Postpartum HA with Postpartum HA with Seizures:Seizures:

““to do a blood patch or not to to do a blood patch or not to do”do”

Contents:Contents:

• Presentation of Case StudyPresentation of Case Study

• Review of CSF infections and findingsReview of CSF infections and findings

• Review of differential diagnosis for Review of differential diagnosis for peripartum seizuresperipartum seizures

• Current literature reviewCurrent literature review

• DiscussionDiscussion

Case Presentation- Case Presentation-

• A 5’ 7”, 152 #, 17 y.o. at post-partum day 7, A 5’ 7”, 152 #, 17 y.o. at post-partum day 7, presented to HR L&D on a Friday afternoon with h/o presented to HR L&D on a Friday afternoon with h/o a GTC seizure earlier that day.a GTC seizure earlier that day.

• She also c/o a bifrontal HA which was worse with She also c/o a bifrontal HA which was worse with sitting/standing, slight stiff neck, cycloplegia, sitting/standing, slight stiff neck, cycloplegia, photophobia, mild fever (100 F), No N/V. photophobia, mild fever (100 F), No N/V.

• Pt’s mother stated she observed legs jerking and Pt’s mother stated she observed legs jerking and foaming from the mouth for approx 3-4 min. Pt had foaming from the mouth for approx 3-4 min. Pt had loss of urine and post-ictal like state as described by loss of urine and post-ictal like state as described by her mother. her mother.

Recent Obstetrical historyRecent Obstetrical history

• PMHx: “anxiety attacks”. Denied Tob, ETOH, drugs. Took no PMHx: “anxiety attacks”. Denied Tob, ETOH, drugs. Took no meds and had no drug allergies.meds and had no drug allergies.

• Pt was a G1P1 who 7 days earlier had an uneventful SVD at Pt was a G1P1 who 7 days earlier had an uneventful SVD at 39 6/7 wks with a uncomplicated labor epidural for analgesia. 39 6/7 wks with a uncomplicated labor epidural for analgesia.

• During her stay she was not treated for pre-eclampsia, but did During her stay she was not treated for pre-eclampsia, but did have elevated Bp’s in the 140’s/ 90’s and a single increased have elevated Bp’s in the 140’s/ 90’s and a single increased TP:Cr ratio of 446 (N <150).TP:Cr ratio of 446 (N <150).

• So- she delivered on a Friday night, was seen in follow-up by So- she delivered on a Friday night, was seen in follow-up by anesthesia the next day and seemingly had no issues. D/Ced anesthesia the next day and seemingly had no issues. D/Ced to home on Sunday in good healthto home on Sunday in good health

And the plot thickens…And the plot thickens…

• Pt was treated in the ED on Tues night with IVF and Pt was treated in the ED on Tues night with IVF and caffeine for a suspected PDPH. She was D/Ced from caffeine for a suspected PDPH. She was D/Ced from the ED with PO ibuprofen. the ED with PO ibuprofen.

• Pt was not evaluated by anesthesia during this visit Pt was not evaluated by anesthesia during this visit because of easily resolved symptoms with the because of easily resolved symptoms with the aforementioned treatment regimenaforementioned treatment regimen

• Thus, because of her continued “PDPH” symptoms Thus, because of her continued “PDPH” symptoms once she hit the HR floor, the OB Dr.’s wanted us to once she hit the HR floor, the OB Dr.’s wanted us to perform a blood patch.perform a blood patch.

Further Work-up…Would you Further Work-up…Would you now do a Blood Patch?now do a Blood Patch?

• NO !NO !

• One must R/O the possibility of a intracranial One must R/O the possibility of a intracranial hematoma/bleed first and then R/O a CSF hematoma/bleed first and then R/O a CSF infectious processinfectious process

• Recall: Pt had combination of fever, HA, Sz, Recall: Pt had combination of fever, HA, Sz, stiff neck, visual changes; with no N/V.stiff neck, visual changes; with no N/V.

What actions to take next…What actions to take next…

• In collaboration with the OB attending, it was decided that we In collaboration with the OB attending, it was decided that we should get a CT of the pt’s head to R/O mass/lesion first---should get a CT of the pt’s head to R/O mass/lesion first---CT CT was unremarkablewas unremarkable. LP was then . LP was then (attempted multiple times at 3 (attempted multiple times at 3 different levels)different levels) performed by the medicine team of doctors. performed by the medicine team of doctors.

