Though rare, intracranial haemorrhage during pregnancy can lead to maternal and fetal mortality and serious neurological morbidity. At present, most published reports focus on the anaesthetic management for parturients with ruptured intracranial aneurysms or arteriovenous malformations. Other causes of intracranial haemorrhage during pregnancy include eclampsia, systemic coagulopathy, intracranial tumours and trauma. We present a case of a pregnant patient with traumatic brain injury whose labour and delivery was managed successfully with continuous lumbar epidural analgesia with 0.2% ropivacaine.
A 41-yr-old gravida 5, para 4 at 38 week gestation was sent to our hospital after a motor vehicle accident. The patient's past medical history was unremarkable. She had facial lacerations and isolated head injury. On arrival in the emergency department, the patient was drowsy, and complained of nausea, vomiting and frontal headache. The computerized tomography (CT) scan revealed mild diffuse axonal injury with bifrontal traumatic subarachnoid haemorrhage and some contusion haemorrhage in the left temporal lobe. She was admitted to the surgical intensive care unit (ICU) for observation and conservative treatment. In the ICU, she was intermittently disoriented to time and to place, without further neurological deterioration. Two days after admission, she began to feel uterine contractions, each of which was accompanied by a worsening of the frontal headache, with nausea and vomiting. The patient was keen to have a vaginal delivery and to be awake during the delivery despite having been informed of the associated risks. The obstetrician, neurosurgeon and anaesthesiologist agreed to this procedure with continuous epidural analgesia. Epidural analgesia was performed when contractions were well established and the cervix was dilated to 3 cm. With the patient in the left lateral decubitus position, epidural puncture was performed with an 18-G Tuohy needle at the L3-L4 using the technique of loss of resistance to air. A 20-G nylon catheter was advanced 4 cm beyond the tip of the Tuohy needle in the cephalad direction. After an uneventful test dose, ropivacaine 0.2% 10 mL was injected slowly. This soon resulted in good analgesia, and the patient stated that the severity of her headaches during uterine contractions had subsided. Epidural analgesia was maintained with continuous infusion of 0.2% ropivacaine at a rate of 5 mL h−1. During labour, the patient's blood pressure (BP) varied between 110/66 and 102/60 and her heart rate (HR) remained stable between 70 and 80 beats min−1. Fetal HR was also monitored and remained stable between 120 and 160 beats min−1 throughout. She was satisfied with labour pain control and reported no motor block. The second stage of labour proceeded smoothly and lasted 30 min. Maternal pushing efforts were effective and neither forceps nor vacuum assistance was required. Four hours after commencement of epidural analgesia she successfully delivered a healthy 3525 g male infant without any complication. The patient's neurological status remained stable during the following days. Although she still had occasional headaches, she remained oriented and was discharged 1 week after her accident.
Epidural block is generally considered to be contraindicated in patients with a head injury and elevated intracranial pressure due to the risk of brain stem herniation if dural tap should occur. On the other hand, the management of obstetric analgesia and anaesthesia in patients with elevated intracranial pressure is controversial, since none of the options is without risk. Further increase in intracranial pressure and cerebral oedema during induction and emergence, pulmonary aspiration of gastric contents, failed endotracheal intubation and neonatal depression are potential problems during general anaesthesia for parturients.
In pregnancies complicated by intracranial haemorrhage, maternal and fetal outcomes are similar after Caesarean and vaginal delivery . The decision for surgical therapy of intracranial haemorrhage during pregnancy should be based upon neurosurgical principles, whereas the method of delivery should be based upon obstetric considerations. Anaesthesiologists should be familiar with the benefits and risks of all the different management strategies.
Galbert and Marx  noted that in parturient patients, extradural and cerebrospinal fluid pressure both increased during uterine contractions and that this could be mitigated by left uterine displacement and adequate analgesia, implying that the pressure elevation was associated not only with inferior vena cava compression, but also with pain and movement secondary to uterine contractions. Goroszeniuk and colleagues  described a pregnant patient with a malignant cerebral tumour who presented with increased severity of headache and fluctuation in her level of consciousness during uterine contractions. Patients with intracranial pathology such as neoplasm or haemorrhage may have reduced cerebral compliance and thus suffer greater increases in intracranial pressures. If delivery is to be per vaginam, then the objective of anaesthetic management will be to provide pain-free labour to lessen the impact of these acute physiological disturbances.
