![]() ![]() The diagnosis of PDPH is based on both the clinical presentation (documented dural puncture and severe postural headache being most characteristic) and a detailed history and physical examination. If headache is more significant such that activities of daily life and caring for the baby are compromised, an EBP should be considered. When PDPH is less severe, which may reflect a smaller dural tear with less CSF leak, conservative therapy may be preferred in the expectation the headache resolves without the need for an EBP. 11 The intensity of maternal symptoms may dictate the need for an Epidural Blood Patch (EBP). If a PDPH is suspected, a member of the anesthesia team should see the patient within 24 hours. 11, 13, 14 Factors influencing the incidence of PDPH includes age, gender, previous history of headache, needle characteristics, number of attempts and clinical experience of the provider. 11, 12 Additionally, in one third of cases, an epidural dural puncture may not have been recognized at all. Even though the PDPH is associated with a postural component, a postural component may not be present in up to 5% of cases of PDPH. ![]() 10, 11 Smaller gauge dural punctures with spinal anesthesia typically resolve in 2-3 days. 10 The headache usually starts within 48 hours of an epidural UDP and if left untreated, resolves spontaneously in about 2-weeks in most women but may last longer in some women. The PDPH usually remits spontaneously within 2 weeks, or after sealing of the leak with an autologous epidural lumbar patch. It is usually accompanied by neck stiffness and/or subjective hearing symptoms. The International Headache Society (IHS) defines PDPH as a headache occurring within 5 days of a lumbar puncture, caused by cerebrospinal fluid (CSF) leakage through the dural puncture. 7 Recent articles have found an increase in persistent headache (aOR 6.4) and backache (aOR 4.4) one year later8 as well as an increased incidence of postpartum depression, post traumatic stress disorder, and a decrease in breastfeeding (p<.0001). Postpartum morbidity following PDPH include readmission (5.2%), increased relative risk for cerebral venous thrombosis (aOR = 11.4) and subdural hematoma (aOR = 76.7). 5 In one report, PDPH was involved in 12% of obstetric closed claims.6 (Davies Anesthesiology 2009). 3, 4 Spinal anesthesia may also result in a PDPH incidence of 0.8-5% in the highest pregnancy risk group, with lower incidences for pencil point needle tip design and smaller gauges. 2 However, labor epidural analgesia is not without complication the most common complication of labor epidural catheter placement is unintentional dural puncture (UDP) with an approximate incidence of 0.51-1.5% in obstetric patients, and 50-80% of patients may develop a post-dural puncture headache (PDPH). 1 Epidural analgesia is commonly used to alleviate labor pain with a reported rate of over 50% at many institutions in the United States and over 85% in tertiary care labor and delivery centers with 24-hour obstetric anesthesia coverage. Headache in the post-partum period is common, up to 39% in one prospective study with only 4.7% of headaches anesthesia related. The postpartum period is characterized by numerous changes such as sleep deprivation, irregular food intake and dehydration. (Approved by the ASA House of Delegates on October 13, 2021) Committee of Origin: Obstetric Anesthesia ![]()
0 Comments
Leave a Reply. |