Background: The management of a pregnant trauma patient has some considerations as alterations in maternal physiology and anatomy, exposure to radiation and teratogens, the assesment of fetal well-being and other problems as Rh isoimmunization, placental abruption, and preterm labour.

Case Report: 28year-old woman in her 24th week of gestation suffered a severe traumatic brain injury (TBI) and the CT showed an epidural hematoma. An emergent craniotomy was performed and then otorhinolaryngology stoped an arterial bleeding due to left sphenoid sinus lesion. Two blood concentrates uncrossmatched (O-) were administered due to a decrease in hemoglobin (9.4 to 8.9g/gL). Thromboelastometry was performed with all the values in normal range. During the surgery, 2L of crystalloids were used resulting in unresponsive hypotension, noradrenaline was initiated to maintain BP. Fetal cardiotocography was monitored continuously by an obstetrician. During surgery presented a premature birth threat and tocolytic treatment was started with indomethacin, pulmonary maturation with betamethasone and fetal neuroprotection with magnesium sulfate. After surgery, in ICU, uterine contractions didn’t stop and atosiban was added. All tocolytic drugs were stopped on the third day. After 10 days she was extubated without neurologic disorders. She was discharged to home one week later. The baby was born in the 38th week of gestation with correct Apgar score.

Discussion: In a major trauma, the stabilization and care of the pregnant women is the priority and if the fetus is viable (>23 weeks), continuous fetal heart rate and uterine contraction monitoring must be done. If a pregnant patient presents a premature birth threat under the 24th week of gestation, tocolytic drugs must be started with indomethacin and if contractions don't stop, atosiban should be added. Pulmonary maturation with corticoids and neuroprotection with magnesium sulfate should be started as well. In our case, contractions could be stopped with these treatments, and baby was born in the 38th week without alterations. There are other issues that must be controlled like uteroplacental perfussion (trying to not to use vasopressors), avoid rhesus D (Rh) alloimmunization in Rh-negative mothers or consider physiological changes during pregnancy.

Learning point:
1. Pregnant women is the priority
2. Start tocolytic treatment and maturation when premature birth threat appears
3. Consider physiological changes during pregnancy.

02 / Anaesthetic management of a 24 week pregnant polytraumatized patient undergoing an emergent craniotomy with premature birth threat