Hilt and colleagues directly measured intracranial pressures in two patients with head injuries . They noted that intracranial pressure increased significantly after epidural injection of local anaesthetic or saline. Such increases can be attributed to dural compression and cephalad displacement of cerebrospinal fluid. When the intracranial compliance is poor, intracranial pressure will rise significantly. They concluded that epidural anaesthesia should not be used in patients with severe intracranial hypertension or obvious space-occupying lesions. A very slow injection rate should be used in patients with reduced intracranial compliance requiring epidural injection. Murthy and colleagues  described a parturient with reduced intracranial compliance who experienced transient severe frontal headache as a symptom of increased intracranial pressure during each epidural top-up injection during labour. This patient finally received Caesarean section and continuous epidural infusion for postoperative analgesia and no more headaches were reported during this infusion.
Our patient, who had traumatic brain injury and signs of increased intracranial pressure requested vaginal delivery. Since adequate pain relief during labour reduces the risk to the mother and, in our opinion, epidural analgesia is the most reliable technique for providing pain-free labour, we decided to perform the technique using great caution. The loading dose was given as slowly as possible and analgesia was maintained with continuous epidural infusion. This resulted in satisfactory relief of labour pains and symptoms of increased intracranial pressure.
Ropivacaine is a well-tolerated local anaesthetic for epidural anaesthesia and analgesia. Its analgesic efficacy is broadly similar to that of bupivacaine but with less motor block than bupivacaine. It is also a preferred option because of lower neurologic and cardiac toxicity. Used during labour and delivery, ropivacaine and bupivacaine provide equivalent analgesia but there is a higher rate of spontaneous deliveries with ropivacaine. Beilin and colleagues  recommended that if ropivacaine is used as the sole local anaesthetic for epidural analgesia in labour the minimal concentration should be 0.2%. Cascio and colleagues  showed that 0.2% ropivacaine produced satisfactory labour analgesia at epidural infusion rates between 4 and 10 mL h−1.
In order to not aggravate our patient's nausea and vomiting, which might confound our clinical evaluation of her neurological situation, we decided to avoid fentanyl and used epidural ropivacaine only, although fentanyl has been reported to reduce local anaesthetic requirements. The slow bolus injection of ropivacaine 0.2% 10 mL followed by a continuous infusion at 5 mL h−1 allowed a painless vaginal delivery. Most importantly, no maternal and fetal complications occurred.
In conclusion, as in many complicated situations, the advantages and disadvantages of anaesthetic techniques for head-injured patients in labour should be carefully weighed against each other. It is our opinion that continuous lumbar epidural analgesia with 0.2% ropivacaine as described here is a sound alternative.
Department of Anaesthesiology, National Cheng Kung University Medical Center, Tainan, Taiwan
1. Dias MS. Neurovascular emergencies in pregnancy. Clin Obstet Gynecol
2. Galbert MW, Marx GF. Extradural pressures in the parturient patient. Anesthesiology
3. Goroszeniuk T, Howard RS, Wright JT. The management of labour using continuous lumbar epidural analgesia in a patient with a malignant cerebral tumour. Anaesthesia
4. Hilt H, Gramm HJ, Link J. Changes in intracranial pressure associated with extradural anaesthesia. Br J Anaesth
5. Murthy BV, Fogarty DJ, Fitzpatrick K, Brady MM. Headache during epidural top-ups in labour - a sign of reduced intracranial compliance. Anaesth Intens Care
6. Beilin Y, Galea M, Zahn J, Bodian CA. Epidural ropivacaine for the initiation of labor epidural analgesia: a dose finding study. Anesth Analg
7. Cascio MG, Gaiser RR, Camann WR, Venkateswaran P, Hawkins J, McCarthy D. Comparative evaluation of four different infusion rates of ropivacaine (2 mg mL−1
) for epidural labor analgesia. Reg Anesth Pain Med