Review Note
Last Update: 03/02/2025 08:22 PM
Current Deck: ACG Part 2::Obstetrics
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Commit #293197
SS_OB 1.28 Discuss the management of significant complications of neuraxial analgesia and anaesthesia in childbirth, for example:
- Post dural puncture headache
- Post dural puncture headache
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Commit #293197Immediate management:
- Goal: To achieve effective analgesia without further complications
Options if due to inadvertent dural puncture at time of epidural :
- Insert intrathecal catheter
- 2-3cm into subarachnoid space
- Label clearly as intrathecal - anaesthetist only top ups
- Top ups of 1-2.5mg bupivacaine +/- 5-25mcg fentanyl
- Tachyphylaxis seen in prolonged labour
- Advantage - can’t perform another dural puncture, may reduce need for blood patch, excellent analgesia
- Disadvantages: Unfamiliar dosing, tachyphylaxis, labour intensive
- Remove and insert epidural catheter
- Chose a different space, ask for help
- Beware intrathecal spread - especially if large top up for OT (may get much higher block)
- Top ups by anaesthetist
Late management:
- Headaches are common in post-natal period, rule out other causes (dehydration, tiredness, migraines, anaemia, meningitis, SAH, venous sinus thrombosis, pituitary bleed)
- Common features of PDPH:
- Recognised dural puncture (1/3rd of PDPH’s it is not recognised at insertion)
- Onset 24-48hrs after dural puncture, can be up to 5 days
- Headache worse when standing, often absent overnight while in bed (note 5% not postural)
- Fronto-occipital, may be associated with neck stiffness, muffled hearing
- May be relieved by tight abdominal compression (use diagnostically)
- Photophobia and difficulty with accommodation
- Hearing loss, tinnitus, CN VI nerve palsy possible (diplopia, eye turned inwards) - if these signs are present should have blood patch, nerve injury may not recover if not treated appropriately
- Management:
- Conservative
- Symptomatic treatment
- Bed rest (but risk of VTE, consider prophylaxis)
- Fluid intake (PO)
- Simple analgesics
- Caffeine (reduces intracranial vasodilation), maximum 900mg per day, 200mg if breastfeeding
- Insufficient evidence for: sphenopalatine block, greater occipital block, theophylline, ACTH analogues, steroids, triptans, gabapentin, acupuncture, epidural opioid or fluid
- Await resolution
- Active
- Epidural blood patch
- Only 1/3rd of women will have complete symptomatic resolution with EBP
- Common for relapse and need for second blood patch
- Success rates lower if performed >48hrs
- Mechanism:
- Blood compressed dural sac and raises ICP
- Blood forms a clot over dural tear and seals leak
- Complications:
- Backache
- Repeat dural puncture possible
- Neurological deficit, arachnoiditis, infection, epileptiform fits, cranial nerve damage
- Technique:
- As per epidural
- Two operators, one for epidural, one for sterile blood draw (NR fit syringe if using)
- Perform at same or lower epidural space to puncture (blood spread cephalad)
- 20ml of blood injected slowly until backache or whole volume injected
- Bed rest for 2 hours post procudure
- Neurosurgical closure (rare)