• During this time she was also being treated for During this time she was also being treated for severe severe preeclampsiapreeclampsia and given Magnesium; and given Magnesium;– Negative findings for this diagnosis- BP’s were 130’s/70’s, she was Negative findings for this diagnosis- BP’s were 130’s/70’s, she was

not oliguric, Uric acid level WNL, no signs of hemolysis as CBC was not oliguric, Uric acid level WNL, no signs of hemolysis as CBC was WNL, no peripheral edema noted, liver enzymes WNL’s and plts were WNL, no peripheral edema noted, liver enzymes WNL’s and plts were over 300. over 300.

– Positive findings included- spot urine protein was 10.9 (0.0-10.0), Positive findings included- spot urine protein was 10.9 (0.0-10.0), TP:Cr 330 and she did exhibit Sz, HA, visual disturbances.TP:Cr 330 and she did exhibit Sz, HA, visual disturbances.

Pt’s CSF Findings: Pt’s CSF Findings: Cells:100, Polys:23%, Glu:41, Prot:81, WBC:59; Cells:100, Polys:23%, Glu:41, Prot:81, WBC:59; gs and cx-, equine enceph-; bld cx -, HIV Ab – gs and cx-, equine enceph-; bld cx -, HIV Ab –

Infect.Infect. CellsCells PolysPolys GlucoseGlucose ProteinProteinbacterial bacterial meningitismeningitis

500-500-10,000/mL10,000/mL

> 90%> 90% < 40 < 40 mg/dLmg/dL

>150 >150 mg/dLmg/dL

Aseptic Aseptic Meningitis Meningitis

10-500/mL10-500/mL Early > Early > 50%50%

Late<20%Late<20%

NormalNormal <100 <100 mg/dLmg/dL

Syphilitic Syphilitic meningitismeningitis

50-500/mL50-500/mL < 10%< 10% <40 mg/dL<40 mg/dL <100 <100 mg/dLmg/dL

HSV HSV encephalitiencephalitiss

0-1000/mL0-1000/mL <50%<50% NormalNormal < < 100mg/dL100mg/dL

Review of Characteristics of Review of Characteristics of Abnormal CSF :Abnormal CSF :• Bright Red-Bright Red- indicates acute hemorrage indicates acute hemorrage• Xanthochromia (yellowish to light red discoloration)-Xanthochromia (yellowish to light red discoloration)-

breakdown of RBC’sbreakdown of RBC’s• Cloudiness-Cloudiness- turbidity indicates infection due to increased turbidity indicates infection due to increased

WBC’s or proteinWBC’s or protein• Elevated Protein-Elevated Protein- assoc w/ CNS tumors, viral meningitis, assoc w/ CNS tumors, viral meningitis,

hemorrage, MS, GBShemorrage, MS, GBS• Elevated WBC’s-Elevated WBC’s-

– Lymphocytes: viral or TB meningitis, MS, HSV, Syphillis, CNS Lymphocytes: viral or TB meningitis, MS, HSV, Syphillis, CNS tumorstumors

– Granulocytes: bacterial meningitisGranulocytes: bacterial meningitis

Abnormal CSF characteristics Abnormal CSF characteristics cont.cont.

• Decreased glucose-Decreased glucose- bacterial meningitis, SAHbacterial meningitis, SAH

• Elevated Lactate-Elevated Lactate- inc glucose metabolism assoc c inc glucose metabolism assoc c bacterial or fungal meningitisbacterial or fungal meningitis

• CSF pressures-CSF pressures- (N in lat recumb position are 60-180 mm H2O)(N in lat recumb position are 60-180 mm H2O)

– Increased- Increased- space occupying lesions, hydrocephalus, SAH, space occupying lesions, hydrocephalus, SAH, intracranial infections, severe head injury, and intracranial infections, severe head injury, and hypoxic/ischemic insultshypoxic/ischemic insults

– Decreased- Decreased- spontaneous intracranial hypotension, colloid spontaneous intracranial hypotension, colloid cyst of the third ventricle and PDPH.cyst of the third ventricle and PDPH.

