Idiopathic intracranial hypertension in the pregnant patient: a narrative review on the management of visual disturbances

Introduction

Idiopathic intracranial hypertension (IIH), also known as pseudotumor cerebri, is a condition characterized by an elevated intracranial pressure (ICP) without an identifiable cause. It primarily affects obese women of childbearing age and is defined by an opening pressure >250 mmH₂O, normal cerebrospinal fluid (CSF) composition, and absence of secondary causes on neuroimaging (1). The Modified Dandy Criteria used to diagnose IIH have been reviewed and updated by Friedman et al. in 2013 to further distinguish primary from secondary causes of intracranial hypertension (2). The most common presenting symptoms are headache, transient visual obscurations, back pain, and pulse-synchronous tinnitus (3). The major morbidity associated with IIH is permanent vision loss due to chronic papilledema (4-8). Oftentimes, this course is chronic and insidious. As such, it is important to diagnose and manage IIH immediately, as early treatment can reverse papilledema (9,10).

Although the etiology of IIH remains unclear, several mechanisms have been proposed. These include CSF overproduction from the choroid plexus, impaired CSF outflow at the arachnoid villi or granulations, glymphatic dysfunction, and elevated intra-abdominal pressure from central obesity impeding venous return from the intracranial circulation (11-16). Obesity, as a proinflammatory state, is thought to play an additional role via upregulation of cytokines that disrupt CSF absorption (16-18). Elevated venous sinus pressure, previously thought to be the primary mechanism, may instead reflect secondary compression by exacerbating IIH through compression of the intracranial venous sinuses, causing further reduction of flow across the arachnoid villi (19). Hormonal factors, such as sex hormones and other metabolites, have also been implicated, as conditions such as pregnancy, polycystic ovarian syndrome (PCOS), and elevated leptin levels appear to promote or worsen IIH symptoms (13,16,20).

As IIH primarily affects women of childbearing age, its intersection with pregnancy raises several difficult and unique questions, many of which remain unanswered or fragmented, with findings dispersed across various disciplines. The incidence of new-onset IIH diagnosed during pregnancy is estimated between 5.9% and 10% (21-23). Beyond the typical complications, IIH in pregnancy also increases the risk of hypertensive disorders such as preeclampsia and eclampsia, posing significant morbidity and mortality risk to both the mother and fetus (21,23,24). As such, it is important for physicians who manage patients with IIH to have a clear understanding of IIH management during pregnancy to better optimize maternal and fetal outcomes. Additionally, because management of IIH during pregnancy requires balancing between maternal health and fetal safety, coordinated care between neuro-ophthalmology and OB-GYN is essential to provide comprehensive monitoring, thus highlighting the importance of interdisciplinary care. This narrative review summarizes what is currently known about IIH in pregnancy and identifies areas requiring further investigation. We present this article in accordance with the Narrative Review reporting checklist (available at https://aes.amegroups.com/article/view/10.21037/aes-24-35/rc).

Methods

A literature search of PubMed and MEDLINE was conducted through April 21, 2025 for studies on IIH in pregnancy. Non-English publications were excluded. Search terms included different packages of the following: “idiopathic intracranial hypertension”, “pseudotumor cerebri”, “pregnancy”, “pregnancy/pregnant”, “etiology”, “pathophysiology”, “diagnosis”, “acetazolamide”, “surgery”, “surgical management”, “optic nerve sheath fenestration”, and “shunt” (Table 1).

IIH in pregnancy

IIH can develop during any trimester but most commonly presents during the first half of pregnancy (25). Current studies suggest that pregnancy itself is not a significant risk factor for development of IIH, as its incidence mirrors that of the general population, suggesting that the association is due to the demographic overlap of women of childbearing age (26,27). Additionally, IIH does not lead to an increase in pregnancy loss. Therapeutic abortion to limit the progression of IIH is not indicated if the patient is able to remain stable and preserve her vision throughout the pregnancy (28). While earlier studies suggested that subsequent pregnancies do not increase the risk of developing IIH, a recent study by Thaller et al. examining the disease course and long-term outcomes of patients diagnosed with IIH during pregnancy reported a higher incidence of IIH with successive pregnancies (24,29,30). However, successive pregnancies do not appear to be associated with poor visual outcomes, indicating that future pregnancies are not contraindicated in patients with a prior IIH diagnosis (24).

