Management and outcomes of a term pregnant patient with a significant craniotomy defect: A multidisciplinary approach

A 28-year-old primigravida patient presented to our hospital at 38 weeks of gestation with a diagnosis of oligohydramnios and membrane rupture. On admission, vaginal examination revealed a cervical dilation of 6 cm with 70% effacement. In her medical history, the patient reported having undergone surgery 10 years ago for a brain cyst. The patient was referred to neurology with her computed tomography (CT) scan taken 9 months earlier. Imaging revealed a significant craniectomy defect (bone removed and not replaced) in the right parietal bone. The defect measured approximately 64 × 60 mm at its widest dimensions (Figure 1). Neurosurgery approved a cesarean delivery, advising that conditions increasing intracranial pressure be avoided.1-3 The patient was also consulted by the anesthesiology department. With advancing labor, the decision was made to proceed with an emergency cesarean section in consultation with the anesthesia team. After ensuring proper fasting, the cesarean section was performed under general anesthesia by an experienced team, with the surgery duration minimized. General anesthesia was preferred over neuraxial anesthesia to ensure hemodynamic stability, prevent intracranial pressure fluctuations associated with potential hypotension, and secure the airway, as per the consensus between the anesthesiology and neurosurgery departments. A live newborn, with an Apgar score of 7–8 and weighing 2800 grams, was delivered.4 No perioperative or postoperative complications occurred. Postoperatively, the patient was closely monitored in the intensive care unit for neurological follow-up. Postoperative neurological examination was unremarkable. Neurosurgery was consulted again, and a postoperative brain CT was performed (Figure S1). Postoperative follow-up included close monitoring of vital signs and neurological status. Laboratory evaluations demonstrated stable postoperative values without signs of infection or hemorrhage (hemoglobin: 11.4 g/dL, platelets: 176 × 103/μL, white blood cells: 11.59 × 103/μL). Electrolyte levels and kidney function tests were also within normal limits. The patient did not have any complaints other than usual postoperative pain. Her neurological examination was the same as the preoperative examination. As the patient's condition and laboratory results were stable, she was transferred to the ward. Based on neurosurgery's recommendations, antithrombotic therapy with Clexane 0.4 mL once daily was initiated. Neurosurgery consultation concluded that there was no neurological contraindication to discharge. After a 24-h observation period in the ward, the patient was discharged with a follow-up appointment scheduled in the neurosurgery outpatient clinic. Despite having a significant craniectomy defect, the patient proceeded with her pregnancy after accepting all associated risks and reaching term. With coordinated multidisciplinary management by the obstetrics, anesthesia, and neurology teams, the patient successfully underwent a safe term delivery with no maternal or neonatal complications. Prior to discharge, contraceptive counseling was provided. As the patient declined bilateral tubal ligation, an intrauterine device was recommended for reliable non-hormonal contraception to optimize the interval before any potential future pregnancy. This case highlights the importance of multidisciplinary management in pregnant patients with significant craniectomy defects or prior neurosurgical interventions and serves as a reference for the pregnancy and delivery processes in such cases.5-8 Term pregnant patients with chronic cranial pathologies must be managed in a multidisciplinary center, with appropriate intensive care facilities available. These patients require close monitoring by an experienced team throughout the delivery or surgical process. Sezin Eda Karsli: literature review, management of delivery, writing of manuscript. Cagri Kutlugun Emral: initial assessment of the patient in the ER, arrangement of the manuscript. Yusuf Ziya Kizildemir: postoperative care, revision of the manuscript. Isil Isik Okuyan: postoperative care, gathering images. The authors declare that no funding or any type of sponsorships were received. The authors declare that they have no conflict of interest. Written informed consent was obtained from the patient for publication of this case report and accompanying images. The patient's identity has been protected, and all data were anonymized. The authors declare that they have no financial, personal, or professional conflicts of interest that could be perceived to influence the results or interpretation of this study. Research data are not shared. Figure S1. Postoperative CT: vertical and sagittal images. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.