Anesthetic considerations:Anesthetic considerations:

• Peripartum Seizures- Differential Peripartum Seizures- Differential DiagnosisDiagnosis::– Must rule out life threatening medical issues firstMust rule out life threatening medical issues first

• A) Cerebrovascular compromiseA) Cerebrovascular compromise• B) Mass lesionsB) Mass lesions• C) infectious diseasesC) infectious diseases• D) Metabolic disorders/ epilepsyD) Metabolic disorders/ epilepsy• E) EclampsiaE) Eclampsia

A) Cerebrovascular A) Cerebrovascular CompromiseCompromise• Cerebral infarctionCerebral infarction

• Cerebral hemorrhageCerebral hemorrhage

• Subarachnoid Subarachnoid hemorrhage*hemorrhage*

• Cerebral venous Cerebral venous thrombosisthrombosis**

• Cerebral edemaCerebral edema

• Malignant HTNMalignant HTN

B) Mass lesionsB) Mass lesions

• A-V malformations*A-V malformations*

• Benign and/or malignant tumorsBenign and/or malignant tumors

• Cerebral abcessCerebral abcess

C) Infectious DiseasesC) Infectious Diseases

• ViralViral

• BacterialBacterial

• Parasitic infestationsParasitic infestations

• HIVHIV

• FungalFungal

D) Metabolic Disorders/ D) Metabolic Disorders/ EpilepsyEpilepsy

• HyponatremiaHyponatremia

• HypocalcemiaHypocalcemia

• Hypo or HyperglycemiaHypo or Hyperglycemia

• Central stimulants- cocaine, theophylline etc.Central stimulants- cocaine, theophylline etc.

• Idiopathic epilepsyIdiopathic epilepsy

E) Severe PreeclampsiaE) Severe Preeclampsia

• In OB, this is obviously one of the most In OB, this is obviously one of the most common etiologiescommon etiologies

Then comes the Neurology Then comes the Neurology Consult…Consult…

• Impression: Postpartum fever, HA, Seizure= clinical Impression: Postpartum fever, HA, Seizure= clinical meningoencephalitis involving a viral or aseptic meningoencephalitis involving a viral or aseptic etiology. No focal neurological Sx.etiology. No focal neurological Sx.– Although one can not exclude early bacterial, listeria or Although one can not exclude early bacterial, listeria or

paramenigeal processparamenigeal process

– Mentioned, but was doubtful about a diagnosis of chemical Mentioned, but was doubtful about a diagnosis of chemical meningitis secondary to PO ibuprofen or of pleocytosis meningitis secondary to PO ibuprofen or of pleocytosis from low-pressure (CSF <60 mm H2O) or from Sz alone.from low-pressure (CSF <60 mm H2O) or from Sz alone.

* Note: the medicine team never got an opening pressure* Note: the medicine team never got an opening pressure

Neurology Consult Cont.Neurology Consult Cont.

• Treatment Plan:Treatment Plan:

- Dilantin, cont. Magnesium for Sz - Dilantin, cont. Magnesium for Sz

- Empiric Abx Txmnt: acyclovir until HSV studies - Empiric Abx Txmnt: acyclovir until HSV studies came back negative; ceftriaxone and vanco given came back negative; ceftriaxone and vanco given until all bld and CSF cultures came back negativeuntil all bld and CSF cultures came back negative

- ID consult, send CSF for viral studies (HSV PCR, - ID consult, send CSF for viral studies (HSV PCR, enteroviral, arboviral, HIV)enteroviral, arboviral, HIV)

- Get MRI of head- Get MRI of head

MRI Results 2 days MRI Results 2 days later:later:• Findings “consistent with intracranial hypotension.”Findings “consistent with intracranial hypotension.”

– IIncluding T1-weighted images with diffuse meningeal ncluding T1-weighted images with diffuse meningeal gadolinium enhancement with or without subdural and gadolinium enhancement with or without subdural and extraarachnoid fluid collections or evidence of descent of extraarachnoid fluid collections or evidence of descent of the cerebellar tonsils. Furthermore, there is a thick, the cerebellar tonsils. Furthermore, there is a thick, homogeneous pattern to the extra-axial fluid over the homogeneous pattern to the extra-axial fluid over the hemispheres bilaterally representing cerebral venous hemispheres bilaterally representing cerebral venous engorgement.engorgement.

– Can also see enlargement of the pituitary gland in cases of Can also see enlargement of the pituitary gland in cases of intracranial hypotension (Alvarez-Linera et al., Neurology. intracranial hypotension (Alvarez-Linera et al., Neurology. 2000;55;1895-1897) as the radiologist did appreciate with 2000;55;1895-1897) as the radiologist did appreciate with our pt.our pt.

