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LETTER TO EDITOR
Year : 2013  |  Volume : 61  |  Issue : 4  |  Page : 423-425

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


1 Department of Neurosurgery, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
2 Department of Obstetrics and Gynecology, Deen Dayal Upadhyay Hospital, New Delhi, India

Date of Submission02-May-2013
Date of Decision02-May-2013
Date of Acceptance30-Jun-2013
Date of Web Publication4-Sep-2013

Correspondence Address:
Deepak Agrawal
Department of Neurosurgery, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.117588

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How to cite this article:
Dawar P, Kalra A, Agrawal D, Sharma BS. Decompressive craniectomy in term pregnancy with combined cesarean section for traumatic brain injury. Neurol India 2013;61:423-5

How to cite this URL:
Dawar P, Kalra A, Agrawal D, Sharma BS. Decompressive craniectomy in term pregnancy with combined cesarean section for traumatic brain injury. Neurol India [serial online] 2013 [cited 2021 Jan 26];61:423-5. Available from: https://www.neurologyindia.com/text.asp?2013/61/4/423/117588


Sir,

Trauma during pregnancy is a leading cause of non-pregnancy related maternal death and the most common cause of fetal demise [1] and the causes include road traffic accidents, fall from height, physical assaults and burns. [2] Trauma during pregnancy complicates 6-7% of all pregnancies. [3] We present here a case of moderate head injury in a lady with term pregnancy.

A 26-year-old female patient presented with term uncomplicated pregnancy (prime, 36 weeks gestation) sustained road traffic accident. Glasgow coma scale (GCS) score was 11 (E3V3M5) at the accident scene and left pupil was dilated and non-reactive to light. She also sustained facio-maxillary injuries and her airway was compromised, oxygen saturation was 78% on room air. Before shifting to our facility, she was intubated and hemodynamically stabilized. At our emergency department, nearly 8 h after the injury, the GCS score was 8 (E3V ET M5), pulse: 90/min, blood pressure: 96/66 mmHg and there were multiple facial and chest lacerations and abrasions, left pupil dilated and non-reactive to light. Regular uterine contractions, 4 in 10 min were noted during the palpation of uterus. There was no vaginal bleeding and focused abdominal sonography for trauma was negative except for gravid uterus. Computed tomography scan with abdominal lead shield revealed an acute left fronto-temporo-parietal subdural-hemorrhage (SDH) with left frontal contusion with midline shift of 5 mm and effaced sulci and left lateral ventricle.

The treating team consisted of neurosurgeon, obstetrician and Anesthetist. With the informed consent of the family patient was taken up for urgent cesarean section (CS) and in the meantime she was prepared for cranial surgery. A live baby boy was delivered by CS within 30 min. The baby's weight was 2,980 g and Apgar score at 1 min was 6 and at 5 min it was 9. The baby on delivery was resuscitated and shifted to neonatal intensive care unit. There was no retroplacental clot evident at closure and meticulous hemostasis was performed with no oozing from placental surface. Immediate to CS, she underwent left fronto-temporo-parietal decompressive craniectomy, evacuation of SDH and contusectomy and lax duraplasty with pericranial graft. Following this facial lacerations were debrided and sutured. She was shifted to neurosurgery intensive care unit and on reversal from general anesthesia her GCS score was E2V ET M5 for 2 days. She started obeying commands on day-3. She was extubated on day-4 and was shifted to ward on day-5 as she was maintaining adequate oxygen saturation on room air. She was discharged on the 10 th day with stable vitals and GCS of E4V5M6. At 1 year follow-up, both mother and baby were doing well with no neurological deficits.

The pregnant trauma victim presents a distinctive spectrum of challenges to the trauma health-care team. The fact that the victim is pregnant may not always be known to the health-care team complicates the situation. Pregnancy must always be suspected until proven otherwise in any female trauma patient of childbearing age [4] and must be excluded in this age group. [5] This a routine practice at our center.

The management priority in a pregnant patient sustaining major trauma should always be early aggressive maternal stabilization as effective maternal resuscitation also provides fetal resuscitation. However, in third-trimester pregnancy if the prognosis of maternal survival is poor, CS takes precedent. [6] The risk of fetal death is high in pregnant women with severe head injury. [6] Thus, early recognition of fetal compromise is of importance in these patients. Up to 60% of fetal deaths resulted from delayed recognition of fetal distress and delayed CS. [7] All pregnant trauma patients should have fetus monitoring from the time of injury and should be continued until the danger has passed. [6] If the mother's condition is stable, the status of the fetus and the extent of uterine injury determine further management. A potentially viable fetus with no signs of distress should be monitored by external ultrasonography or fetal heart rate monitoring frequently. Since pre-mature labor is always a possibility in these patients, an external tocotransducer should be used to detect the onset of uterine contractions. If pre-mature labor ensues, tocolytic therapy may be initiated. When a viable fetus shows signs of distress, despite successful resuscitative measures, a cesarean delivery must be performed expeditiously. A non-viable fetus may be managed conservatively in utero to optimize maternal oxygenation and circulation. If the fetus is viable at the time of emergent neurosurgery, a decision must also be made for the appropriate time and method of delivery. Placental abruption complicates 1-5% of minor injuries and 20-50% of major injuries. Fetal death, resulting from injuries to the obstetric patient is most commonly associated with placental abruption. [8] In our case, there were four contractions in every 10 min when the patient was assessed at 8-9 h after the injury. The lack of vaginal bleeding did not exclude placental abruption. [9]

