Successful multidisciplinary management of massive cerebral hemorrhage at 19 weeks of gestation to full-term delivery: a case report

Cerebral hemorrhage (ICH) during pregnancy is a rare but catastrophic event. Its occurrence in the early-to-mid second trimester without classic risk factors poses significant diagnostic and therapeutic challenges. Here, we report a 33-year-old pregnant woman at 19 weeks of gestation with a history of tuberculous meningitis (requiring ventriculostomy) and in vitro fertilization-embryo transfer (IVF-ET), who developed a massive cerebral hemorrhage (>140 mL), intraventricular hemorrhage, and acute hydrocephalus. Notably, she had no hypertension or preeclampsia, but serological testing revealed positive anti-Ro-52 and anti-Scl-70 antibodies. Emergency neurosurgical interventions, including craniotomy, hematoma evacuation, and neuroendoscopic clot removal, were performed. This was followed by multidisciplinary management, incorporating hydroxychloroquine for immunomodulation and thromboprophylaxis. The patient achieved favorable neurological recovery and delivered a healthy infant at term without the need for permanent shunting. The uniqueness of this case lies in the concurrent presence of prior tuberculous meningitis, neurosurgical history, positive autoimmune serology, and assisted reproductive technology (ART). We propose a ‘multiple-hit’ hypothesis as a speculative, hypothesis-generating framework—rather than a proven pathogenic mechanism—involving chronic infection-induced vascular remodeling, autoimmune-mediated endothelial injury, and pregnancy-related immune dysregulation, which warrants further investigation in larger cohorts. This report raises the question of whether comprehensive autoimmune screening might be considered in pregnant patients with ICH of unknown etiology, although larger studies are needed to validate this approach. It also underscores the role of coordinated multidisciplinary care in the management of such complex cases, although its impact on outcomes remains to be determined.