MRI Findings: MRI Findings: axial T1-WI c gad enhaceaxial T1-WI c gad enhace

Case continuation: HD #4Case continuation: HD #4

• MRI results back and focus shifts to PDPH MRI results back and focus shifts to PDPH secondary to CSF leak and intracranial hypotension.secondary to CSF leak and intracranial hypotension.

• Pt seen by anesthesia, HA resolving; not increasingly Pt seen by anesthesia, HA resolving; not increasingly worse from laying downworse from laying down sittting sittting standing. No standing. No indication for blood patch at this time.indication for blood patch at this time.

• Pt D/C home on phenytoin and was suppose to f/u Pt D/C home on phenytoin and was suppose to f/u with neurologist as outpt. with neurologist as outpt. – Of note: pt had no further Sz activity during hospital stayOf note: pt had no further Sz activity during hospital stay

Summary:Summary:

• 17 y.o. on post-partum day 7 with GTC Sz, HA, 17 y.o. on post-partum day 7 with GTC Sz, HA, visual changes and fever. visual changes and fever. – Considerations/Proposed questions:Considerations/Proposed questions:

• Was it a sequela of Severe Pre-eclampsia?Was it a sequela of Severe Pre-eclampsia?• Could it have been from an unintentional dural puncture when Could it have been from an unintentional dural puncture when

performing the labor epidural?performing the labor epidural?• Was it an aseptic meningitis secondary to a virus or to a chemical?Was it an aseptic meningitis secondary to a virus or to a chemical?• Who knows?Who knows?• How common are these outcomes? Let’s look at ways to avoid How common are these outcomes? Let’s look at ways to avoid

these clinical symptoms and potential complications in the future.these clinical symptoms and potential complications in the future.– First, let’s look deeper into the syndrome of intracranial First, let’s look deeper into the syndrome of intracranial

hypotension.hypotension.

Intracranial hypotension:Intracranial hypotension:

• Pathophysiology behind MRI findings-Pathophysiology behind MRI findings-– Monroe-Kellie Doctrine or Rule: states that when Monroe-Kellie Doctrine or Rule: states that when

the volume of any of the three cranial components the volume of any of the three cranial components (brain parenchyma, CSF, and blood) increases, the (brain parenchyma, CSF, and blood) increases, the volume of one of the others must decrease or the volume of one of the others must decrease or the ICP will rise when considering an intact cranial ICP will rise when considering an intact cranial vault. Thus, if CSF volume decreases (ie. a leak), vault. Thus, if CSF volume decreases (ie. a leak), the compensatory mechanism to maintain ICP is the compensatory mechanism to maintain ICP is by increasing blood volume, especially in the by increasing blood volume, especially in the venous capacitance systemvenous capacitance system

Intracranial hypotensionIntracranial hypotension

• A syndrome occurring secondary to various A syndrome occurring secondary to various etiologiesetiologies– Can occur spontaneously; secondary to anything that Can occur spontaneously; secondary to anything that

causes a decrease production of CSF,or increased causes a decrease production of CSF,or increased absorption; or a disruption of a compartment as seen in absorption; or a disruption of a compartment as seen in dural tears.dural tears.

– No matter what the etiology, we treat this condition most No matter what the etiology, we treat this condition most commonly with a blood patch or conservatively with IV commonly with a blood patch or conservatively with IV caffeine, IVF and pain medscaffeine, IVF and pain meds

Can preeclampsia occur on Can preeclampsia occur on postpartum day 7 ?postpartum day 7 ?

• International Journal of Obstetric Anesthesia,International Journal of Obstetric Anesthesia, Akerman and Hall (from UK), April 2005,14(2), 163-Akerman and Hall (from UK), April 2005,14(2), 163-166 presented a case of a 29 y.o. in her 3166 presented a case of a 29 y.o. in her 3rdrd pregnancy pregnancy developed Sz on PPD 7. developed Sz on PPD 7. – No evidence of preeclampsia antepartum or postpartum. No evidence of preeclampsia antepartum or postpartum.

Only symptoms preceding sz were fever, HA and visual Only symptoms preceding sz were fever, HA and visual disturbances.disturbances.

– She c/o sudden onset of frontal and occipital HA on PPD She c/o sudden onset of frontal and occipital HA on PPD 3 which was worse on standing. Over the course of the 3 which was worse on standing. Over the course of the next 3 days, HA remained unchanged other than a next 3 days, HA remained unchanged other than a fluctuation in severity. No focal neurological signs.fluctuation in severity. No focal neurological signs.