Shaia et al. and Amikam et al. demonstrated that IIH increases the risk of hypertensive disorders of pregnancy, including preeclampsia, eclampsia, and hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome (21,31). In addition, Amikam et al. found that pregnant patients with IIH are at a greater risk for preterm delivery, wound complications, and congenital abnormalities, even after adjusting for confounding factors such as smoking and diabetes (31). Thaller et al. observed that patients who developed IIH during pregnancy exhibited greater degrees of papilledema compared to those with established IIH; however, visual acuity and field deficits were comparable between the two groups (24). Current evidence indicates that pregnancy does not adversely affect long-term vision, and the trajectory of disease progression is comparable between pregnant and nonpregnant individuals (24). Nonetheless, given the significant morbidity and mortality risks for both mother and fetus, it is important for physicians to be familiar with current management strategies to better optimize outcomes.

Diagnosis and management

The primary goals in managing IIH are to limit visual morbidity from persistent optic nerve edema and to alleviate symptoms—most commonly headache. Management during pregnancy largely mirrors that of non-pregnant patients, with careful attention to relative drug contraindications and diagnostic limitation (25).

Imaging and lumbar puncture considerations

Following a thorough patient history including symptomatology and recent weight gain, a complete ocular evaluation is indicated prior to ruling out secondary causes such as use of potential offending medications. A complete ocular evaluation should include dilated fundus examination, extraocular motility testing, and formal visual field testing, including optical coherence tomography (OCT), to assess for stigmata of elevated ICP such as papilledema and unilateral or bilateral, non-localizing sixth nerve palsies. Subsequently, neuroimaging is needed to exclude secondary causes of increased ICP. It is considered safe to have computed tomography (CT) evaluation in pregnancy as the fetal dose of ionizing radiation during a head CT scan is significantly lower (<0.005 mGy) than the accepted background cumulative dose of ionizing radiation during pregnancy (50 mGy) (32). CT lacks the sensitivity and specificity of magnetic resonance imaging (MRI) for evaluating subtle intracranial findings such as intracranial tumors, meningeal disease, and cerebral and dural venous sinus thrombosis (32). Despite the low ionizing radiation, many practitioners are still wary of potential fetal exposure, therefore CT is typically reserved for cases with clear clinical indication (33). As a result, MRI is generally the preferred imaging modality during pregnancy due to its superior soft tissue resolution and the absence of ionizing radiation. However, there are concerns regarding the use of gadolinium-based contrast agents (GBCAs). While some studies suggest no significant adverse fetal outcomes, especially when administered during the first trimester, existing data is limited by small sample sizes and short follow-up periods and definitive answer on the safety of GBCAs during pregnancy remain uncertain (34-37). Current American College of Obstetricians and Gynecologists (ACOG) and American College of Radiology guidelines recommend avoiding GBCAs unless the potential diagnostic benefit outweighs the theoretical fetal risks (33,38).

After ruling out the presence of a secondary cause for elevated ICP, a lumbar puncture should be performed in the relaxed lateral decubitus position without sedation. Positioning for a diagnostic lumbar puncture in a pregnant patient may be technically challenging due to body habitus, and radiologists consider pregnancy to be a relative contraindication to the use of fluoroscopy due to the theoretical risk of teratogenicity (39). Since many anatomic landmarks for lumbar puncture are obscured in pregnancy due to edema and is often complicated by pre-existing obesity, Locks et al. reported that ultrasound could be used to aid in pre-procedural identification of the L3–L4 space (40). As such, CSF evaluations by lumbar puncture, though challenging, can still be performed safely and interpreted easily during pregnancy.

