Question: What can you tell me about the risks, if any, of childbirth after traumatic brain injury? In particular, I was wondering whether the risk of stroke as a result of weakened blood vessels is higher in women who have had a traumatic brain injury (TBI).
Answer: Ask The Doctor
Dear KM:
Thanks for your challenging question. Unfortunately, there is very little literature in the area of obstetrical issues in persons with TBI. In fact, I was unfamiliar with any studies when I received your question, nor could I find any literature on this issue when I conducted a search. I would note several things, however, regarding the issue of childbearing after brain injury.
As a rule, childbearing capacity is not adversely affected by TBI, whether mild or severe. There certainly are individuals who have endocrine (hormonal) problems following TBI that may cause difficulties in becoming pregnant; in particular, amenorrhea, or lack of a period. Generally, however, amenorrhea is transient, with menses normally returning within the first six to twelve months post-injury. If menses does not return on its own, the treating obstetrician and gynecologist, or TBI specialist could consider administering oral estrogen/progesterone preparations which will not only restore the menstrual cycle but maintain secondary sexual characteristics and reduce the risk of osteoporosis.
It is also important to note that in women who have more significant physical disabilities (e.g., gait disturbances secondary to hemiparesis or ataxia) pregnancy can cause further difficulty in general mobility status. One phenomena that I have also seen frequently over the years in pregnant women who had a history of severe TBI, is that their baseline ataxia worsens. This may be related to effects of systemic hormonal changes. Even persons who regularly use wheelchairs need to be aware that pregnancy may compromise their seating and wheelchair mobility and they may need to look at wheelchair modifications or temporary alternative seating.
In persons with significant physical impairments after TBI, pregnancy can also exacerbate post- injury musculoskeletal problems, including arthritis and low back pain due to the alteration in normal body biomechanics associated with pregnancy.
Generally, fertility is unaffected by TBI, whether mild, moderate or severe. What individuals with brain injury and their families need to be aware of is the fact that many of the medications prescribed to persons with TBI have the potential to cause birth defects (also known as teratogenic drugs). These issues are particularly problematic in individuals who have established post-traumatic epilepsy and require long-term maintenance on anti-convulsant drugs. In a situation such as this, it is recommended to continue on the drugs and have close prenatal screening to determine if the fetus has any birth defects, such as neural tube defects. If such defects are found, the individual has the option of continuing the pregnancy or having an abortion. Many commonly used drugs, including anti-depressants such as SSRIs, may be associated with teratogenic effects. There are some drugs for which there is little to no literature on their use during pregnancy. It has been my experience that it is best to avoid such medications during pregnancy, if at all possible.
It must be mentioned that there is no data to suggest, with regard to your specific questions, that women with TBI are at increased risk of stroke during the birthing process due to weakened blood vessels from the brain injury. As a rule TBI does not "weaken" blood vessels. It certainly is possible but rare to have post-traumatic aneurysms which may put a woman at increased risk for aneurysmal rupture if there is significant hypertension during the pregnancy and/or birthing process. This vascular complication of neck and traumatic brain injury is extremely rare, so this should not be a concern for the typical individual. As noted in the beginning of my answer, I would emphasize that there is no literature that I am aware of that actually looks at this question. As concerns exist about risks, they should be discussed on an individual basis with the treating physician and/or a referral should be made to a specialist in TBI and/or obstetrics.
I would note that in more general terms, not specific to TBI, there has been an ongoing controversy regarding the use of low dose oral contraceptives and stroke in young women. Recent studies seem to suggest that the overall risk for stroke was not increased among current users of low dose oral contraceptives. There is controversy, however, regarding this issue. There are also studies that have shown that, although the rate of stroke is falling in young women over the last few years, the rate of relative risk associated with oral contraceptive use is greater for occlusive stroke and increases with age in hemorrhagic stroke. A recent publication concluded that risk of occlusive stroke increases with increased dosages of estrogen, although the risk related to type or dose of progesterone is less consistent.
Lastly, there is also recent literature to suggest that women in general are at higher postpartum risk (e.g. after childbirth) for stroke. These researchers found that the risk of cerebral infarction (stroke) and intracerebral hemorrhage (bleeding in the brain tissue) are increased in the six weeks after delivery but not during pregnancy itself. This risk is about 8.7 times higher for women in the postpartum period than non-pregnant women.
Overall, there is much that we have to learn regarding pregnancy and its potential risk to women who have sustained traumatic brain injury, particularly those which are more severe. I hope that my answer sheds at least some light on this topic.
Thank you for your questions.
References
Kittner SJ, Stern BJ, Feeser BR et al: Pregnancy and the risk of stroke. NEJM. 12;335(11):768-774.
Sandel ME: Sexuality and reproduction after traumatic brain injury. In: Medical Rehabilitation of Traumatic Brain Injury. LJ Horn & ND Zasler (Eds). Philadelphia: Hanley & Belfus, 1996. Pgs. 557-572.
Schwartz SM, Siscovick DS, Longstreth WT et al: Use of low dose oral contraceptives and stroke in young women. Ann Intern Med. 15;127(8):596-603, 1997.
Schwartz SM, Petitti DB, Siscovick DS et al: Stroke and use of low-dose oral contraceptives in young women: A pooled analysis of two US studies. Stroke. 29(11):2277-2284, 1998.
Thorogood M: Stroke and steroid hormonal contraception. Contraception. 57(3):157-167, 1998.
Zasler ND: Sexual dysfunction. In: Neuropsychiatry of Traumatic Brain Injury. JM Silver, SC Yudofsky & RE Hales (Eds). Washington, DC: American Psychiatric Press, Inc., 1994. Pgs. 443-470.