was not
related to the pregnancy. These tumors in-
cluded a rapidly growing glioma, a heman-
gioma, and a rapidly growing neurofibroma;
and in each instance the lesion could not
be completely removed surgically.
The other 12 patients all had supraten-
torial tumors and, as a group, these patients
had a much more favorable course. At last
follow-up, which varied up to as long as 7
years post partum, these patients were known
to be alive with the exception of the patient
in Case 11 who died within a year while in
another city undergoing neurologic investi-
gation, and the patient in Case 10 who did
not submit follow-up information. Eight of
the 12 lesions were proved, or strongly sus-
pected, to be meningioma. Of this group of
12 patients, 4 had tumors which could be
Volume 87
Number 7
totally removed with resulting cure. Two
other patients either delayed or refused to
permit neurologic surgery. These findings
correlate well with those of Tarnow, 5 who
noted that the best prognosis was in patients
with tumors in a supratentorial location.
Meningioma and other brain tumors, with
some exceptions such as glioblastoma multi-
forme, often may not produce symptoms un-
til after the onset of the pregnancy, and,
even without operation, the symptoms may
reverse completely or partially after deliv-
ery.1-3' 5 This was noted in each of our ex-
amples of meningioma. These tumors grow
relentlessly, but the increase in symptoms
during pregnancy may not be related to
growth, but rather to increased accumula-
tion of intracellular fluid. Often, only care-
ful observation of these patients is necessary,
but neurologic surgery may be required if
there is a sudden onset of increased intra-
cranial pressure or evidence of sudden en-
largement of the tumor producing an in-
crease in focal neurologic symptoms.
When neurologic surgery is contemplated,
it has usually been found feasible to manage
the patient conservatively with diuretics,
sedatives, and careful observation until the
fetus has reached a size that offers a good
chance for viability. Labor may be induced
at 33 to 35 weeks' gestation, and the defini-
tive surgical procedure then may be per-
formed post partum. Although diagnostic
studies such as carotid angiography and
fractional pneumoencephalography occasion-
ally may be performed during pregnancy, it
seems preferable to wait until the postpar-
tum period. It seems distinctly preferable
not to perform neurologic surgery during
pregnancy because the increased vascularity
is a hazard to both the mother and the fetus.
Also, the use of hypotension or hypothermia
increases the hazard to the fetus. In the
series described in this report, neurosurgical
procedures often were performed as early as
3 days post partum.
As noted in this series, early induction of
labor by amniotomy usually is feasible in
multiparous patients. Although stimulation
of the uterus with oxytocin (Pitocin) was
Pregnancy and brain tumors 863
not required, the presence of a brain tumor
is not a contraindication to its judicial use
after amniotomy when vaginal delivery has
been decided upon. Marx and co-workers 6
have shown that uterine contractions, them-
selves, do not increase cerebrospinal fluid
pressure. When some elevation is noted in
the first stage of labor, it is the result of
skeletal muscle contractions which occur in
response to pain. Bearing-down efforts in the
second stage markedly increase cerebrospinal
fluid pressure. Therefore, these pressure in-
creases should be minimized by shortening
the second stage of labor by using outlet
or lo\v forceps. Choice of anesthesia for
vaginal delivery must be individualized. We
have preferred to use the pudendal block.
In one multiparous patient, delivery was by
cesarean section because of a past history of
subarachnoid hemorrhages. To allow her to
labor would have incurred the risk of further
hemorrhage. When early delivery is desired
in primigravid patients with long-closed
cervices, cesarean section may be indicated,
as in 2 of our patients.
Of the 5 patients cared for here who were
not delivered before 40 weeks' gestation, 3
did not present themselves for care until ap-
proximately that time. One other had re-
ceived roentgen ray therapy to the tumor and
was thought to be somewhat improved. The
fifth patient, a primipara, had refused neu-
rologic surgery and was being observed
closely.