Medical management

The mainstays of treatment for IIH, weight loss and carbonic anhydrase inhibitors such as acetazolamide, carry several important implications in pregnant patients. Significant calorie restriction, especially with ketosis, is not recommended during pregnancy due to potential fetal harm and weight loss during a routine healthy pregnancy is less feasible (41). Evans and Friedman recommended controlling weight gain during pregnancy to no more than 20 pounds (42). The Institute of Medicine and ACOG recommends gestational weight gain of 15 to 25 pounds for women whose pre-pregnancy body mass index (BMI) is 25 to 29.9 kg/m² and gestational weight gain of 11–20 pounds for women whose pre-pregnancy BMI is greater than 30 kg/m² (43,44). However, nearly 50% of women exceed their weight gain goals with overweight and obese women having the highest prevalence of excessive weight gain during pregnancy (45). Despite this theoretical risk, Thaller et al. found that visual prognosis was not affected by pregnancy weight gain; rather, the patient’s baseline pre-pregnancy BMI is what determined prognosis (24). Diet changes, 30 to 60 minutes of moderate intensity physical activity for 3 to 5 days per week, and early referral to dietitian are some modifications that can help moderate excessive weight gain during pregnancy (46).

The Idiopathic Intracranial Hypertension Treatment Trial (IIHTT) was a multicenter, double blind, randomized, placebo-controlled study of acetazolamide in 165 IIH participants with mild visual loss that found subjects taking acetazolamide along with a low-sodium diet program had significantly better visual outcomes than those taking placebo along with the diet. Importantly, the IIHTT did not include pregnant patients (3). Most practitioners hesitate to prescribe carbonic anhydrase inhibitors during pregnancy, particularly during the first trimester, largely based on a single report of sacrococcygeal teratoma in 1978 (47). Although animal studies and some retrospective studies demonstrated no fetal loss or adverse effects with acetazolamide use during pregnancy, its use remains controversial due to the limited evidence in humans (48-50). As such, current guidelines recommend against its use during pregnancy (27). Multiple authors have reported renal tubular acidosis with hyperchloremic metabolic acidosis, hypocalcemia, and hypomagnesemia upon birth in fetuses of mothers taking acetazolamide, but these cases resolved with treatment without long-term deleterious effects (51-53). Al-Saleem et al. reported a case of a boy who was exposed to maternal acetazolamide (1,000 mg/day) for treatment of pre-existent IIH through all three trimesters and suggested that this treatment might have resulted in observed congenital malformations, such as ectrodactyly, syndactyly, and oligodontia (54).

There are, however, situations where the benefits of starting acetazolamide may outweigh the potential risks to the fetus. Falardeau et al. recommend that acetazolamide be considered if there is risk of progressive visual loss with non-treatment and state that most pregnant patients with IIH can stop acetazolamide until the end of the first trimester without visual morbidity (50). This is an important consideration given that most cases of IIH appear in the first half of pregnancy (9). Ultimately, treatment is aimed at alleviating headaches and preserving visual function, and as a class C drug, acetazolamide should be prescribed only if the potential benefit justifies the potential risk to the fetus (53). Multidisciplinary discussions can help facilitate shared decision making with the patient and treating physicians. Acetazolamide has a very low rate of excretion into breast milk at high doses exceeding 1,000 mg daily, and as such, its use is generally considered to be compatible with breastfeeding (54).

With regards to headache management, many of the commonly prescribed medications, such as non-steroidal anti-inflammatory drugs (NSAIDs), topiramate, and opioids, are contraindicated in pregnancy (9). Patients must be reminded to avoid non-steroidal anti-inflammatory drugs in the third trimester due to concern for premature closure of the ductus arteriosus and oligohydramnios (55). Topiramate is associated with a higher rate of congenital malformations (56). Opioids should be avoided for headache management in pregnant IIH patients due to risk of fetal dependence and withdrawal symptoms (9). As a result, it is important to have a clear discussion with the patient regarding risks and benefits of headache treatment during pregnancy. Evans and Lee recommend collaborative headache management with the OB-GYN specialist and a neurologist to aid in the selection of pregnancy-appropriate therapies, given that some medications, such as tricyclic antidepressants, can be considered after the first trimester (57).