Cont.Cont.

– On PPD 7, HA worsened, was febrile, pt had acute On PPD 7, HA worsened, was febrile, pt had acute visual disturbacnes and became agitated. She then visual disturbacnes and became agitated. She then proceeded to have 2 GTC Sz.proceeded to have 2 GTC Sz.

– All studies were WNL incl CBC, Uric acid levels, All studies were WNL incl CBC, Uric acid levels, plts, electrolytes as well as CT head, MRI, and plts, electrolytes as well as CT head, MRI, and LP.LP.

Eclampsia- with Sz on PPD Eclampsia- with Sz on PPD 22?22?

Akerman and Hall site a couple influencial articles Akerman and Hall site a couple influencial articles that prehaps challenge the way we traditionally that prehaps challenge the way we traditionally think of eclampsia of occurring btwn 20 wks and think of eclampsia of occurring btwn 20 wks and 48hr postpartum.48hr postpartum.

• One larger retrospective study One larger retrospective study (from the US, Lubarsky, (from the US, Lubarsky, Barton, Freidman, Nasreddine, Ramadan, Sibia reported in Barton, Freidman, Nasreddine, Ramadan, Sibia reported in

1994; 83, 502-505, in the green journal)1994; 83, 502-505, in the green journal) reported that up to reported that up to 15% of eclamptic pts developed sz btwn days 3 and 15% of eclamptic pts developed sz btwn days 3 and 22 postpartum.22 postpartum.

Cont.Cont.

• In another review In another review (by Douglas and Redman of the (by Douglas and Redman of the UK in the BMJ 1994; 309;1395-1400) UK in the BMJ 1994; 309;1395-1400) found that in found that in over 300 cases of eclampsia, 12% occurred over 300 cases of eclampsia, 12% occurred more than 48hr and 2% more than 7 days post-more than 48hr and 2% more than 7 days post-partum. partum. – Among these cases reported, up to 90% suffered Among these cases reported, up to 90% suffered

from HA and visual disturbances prior to sz and no from HA and visual disturbances prior to sz and no classical preeclamptic signs were present in over classical preeclamptic signs were present in over 50% of the cases.50% of the cases.

The Big Picture…The Big Picture…

• The main objective of this article was to raise one The main objective of this article was to raise one major point…that far too often it is assumed by our major point…that far too often it is assumed by our colleagues that most postnatal HA’s are caused by colleagues that most postnatal HA’s are caused by our epidurals. It is this unwillingness to consider all our epidurals. It is this unwillingness to consider all possible causes for postnatal HA’s (other than PDPH) possible causes for postnatal HA’s (other than PDPH) which may lead to a delay in the exclusion or which may lead to a delay in the exclusion or diagnosis of more serious causes of HA’s diagnosis of more serious causes of HA’s – Including, but not limited to, cortical vein thrombosis, SAH Including, but not limited to, cortical vein thrombosis, SAH

or meningoencephalitis.or meningoencephalitis.

How clearly can you see through How clearly can you see through mud?mud?

• And, as is many aspests of medicine, it is And, as is many aspests of medicine, it is never a clear-cut matter. Thus, it is imperative never a clear-cut matter. Thus, it is imperative to collaborate with colleagues (neurologists, to collaborate with colleagues (neurologists, OB, ID, radiologists) and make a conjoined OB, ID, radiologists) and make a conjoined effort to properly diagnose and treat each case effort to properly diagnose and treat each case appropriately.appropriately.

Aseptic meningitis secondary Aseptic meningitis secondary to chemical irritation.to chemical irritation.

• ““chemical meningitis” is an aseptic meningitis with chemical meningitis” is an aseptic meningitis with it’s acute clinical course and standard laboratory it’s acute clinical course and standard laboratory findings mimicking bacterial meningitis.findings mimicking bacterial meningitis.

• Most commonly it’s a rare complication of giving Most commonly it’s a rare complication of giving dyes for myelographydyes for myelography– There has been case reports of chemical meningitis There has been case reports of chemical meningitis

following intrathecal or epidural corticosteroid thaerapiesfollowing intrathecal or epidural corticosteroid thaerapies

– Also following PO TMP/SMX, ibuprofen, celecoxib and Also following PO TMP/SMX, ibuprofen, celecoxib and rofecoxibrofecoxib

More cases of chemical More cases of chemical meningitis:meningitis:• In In Neurosurgery Neurosurgery 55(5): 1222, November 200455(5): 1222, November 2004, Meyers et , Meyers et

al. reported two cases of chemical meningitis al. reported two cases of chemical meningitis secondary to the placement of second-generation secondary to the placement of second-generation aneurysm coils for treatment of large cerebral aneurysm coils for treatment of large cerebral aneurysms.aneurysms.

