Idiopathic Intracranial Hypertension and Pregnancy: Recent Developments

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Abstract Purpose to Review This review summarizes what is currently known about idiopathic intracranial hypertension (IIH) during pregnancy, with a focus on recent developments. Monitoring of IIH during pregnancy, pharmacologic and surgical treatment options, prognostic factors, and comorbidities are discussed. Recent Findings Although this is an understudied area, several recent prospective and large database studies have expanded knowledge of this important topic. Recent data continues to support prior understanding that patients with IIH are not more likely to have spontaneous abortions, acetazolamide can be used when appropriate, and vaginal birth does not worsen the disease, but has raised new concerns, such as a possible association with hypertensive disorders of pregnancy, including eclampsia. Body mass index prior to pregnancy may affect outcomes, but weight gain during pregnancy may have less influence on recurrence rates and outcomes. Summary Patients with IIH can have successful pregnancies with good outcomes. Patients should be monitored during pregnancy with ophthalmoscopy, formal visual fields, and optical coherence tomography. If papilledema progresses or visual field changes develop, acetazolamide can be used in appropriate cases after discussion with the patient and their obstetrician. IIH status should not typically affect the patient’s birth plan, including plans for vaginal birth or anesthesia choice. Opinion Statement I counsel my patients that a diagnosis of idiopathic intracranial hypertension (IIH) does not mean that they cannot successfully become pregnant and have a good outcome. I counsel patients to update me if they become pregnant. For patients who are in remission prior to pregnancy, I counsel them that it is possible that their IIH may recur during pregnancy, that we cannot predict who will have a recurrence, and that we will monitor them closely during pregnancy. I discuss with them that being in remission off treatment, achieving a healthy weight or achieving some weight loss before becoming pregnant, and limiting weight gain to a healthy rate during pregnancy may minimize their likelihood of having recurrent disease. We discuss that if they have recurrence and if necessary to protect their vision, there are treatments that we can offer during pregnancy. If possible, I observe closely and avoid pharmacologic treatment. When necessary, such as if they develop severe symptoms or vision-threatening disease, I treat with acetazolamide in close communication with the patient’s obstetrician. Topiramate should not be used. If there is no papilledema or mild papilledema, I specifically state in my notes that their IIH diagnosis is not a contraindication to a vaginal birth or spinal or epidural anesthesia, and that their IIH diagnosis need not alter their birth plan. For patients who do not desire pregnancy, I counsel them that they can continue their birth control method of choice, including hormonal contraceptives, and that it is not likely to be the cause of or a contributing factor to their IIH.