Although serial therapeutic lumbar punctures are considered safe for acute symptom management and continues to be a common, temporizing measure for fulminant, vision-threatening IIH, they should not be performed to achieve IIH remission, as the CSF is secreted by the choroid plexus at a rate of 25 mL per hour and CSF pressure returns to pre-treatment baseline within 6 hours (41,58,59). Importantly, there is no current consensus on how much CSF should be drained or what the closing pressure should be. Additionally, overdrainage is associated with acute exacerbations of symptoms (9).

Some authors have advocated for visual acuity and field determination with emphasis on the size of the blind spot to occur every 1 to 3 months while instructing patients to call if vision declines or headache or diplopia worsen (29,57). Currently, a standardized evidence-based guideline for managing IIH during pregnancy does not exist. Therefore, follow-up is largely individualized, guided by shared patient-physician goals, with recognition of the potential for pregnancy to predispose to rapid changes in disease state.

Surgical management

Surgical procedures, including optic nerve sheath fenestration (ONSF) and CSF diversion procedures such as lumboperitoneal shunt (LPS) and ventriculoperitoneal shunt (VPS), are options that can be considered should escalation of management is needed (29). Importantly, a longitudinal study by Thaller et al. suggest that long-term vision outcomes are similar between pregnant and non-pregnant patients (24). Additionally, a standardized evidence-based guideline for surgical intervention of IIH during pregnancy does not exist either. As a result, surgical management is oftentimes reserved as a last resort for cases where vision is deteriorating rapidly despite maximally tolerated medical therapy (29).

Surgical management of IIH in pregnant patients is largely unchanged compared to non-pregnant patients, but a few unique considerations are pertinent. A common concern for the patient and the fetus is the safety of general anesthesia during pregnancy for non-obstetric surgery. Careful multidisciplinary anesthesia management, including intraoperative positioning, fetal monitoring, monitoring for contractions, maintenance of hemodynamic stability, and post-operative analgesia, is necessary to ensure the safety of the mother as well as the fetus (60). Of note, the Duncan study of 2,565 pregnant Canadian women showed a statistically significant increase in the risk of spontaneous abortion in both the first and second trimesters following surgery under general anesthesia (from 6.5% to 7.1%) (61).

ONSF involves the creation of a surgical durotomy in the optic nerve sheath, allowing CSF to drain into the retrobulbar space where it is safely absorbed, thereby relieving pressure in the perioptic subarachnoid space (29). ONSF can be performed as an outpatient procedure under local or general anesthesia and offers the advantage of reduced anesthesia time compared to CSF diversion procedures, which is particularly beneficial for pregnant patients (29,62). Although routine ONSF can be performed in an outpatient setting, one potential drawback during pregnancy is the need for postoperative uterine and fetal monitoring, which may necessitate inpatient care (62).

Several authors have reported that LPS for pregnant patients with IIH is a safe and effective treatment with no effect on obstetric or neonatal outcomes (25,41,62,63). CSF diversion procedures, however, carry significant risk of intracranial hypotension from overdrainage, shunt obstruction, and valve malfunction, ultimately leading to high reoperation rates (64). The risk of valve malfunction in pregnancy has been estimated at 27.5% as a result of numerous anatomic changes that promote mechanical failure of the apparatus (65-67). There is increased risk of functional obstruction and valve displacement due to an increase in intra-abdominal pressure from the enlarging uterus in the third trimester. Additionally, the LPS is prone to mechanical stresses and pressures due to the lateral course of the shunt and the enlarging girth of patients (65-67). Bynke et al. compared a small series of 17 IIH patient treated with VPS to a similar series treated with LPS and found that the revision rate was significantly less with VPS (68).