• In In Neurosurgery Neurosurgery 25 (2): 264-270, August 1989, 25 (2): 264-270, August 1989, Lunardi et al reported a case of chemical meningitis Lunardi et al reported a case of chemical meningitis resulting from spillage of the contents of a cystic resulting from spillage of the contents of a cystic cranial tumor. He also reviewed some 35 different cranial tumor. He also reviewed some 35 different cases in which cranial and spinal tumors were cases in which cranial and spinal tumors were associated with a chemical meningitis.associated with a chemical meningitis.

How do we avoid the sequelea How do we avoid the sequelea that can originate from a dural that can originate from a dural puncture?puncture?• Should we always use LOR technique with NS and Should we always use LOR technique with NS and

not air? not air?

• Should we consider threading intrathecal catheters in Should we consider threading intrathecal catheters in cases where we accidentally puncture the dura while cases where we accidentally puncture the dura while attempting placement of an epidural catheter?attempting placement of an epidural catheter?

• Should we prophylactically place EBP in parturients Should we prophylactically place EBP in parturients after inadvertent dural puncture?after inadvertent dural puncture?

- Let’s investigate…- Let’s investigate…

LOR techniques…does it LOR techniques…does it matter?matter?

• One larger study involving over 3700 pts investigated One larger study involving over 3700 pts investigated upon the role of intrathecal air.upon the role of intrathecal air.

• In the journal In the journal AnesthesiolgyAnesthesiolgy, 1998; 88; 76-81, Aida et , 1998; 88; 76-81, Aida et al al from Japan from Japan formed two investigative groups- formed two investigative groups- – 1,918 in the saline LOR group and 1,812 in the air LOR 1,918 in the saline LOR group and 1,812 in the air LOR

groupgroup– Epidurals were performed for chronic and acute pain Epidurals were performed for chronic and acute pain

purposes purposes – Incidence, onset time, and duration of PDPH were Incidence, onset time, and duration of PDPH were

examined and compared in each of the two groups. examined and compared in each of the two groups.

Cont.Cont.• Results: incidence of PDPH in the air group (32 cases) was Results: incidence of PDPH in the air group (32 cases) was

significantly higher than that in the saline group (5 cases) significantly higher than that in the saline group (5 cases) ((more than 6 times more likely)), although the occurrences of ((more than 6 times more likely)), although the occurrences of meningeal perforation btwn the two groups did not differ- 48 meningeal perforation btwn the two groups did not differ- 48 cases of unintentional dural puncture in the air group vs 51 cases of unintentional dural puncture in the air group vs 51 cases in the saline group.cases in the saline group.

• Also, PDPH’s were significantly more rapid in onset and Also, PDPH’s were significantly more rapid in onset and shorter in duration in the air group vs the NS.shorter in duration in the air group vs the NS.

• Lastly, of the 32 cases of PDPH in the air group, 30 of them Lastly, of the 32 cases of PDPH in the air group, 30 of them had intrathecal air bubbles (highly contributing to HA) had intrathecal air bubbles (highly contributing to HA) detected on brain CT, whereas no intrathecal air bubbles were detected on brain CT, whereas no intrathecal air bubbles were seen in the NS groupseen in the NS group

Conclusion:Conclusion:

• That perhaps the use of air for loss-of-That perhaps the use of air for loss-of-resistance techniques used when performing resistance techniques used when performing epidural blocks, epidural blocks, may bemay be associated with a associated with a higher incidence of PDPH as this article higher incidence of PDPH as this article suggests.suggests.

Thread ‘em Subarachnoid? Thread ‘em Subarachnoid?

• Placement of a subarachnoid catheter after Placement of a subarachnoid catheter after unintentional dural puncture may reduce the unintentional dural puncture may reduce the incidence of PDPH. This is a contraversial issue, but incidence of PDPH. This is a contraversial issue, but shown to be the case in the following study.shown to be the case in the following study.