When neurosurgery is indicated urgently during pregnancy, general anesthesia is almost always indicated. During neurosurgery, osmotic diuresis, controlled hypotension, hypothermia and hypocarbia are commonly induced to reduce the intracranial pressure (ICP). In pregnant patients, these may adversely affect the fetus. During the third trimester, patient may be suitable for initial cesarean delivery, followed by the neurosurgical procedure, using an appropriately modified anesthetic technique. [4] Post-partum hemorrhage from uterine atony remains a risk during the subsequent neurosurgery warranting continuous infusion of an oxytocic drug. [10] There seems to be no ideal "best" way of perioperative management of the head-injured pregnant trauma victim and involves consideration of several confounding issues. [4] Positioning needs head elevation for the neurosurgery, whereas a lateral tilt is required for the avoidance of aortocaval compression and reduced venous return. If preceded by vaginal or cesarean delivery prolonged supine positioning may facilitate neurosurgery. Airway management must address the risks of possible cervical trauma, avoidance of increases in ICP; the presence of a potentially full stomach, pregnancy induced changes in the airway and enlarged breasts, which increase the incidence of a difficult intubation. [11] A rapid sequence induction with cricoid pressure is advocated despite airway management being more difficult. Post-operative management of pregnant patients after a neurosurgical intervention is not so much different than that of non-pregnant. Extubation should be delayed until patient is sufficiently awake to protect her airway from regurgitation and aspiration.

A pregnant woman is no more pre-disposed to head injury than a non-pregnant one. However, because of the physiological, hormonal, hemodynamic and anatomical changes associated with pregnancy, certain standard neurosurgical practices may be challenged. There is no Class 1 or Class 2 level evidence exists to guide management and practice is mainly dependent on case reports and inherited wisdom. Thus, close communication and constant discussion between the neurosurgeon, Neuroanesthetist, obstetrician and the patient's family is essential. Care of the pregnant neurosurgical patient in essence follows the general principles of obstetrics and neurosurgery, with a few specific considerations. Above all, it is a challenge in team work and communication between all parties concerned in the patient's care.

 
  References Top

1.Aitokallio-Tallberg A, Halmesmäki E. Motor vehicle accident during the second or third trimester of pregnancy. Acta Obstet Gynecol Scand 1997;76:313-7.  Back to cited text no. 1
    
2.Shah AJ, Kilcline BA. Trauma in pregnancy. Emerg Med Clin North Am 2003;21:615-29.  Back to cited text no. 2
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3.Cirak, B, Kiymaz N, Kerman M, Tahta K. Neurosurgical procedures in pregnancy. Acta Cir Bras 2003;18:1-13.  Back to cited text no. 3
    
4.Kuczkowski KM. Trauma in pregnancy. Perioperative anesthetic considerations for the head-injured pregnant trauma victim. Anaesthesist 2004;53:180-1.  Back to cited text no. 4
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5.Lippmann S, Bordador B, Shaltout T. Detection of unknown early pregnancy. A matter of safety. Postgrad Med 1988;83:129-31, 135.  Back to cited text no. 5
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6.Goldman SM, Wagner LK. Radiologic ABCs of maternal and fetal survival after trauma: When minutes may count. Radiographics 1999;19:1349-57.  Back to cited text no. 6
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7.Morris JA Jr, Rosenbower TJ, Jurkovich GJ, Hoyt DB, Harviel JD, Knudson MM, et al. Infant survival after cesarean section for trauma. Ann Surg 1996;223:481-8.  Back to cited text no. 7
    
8.Schiff MA, Holt VL. The injury severity score in pregnant trauma patients: Predicting placental abruption and fetal death. J Trauma 2002;53:946-9.  Back to cited text no. 8
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9.Kettel LM, Branch DW, Scott JR. Occult placental abruption after maternal trauma. Obstet Gynecol 1988;71:449-53.  Back to cited text no. 9
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10.Thomas JS, Koh SH, Cooper GM. Haemodynamic effects of oxytocin given as i.v. bolus or infusion on women undergoing Caesarean section. Br J Anaesth 2007;98:116-9.  Back to cited text no. 10
    
11.Kuczkowski KM, Fouhy SA, Greenberg M, Benumof JL. Trauma in pregnancy: Anaesthetic management of the pregnant trauma victim with unstable cervical spine. Anaesthesia 2003;58:822.  Back to cited text no. 11
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