While ONSFs are generally preferred in patients with severe, progressive visual loss and minimal headache symptoms, LPS and VPS are the preferred treatment for IIH patients with more severe, refractory headache symptoms with or without visual loss (69). However, one should note that ONSF has failure rates that have been described from 10% to 32% (70-72).

Another surgical technique that can alleviate headache symptoms is dural venous sinus stenting. Many have observed similar anatomical abnormalities between IIH and cerebral venous sinus stenosis, thus Higgins et al. hypothesized that dilation of one of the venous sinuses can reduce the pressure gradient (9,73). Dural venous sinus stenting involves inserting a catheter through the internal jugular vein and deploying the stent across the site of stenosis (74). Unfortunately, much of the literature regarding dural venous sinus stenting is observational and lack sufficient long-term follow-up (9). The use of venous sinus stenting in pregnancy is limited by the requirement for anticoagulation, often dual antiplatelet therapy, though some reports of success with ticagrelor or more classic dual anti-platelet therapy have been published for cases with fulminant IIH (75,76).

The use of prophylactic antibiotics during labor and delivery to prevent shunt infection and ascending meningitis has been debated. Some authors argue that modern shunts and one-way valves prevent peritoneal reflux and report no cases of shunt infection from this scenario in their own practice (65). Others report that the presence of a VPS has not been proven to increase risk of post-partum infection (77,78). Liakos et al. recommended prophylactic antibiotics in pregnant VPS patients who are undergoing caesarian section, but the effectiveness of this practice has not been well established (77).

Although these procedures are without absolute obstetric contraindications and can be effective in managing progressive visual loss in pregnant IIH patients, they carry potentially significant risks, including limited symptomatic improvement, high reoperation rates, and, albeit rare, death (79). As a result, surgical intervention is generally reserved for patients with progressive visual loss refractory to first-line treatment, following a thorough discussion of risks and benefits between the surgeon and the patient.

It is important to mention that, at present, there is no universally accepted surgical treatment for IIH. Although the surgical interventions mentioned previously have demonstrated symptomatic and visual improvement in clinical practice, consensus on the most optimal approach, particularly in cases of fulminant or rapid severe vision loss, remains unknown. This is largely due to the lack of randomized control trials that directly compare these surgical methods. To establish evidence-based surgical management strategies for IIH, randomized control trials assessing both short- and long-term outcomes of available neurosurgical treatments are critically needed.

Differential diagnosis

Over 80% of women of childbearing age experience headache at some point, but headache during pregnancy warrants careful evaluation, especially if it deviates from pre-pregnancy patterns, as it may signal serious secondary conditions such as cerebral or dural venous sinus thrombosis, hypertensive disorders, pre-eclampsia/eclampsia, stroke, or pituitary apoplexy (80,81). The elevated risk of secondary headaches in pregnancy can be attributed to hypercoagulability, hormonal changes, and anesthesia during labor (82). Clinical assessment should consider the duration, tempo, character, and onset of headache symptoms, along with focal neurologic signs such as ophthalmoplegia and bitemporal or homonymous visual field defects, which may indicate life-threatening conditions like stroke, subarachnoid hemorrhage, or pituitary apoplexy.

Optic nerve edema from hypertensive disorders, such as pregnancy-induced hypertension, pre-eclampsia, and eclampsia, can oftentimes be differentiated from that caused by elevated ICP by the presence of retinal hemorrhages, exudates, arteriolar changes, and arteriolar-venous crossing changes, which are generally absent in the latter (83,84). Fluorescein angiography is generally considered safe in pregnancy and can be used to more clearly visualize posterior segment pathology in more equivocal cases. In general, vascular changes in pre-eclampsia are more likely involving the choroidal circulation rather than the retinal circulation (85,86). In true papilledema from IIH, fluorescein angiography would show leakage of fluorescein from the edematous disc (87,88). On the other hand, fluorescein angiography of preeclampsia oftentimes show normal caliber retinal vessels with no leakage (86). Unfortunately, fluorescein angiography of more severe hypertensive disorders of pregnancy, such as eclampsia or long-standing pre-eclampsia, is not well studied, thus limiting the efficacy of this method.

