Decompressive craniectomy in term pregnancy with combined caesarean section for traumatic brain injury

Abstract

Over the years the maternal mortality depending on the obstetric causes has reduced whereas there is a relative increase in maternal mortality and morbidity due to non-obstetric causes. Trauma during pregnancy, including head injury, is one of the leading causes of incidental maternal death and morbidity, and complicates 6%–7% of all pregnancies. Furthermore it predisposes two lives at risk and creates unique diagnostic and therapeutic challenges. Because of the physiological hormonal, hemodynamic and anatomical changes associated with pregnancy, certain standard neurosurgical practices may be challenged. We present a case of woman with term pregnancy who sustained moderate head injury requiring urgent caesarean section for pregnancy and decompressive craniectomy in the same sitting in Operation Theater. Issues like screening of mother and feto-maternal monitoring; physiological changes during pregnancy, choice of anaesthesia, intraoperative concerns and fetal monitoring, timing of delivery are discussed with review of pertinent literature.

Keywords

Caesarean section - Pregnancy - Head injury - Decompressive craniectomy - Maternal death

• References

• 1 Aitokallio-Tallberg A., Halmesmäki E.. Motor vehicle accident during the second or third trimester of pregnancy. Acta Obstet Gynecol Scand 1997; 76: 313-317
• 2 Shah A.J., Kilcline B.A.. Trauma in pregnancy. Emerg Med Clin North Am 2003; 21: 615-629
• 3 Cirak B., Kiymaz N., Kerman M., Tahta K.. Neurosurgical procedures in pregnancy. Acta Cir Bras 2003; 18: 01-13
• 4 Kuczkowski K.M.. Trauma in pregnancy. Perioperative anesthetic considerations for the head-injured pregnant trauma victim. Anaesthesist 2004; 53: 180-181
• 5 Lippmann S., Bordador B., Shaltout T.. Detection of unknown early pregnancy. A matter of safety. Postgrad Med 1988; 83: 129-131 135
• 6 Goldman S.M., Wagner L.K.. Radiologic ABCs of maternal and fetal survival after trauma: when minutes may count. Radiographics 1999; 19: 1349-1357
• 7 Morris Jr. J.A., Rosenbower T.J., Jurkovich G.J.. et al Infant survival after cesarean section for trauma. Ann Surg 1996; 223: 481-491
• 8 Schiff M.A., Holt V.L.. The injury severity score in pregnant trauma patients: predicting placental abruption and fetal death. J Trauma 2002; 53: 946-949
• 9 Kettel L.M., Branch D.W., Scott J.R.. Occult placental abruption after maternal trauma. Obstet Gynecol 1988; 71: 449-453
• 10 Thomas J.S., Koh S.H., Cooper G.M.. Haemodynamic effects of oxytocin given as i.v. bolus or infusion on women undergoing Caesarean section. Br J Anaesth 2007; 98: 116-119
• 11 Kuczkowski K.M., Fouhy S.A., Greenberg M., Benumof J.L.. Trauma in pregnancy: anaesthetic management of the pregnant trauma victim with unstable cervical spine. Anaesthesia 2003; 58: 822