• From From Regional Anesthesia and Pain Management,Regional Anesthesia and Pain Management, Vol 28, No 6 (Nov-Dec) 2003, 512-515, Ayad et al. Vol 28, No 6 (Nov-Dec) 2003, 512-515, Ayad et al. from CCF over a five year period, retrospectively from CCF over a five year period, retrospectively investigated 115 pts who had unintentional dural investigated 115 pts who had unintentional dural punctures whom were placed randomly into 3 groups.punctures whom were placed randomly into 3 groups.

Methods Cont.Methods Cont.

• Group A- had an epidural catheter placed at Group A- had an epidural catheter placed at another interspaceanother interspace

• Group B- had a subarachnoid catheter placed Group B- had a subarachnoid catheter placed for labor analgesia that was removed for labor analgesia that was removed immediately after deliveryimmediately after delivery

• Group C- had a subarachnoid catheter placed Group C- had a subarachnoid catheter placed for labor analgesia that was removed 24 hrs for labor analgesia that was removed 24 hrs after deliveryafter delivery

Results:Results:

• The incidence of PDPH in the various groups were as The incidence of PDPH in the various groups were as follows…follows…– Group A- 81%Group A- 81%– Group B- 31% Group B- 31% – Group C- 3%Group C- 3%Whereas the overall incidence of PDPH after inadvertent Whereas the overall incidence of PDPH after inadvertent

dural puncture was 46.9% overall. This risk of developing dural puncture was 46.9% overall. This risk of developing a PDPH is reported to be as high as 75% in OB pts after a PDPH is reported to be as high as 75% in OB pts after unintentional dural puncture with a 16-18 G needle. unintentional dural puncture with a 16-18 G needle.

Note: the type of epidural needle was not specifiedNote: the type of epidural needle was not specified

The avoidance technique…The avoidance technique…

• In the journal of In the journal of Anesthesiology,Anesthesiology, 2004; 101: 2004; 101: 1422-1427 Scavone et al performed a 1422-1427 Scavone et al performed a randomized double blind study to access the randomized double blind study to access the effect of prophylactic epidural blood patches effect of prophylactic epidural blood patches on the incidence of PDPH.on the incidence of PDPH.

Methods:Methods:

• 64 parturients who incurred an accidental 64 parturients who incurred an accidental dural puncture were randomized into two dural puncture were randomized into two groupsgroups– 1 group: would randomly receive a prophylactic 1 group: would randomly receive a prophylactic

epidural blood patch with 20 cc autologous blood epidural blood patch with 20 cc autologous blood

– 22ndnd group: was the sham group group: was the sham group

Pt’s were followed daily watching for the Pt’s were followed daily watching for the development of a PDPH for a min of 5 days.development of a PDPH for a min of 5 days.

Results:Results:

• 18 of 32 pts in each group (56%) developed a PDPH. 18 of 32 pts in each group (56%) developed a PDPH. Therapeutic blood patches were recommended in Therapeutic blood patches were recommended in subjects with moderate HA (in those who reported subjects with moderate HA (in those who reported trouble with caring for their children) and in those trouble with caring for their children) and in those who reported severe HA. who reported severe HA. – The groups showed no significant difference in time of The groups showed no significant difference in time of

onset of PDPH, median peak pain scores, and numbers of onset of PDPH, median peak pain scores, and numbers of days spent unable to care for their childrendays spent unable to care for their children

Results Cont.Results Cont.

• The conclusion of the study showed that in The conclusion of the study showed that in this group of pts, prophylactic EBP did not this group of pts, prophylactic EBP did not decrease the incidence of PDPH or that there decrease the incidence of PDPH or that there was a statistical significance in outcome btwn was a statistical significance in outcome btwn the two groups. Therefore, the need to the two groups. Therefore, the need to provide prophylactic EBP was not supported.provide prophylactic EBP was not supported.

In Conclusion…In Conclusion…

• I have reviewed a case report here today with the I have reviewed a case report here today with the intent of addressing other potential causes of intent of addressing other potential causes of peripartum HA and seizures that one must consider peripartum HA and seizures that one must consider when working up a pt with these findings.when working up a pt with these findings.

• Differential diagnosis considerations…Differential diagnosis considerations…

• Lastly, we must always be constantly self evaluating, Lastly, we must always be constantly self evaluating, searching for new data which may support or negate searching for new data which may support or negate ways that we practice so that we can best serve our ways that we practice so that we can best serve our pts.pts.