Obstetric considerations

The optimal method of delivery and anesthesia in pregnant patients with IIH has been subject to debate. With spontaneous vaginal delivery, adequate labor analgesia is recommended to avoid transient elevations in blood pressure, cardiac output, and central venous pressure (89). Additionally, myometrial contractions and pain during labor can cause transient elevations in CSF pressure; however, its impact on vision loss is not well established (90-93). Epidural analgesia minimizes the hemodynamic changes associated with uterine contractions and bearing-down efforts, thus potentially minimizing increases in CSF pressure (89). Similarly, for cesarean sections, regional anesthesia is preferred over general anesthesia, as the latter may transiently raise ICP (89). These risks remain largely theoretical. From an ophthalmic perspective, a transient rise in CSF pressure, such as while pushing during labor, is not commonly thought to result in visual morbidity (90).

Ultimately, the mode of delivery and anesthesia should be guided by obstetric indications alone (28,89). Spinal anesthesia is a safe and effective option for pregnant IIH patients without a prior LPS (27,89). In patients with an LPS, spinal anesthesia may present challenges, including potential egress of anesthetic into the peritoneal cavity resulting in inadequate analgesia, need for X-ray to localize the position of the LPS tube before a spinal block, and potential damage to the shunt during epidural placement (89). Nonetheless, epidural anesthesia can be successfully administered in these patients (94). Adjustments such as shortening the duration of time between doses and placing the epidural catheter above, rather than below, the level of the LPS, as demonstrated by Moreno-Duarte et al., can reduce complications like high spinal and epidural blockade (95).

This highlights the complexity and flexibility necessary to administer epidural anesthesia in pregnant IIH patients. As a result, general anesthesia is typically recommended for patients requiring cesarean section (96). Although Liakos et al. have advocated for the use of prophylactic antibiotics in shunt patients undergoing caesarean section, supporting evidence for this practice remains limited (77).

Strengths and limitations

Strengths of this review include an up-to-date consolidation of the most recent literature on IIH in pregnancy and identification of areas of future research. On the other hand, limitations include a lack of a standardized systematic review protocol or a formal quality assessment of included articles. Additionally, the search was limited to English-language articles in a single database.

Conclusions

The work-up, surveillance, and management of IIH in the pregnant population warrants careful theoretical and practical considerations to prevent visual morbidity. Hormonal effects, fluid compartment shifts, and inevitable weight gain are principal drivers for the potential development of IIH during pregnancy or worsening of preexisting disease. The clinician and the patient should discuss the potential risks of disease progression associated with pregnancy during family planning and understand the general safety of acetazolamide and surgical treatments should progressive visual loss occur. Lastly, the clinician and patient should rest assured that mode of delivery and mode of anesthesia should be determined based on obstetric indications only, as transient rises in CSF pressure associated with spontaneous vaginal delivery and general anesthesia have not been proven to have detrimental effects on visual function. Further research is necessary to establish a standardized evidence-based guideline for the management of IIH during pregnancy, particularly regarding indications for surgical intervention, treatment escalation, and the safety and efficacy between the various neurosurgical procedures. Notably, there is no evidence-based guideline for managing fulminant or rapidly progressive vision loss in pregnant patients with IIH, representing a significant gap in care that must be addressed with future research to improve vision outcomes.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://aes.amegroups.com/article/view/10.21037/aes-24-35/rc

Peer Review File: Available at https://aes.amegroups.com/article/view/10.21037/aes-24-35/prf

Funding: This study was supported by Research to Prevent Blindness, an unrestricted educational grant to Dean McGee Eye Institute.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://aes.amegroups.com/article/view/10.21037/aes-24-35/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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