When a brain tumor is suspected early in
pregnancy, management must be individ-
ualized. In two instances, definitive neuro-
logic surgery was carried out during early
gestation with a happy outcome to both
mother and child. In another instance, the
patient was seen in early pregnancy, but no
treatment except careful observation was in-
stituted until thirty-five and one-half weeks'
gestation, since the mother, being primi-
gravid, was most anxious for a happy out-
come for the baby. One other patient had
an inoperabie metastatic lesion with no evi-
dence of progression of symptoms, and the
pregnancy was not disturbed.
In 2 patients seen in early pregnancy, pre-
864 Kempers and Miller
vious craniotomies had not been successful
in locating the tumor. In one of these 2, the
symptoms were progressing rapidly and the
pregnancy was interrupted. In the other,
there was no change in symptoms and the
pregnancy \vas not disturbed. Interruption of
the pregnancy was offered to 2 other pa-
tients: one of these had an inoperable lesion
producing progressive visual damage, but she
did not consent; the other had suspected
re<;idual tumor and uncontrolled seizures, and
this pregnancy was interrupted.
Interruption of pregnancy, however, seems
seldom to be indicated. We agree with Tar-
now" that, if significant symptoms, such as
uncontrollable seizures, arise during preg-
nancy and the tumor cannot be removed
completely, interruption may be indicated
since condition of these patients may deterio- ,
rate more rapidly during pregnancy. Inter-
ruption would seem indicated especially in
instances of glioblastoma multiforme and its
associated grave prognosis. Sterilization
should be considered after delivery or after
therapeutic abortion in patients with malig-
nant inoperable tumors.
Summary and conclusions
Our experience with 16 patients in whom
pregnancy was associated with brain tumor,
seen at the Mayo Clinic from 1950 to 1963,
was reviewed. All infants born to mothers
who were managed here in the last trimester
of pregnancy survived, and all mothers sur-
REFERENCES
1. Divry, Paul, and Bohon, Jean: Acta neural.
et psychiat. belg. 49: 59, 1949.
\'Veyand, R. D., },.facCarty, C. S., and '\"J'ilson,
R. B.: S. Clin. North America 31: 1225, 1951.
3. Kloss, Karl: Wien Ztschr. Nervenh. 5: 175,
1952.
December I, 1963
Am. J. Obst. & Gynec.
vived the pregnancy, delivery, and post-
partum period. The best prognosis for the
mother can be expected when the tumor is
located supratentorially.
Many patients with brain tumors, particu-
larly meningiomas, note the onset of symp-
toms during pregnancy; these neurologic
symptoms may subside completely or par-
tially after delivery. The increased tumor
size during pregnancy is probably due to in-
creased accumulation of intracellular fluid
rather than to accelerated tumor growth.
Delay of definitive neurologic surgery, with
careful observation, until the infant reaches
a size that offers a good chance for viability
is frequently feasible. However, these patients
must be followed closely for signs of increas-
ing intracranial pressure or other symptoms
of rapid increase in the size of the intra-
cranial tumor. It is preferable not to perform
neurologic surgery during pregnancy because
of an increased operative risk to both mother
and fetus; however, operation often was per-
formed as early as 3 days post partum.
In multiparous patients, when indicated,
early induction by amniotomy at 33 to 35
weeks' gestation is practical and may be fol-
lowed by vaginal delivery aided by outlet
forceps. In primigravid patients, cesarean
section is often preferable. Interruption of
early pregnancy seldom is indicated but
should be considered in patients with uncon-
trolled seizures, particularly if the intracra-
nial tumor cannot be completely removed.
4. Rand, C. W., and Andler, M.: Arch. Neural.
& Psychiat. 63: 1, 1950.
5. Tarnow, G.: Zentralbl. t'~eurochir. 20: i34,
1960.
6. Marx. Gertie F., Zemaitis, Mary T., and
Orkin', L. R.: Anesthesiology 22: 348, 1961.