What is the management approach for a pregnant patient with subdural hematoma and preeclampsia?

Management of Pregnant Patient with Subdural Hematoma and Preeclampsia

Immediate delivery is indicated for a pregnant patient with subdural hematoma and preeclampsia regardless of gestational age due to the high risk of maternal mortality and severe neurological complications.

Initial Assessment and Stabilization

• Neurological evaluation: Assess level of consciousness, focal neurological deficits, and signs of increased intracranial pressure

• Blood pressure control: Urgent treatment required for BP ≥160/110 mmHg in a monitored setting

  • First-line medications:
    • IV labetalol: 10-20 mg initially, then 20-80 mg every 10-30 minutes to maximum 220 mg 1
    • IV hydralazine: 5-10 mg every 15-30 minutes 1
    • Oral nifedipine: Immediate-release formulation 2
  • Target BP: <160/110 mmHg while maintaining diastolic BP ≥85 mmHg to preserve uteroplacental perfusion 1

• Seizure prophylaxis: Administer magnesium sulfate

  • Loading dose: 4-6 g IV over 15-20 minutes
  • Maintenance: 1-2 g/hour continuous infusion 1
  • Monitor for magnesium toxicity: respiratory depression, loss of deep tendon reflexes

Neurosurgical Management

• Urgent neurosurgical consultation for evaluation of subdural hematoma
• Imaging: CT or MRI to assess size, location, and mass effect of hematoma 3
• Surgical evacuation may be necessary based on:
  • Size of hematoma
  • Presence of midline shift
  • Neurological deterioration
  • Increased intracranial pressure

Obstetric Management

• Delivery planning: Immediate delivery is necessary regardless of gestational age 2, 1

  • The presence of subdural hematoma with preeclampsia constitutes a neurological emergency
  • Delivery is the only definitive treatment for preeclampsia 2

• Mode of delivery:

  • Cesarean section is preferred if:
    • Neurological status is deteriorating
    • Urgent decompression of subdural hematoma is needed
    • Fetal distress is present
  • Vaginal delivery may be considered only if maternal condition is stable, no signs of fetal distress, and neurosurgical team approves

• Anesthesia considerations:

  • General anesthesia is often preferred due to increased intracranial pressure
  • Avoid spinal/epidural anesthesia due to risk of herniation with dural puncture and potential coagulopathy 4

Maternal Monitoring

• Continuous vital sign monitoring

• Neurological checks every 1-2 hours

• Laboratory monitoring:

  • Complete blood count with platelets
  • Coagulation profile (PT, PTT, fibrinogen)
  • Liver function tests
  • Renal function tests
  • Uric acid 2, 1

• Monitor for signs of HELLP syndrome:

  • Hemolysis
  • Elevated liver enzymes
  • Low platelets

Fetal Assessment

• Continuous fetal heart rate monitoring
• Ultrasound for fetal biometry, amniotic fluid, and umbilical artery Doppler if time permits 2
• Administration of corticosteroids for fetal lung maturity if <34 weeks gestation and delivery can be safely delayed for 48 hours 2

Post-Delivery Management

• Continue magnesium sulfate for at least 24 hours post-delivery 1
• Continue antihypertensive therapy as needed
• Close neurological monitoring for at least 72 hours
• Serial imaging to monitor subdural hematoma resolution
• Avoid NSAIDs for postpartum analgesia 1

Special Considerations

• Coagulopathy: Correct any coagulation abnormalities before neurosurgical intervention
• Fluid management: Avoid fluid overload which may worsen cerebral edema
• Thromboprophylaxis: Consider mechanical methods initially; pharmacological prophylaxis only after subdural hematoma is stable

Prognosis and Follow-up

• Review at 3 months postpartum to ensure resolution of:

  • Hypertension
  • Proteinuria
  • Laboratory abnormalities
  • Neurological sequelae 1

• Counseling regarding increased risk in future pregnancies:

  • Recurrence of preeclampsia
  • Need for aspirin prophylaxis (150 mg nightly) before 16 weeks' gestation in subsequent pregnancies 1

Pitfalls to Avoid

• Delaying delivery in hopes of fetal maturation - this puts the mother at extreme risk
• Aggressive volume expansion - may worsen cerebral edema
• Inadequate blood pressure control - increases risk of intracranial hemorrhage expansion
• Missing signs of neurological deterioration - requires frequent assessment
• Inadequate seizure prophylaxis - magnesium sulfate is essential

The combination of subdural hematoma and preeclampsia represents a life-threatening emergency requiring prompt multidisciplinary management involving obstetrics, neurosurgery, anesthesiology, and critical care.