Management of spontaneous intracranial hypotension during second trimester of pregnancy and neuraxial labour analgesia for operative vaginal delivery: a case report

Spontaneous intracranial hypotension is a rare condition resulting from cerebrospinal fluid volume depletion. During pregnancy, spontaneous intracranial hypotension may be challenging to diagnose due to symptom overlap with common gestational conditions, and evidence guiding labour and anaesthetic management remains extremely limited. A 33-year-old primigravida conceived via assisted reproductive technology presented at 16 weeks' gestation with progressively worsening orthostatic headache, nausea, and vomiting. Magnetic resonance imaging revealed bilateral subacute subdural hematomas, brain sagging, and a suspected thoracic cerebrospinal fluid leak, confirming spontaneous intracranial hypotension. After initial ineffective conservative management, a clinical deterioration prompted the decision to perform an epidural blood patch, which resulted in significant clinical improvement until delivery. After multidisciplinary consultation at 36 weeks, vaginal delivery with early epidural catheter placement was planned. At 41 weeks + 5 days, labour was induced and epidural analgesia provided effective pain relief without complications. Delivery was achieved via vacuum extraction. Postpartum magnetic resonance imaging showed only millimetric residual collections. Both mother and newborn were discharged in good condition, and the patient reported high satisfaction. This case supports the feasibility of vaginal delivery in spontaneous intracranial hypotension, the safe use of neuraxial labour analgesia after prior epidural blood patch, and the importance of multidisciplinary planning.