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EPM.206
Case Discussion: Severe traumatic brain injury (TBI) in a 32 week pregnant female. Is delivery of the foetus a component of managing raised intracranial pressure?

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Case discussion: Severe traumatic brain injury (TBI) in a 32 week pregnant
female. Is delivery of the foetus a component of managing raised
intracranial pressure (ICP)? C Coyle, P Shirley, N Bunker.
Adult Critical Care Unit, The Royal London Hospital, UK.

 

CASE

  • 32 year old female

  • Blunt head trauma

  • 32 weeks gestation

  • Initial GCS 4

  • Airway obstruction, oxygen saturations 70-80%

  • Pre hospital RSI, transferred to the Royal London Hospital

  • CT head: acute left subdural haematoma, small intraventricular left lateral haemorrhage, multiple facial fractures, hyoid bone fracture. (Fig.1)

  • Foetal ultrasound- normal foetal heart rate, no indication for immediate delivery

  • ICP bolt inserted, initial pressure 7mmHg

  • Transferred to adult critical care

  • Medical management of head injury

  • ICP <20mmHg first 48 hrs

     

     

    DAY 3

  • Significant ICP spikes  (40-54mmHg)

  • Higher sedation and paralysis requirements

  • Repeat CT head- evolution of TBI and diffuse axonal injury (Fig.2)

  • Discussions with obstetric team, decision to proceed to caesarian section as presence of foetus may be having adverse effect on ICP of mother.

  • Live male foetus delivered

     

     

    DAY4

  • Continued spikes in ICP up to 70mmHg

  • Pupils fixed and dilated bilaterally

  • Thiopentone and hypertonic saline administered

  • Repeat CT head- stable appearances, diffuse axonal injury

  • Proceeded to decompressive craniectomy on clinical grounds as ICP continued to be >60mmHg with fixed dilated pupils

  • CSF under very high pressure when decompressed, pupils reacting on return from theatre

     

     

    DISCUSSION

    In this case  the presence of the foetus was felt to be a contributing factor to rising ICP. There is evidence to suggest that a rise in intra abdominal pressure (IAP) can cause a rise in ICP (1).

    The mechanism by which this occurs is due to elevated intrathoracic pressure which impedes  cerebral venous  outflow thus increasing ICP and reducing cerebral perfusion pressure.

    Although the gravid uterus is within the pelvis  rather than the abdomen, the external compression caused by the foetus does cause a raised IAP when measured at term and this  significantly reduces after delivery (2).  In some case reports performing decompressive laparotomy in the absence of abdominal compartment syndrome has reduced ICP that has been refractory to medical management (3,4).

    One series of 17 patients with intractable raised ICP undergoing decompressive laparotomy demonstrated a reduction in ICP of at least 10mmHg. (5)

    In order to optimise  all variables that may be contributing to raised ICP the delivery of the foetus  was felt to represent optimal care for the patient.  Immediately following delivery there was a reduction in ICP for 24 hours. 

     

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