16.4 PDPH

Question 1

A woman experiences a headache 24 hours after delivery having had epidural analgesia for labour.

a) List the clinical features of a post-dural puncture headache (PDPH). (25%)

Answer 1

> > Known/suspected dural puncture,
difficulty with insertion,
multiple attempts,
junior anaesthetist.

> > Fronto-occipital headache developing
within five days of puncture.

> > Worse on standing or sitting,
improves on lying flat.

> > Accompanied by one or more of the following:
• Neck stiffness.
• Tinnitus.
• Hypacusia.
• Photophobia.
• Nausea.

Examination:
» Mainly to rule out other causes.

> > Temperature normal.

> > Cardiovascular examination,
especially blood pressure, normal.

> > Neurological examination usually normal,
BUT neurological symptoms
may occur with PDPH:

• Blindness cranial nerve II.
• Diplopia cranial nerves III, IV, VI.
• Tinnitus, hearing loss cranial nerve VIII.
• Head and facial pain cranial nerve V.
• Neck pain upper cervical nerves.

> > Rarely, leak from the puncture site on the back.

Question 2

b) What is the differential diagnosis of PDPH? (30%)

Answer 2

1. Infective
   Meningitis.
   Encephalitis.
   Sinusitis.
2. Metabolic
   Dehydration.
   Caffeine withdrawal.
3. Vascular
   Migraine.
   Cerebral vein thrombosis.
   Cerebral infarction.
   Subdural haematoma.
   Subarachnoid haemorrhage.
   Posterior reversible leucoencephalopathy syndrome.

Obstetric-related
Pre-eclampsia.
Lactation headache.

Neoplastic
Primary or secondary.

Other
Tension headache.
Benign intracranial hypertension.
Pneumocephalus.

Question 3

c) Outline the conservative treatment options for PDPH. (15%)

Answer 3

> > Adequate oral (or intravenous) hydration.

> > Simple analgesia: regular paracetamol and NSAID.

> > Antiemetics if required.

> > Stool softeners to avoid straining.

> > Encourage mobilisation;
thromboembolic deterrent stockings
and
consideration of low-molecular-weight heparin prophylaxis if immobile.

> > Regular reassessment, communication with woman and community midwifery team if discharged. Written discharge paperwork to accompany the woman.

Question 4

d) How is an epidural blood patch performed? (30%)

Answer 4

> > Patient suitability:
afebrile,
no contraindication for epidural,
more than 24 hours since puncture,
and other causes for headache ruled out.

> > Consent:
• Local bruising on the back.
• Backache and stiffness,
which can last a few days (no risk of longterm back pain).
• Another accidental dural puncture.
• Nerve damage, infection or bleeding.
• Seizure at the time of performing the EBP.
• Failure to treat headache: 30%–40%.

> > Two anaesthetists,
ideally one should be a consultant.

> > Theatre environment.

> > Full asepsis for both anaesthetists.

> > Consultant locates epidural space
at or below space at which the
puncture occurred
(because the injected blood is t
hought to spread in a
cephalad direction).

> > Other anaesthetist contemporaneously
withdraws 30 ml blood.

> > Blood injected via Tuohy
until pain in back or all 30 ml used.

> > Flush Tuohy with saline before withdrawal.

> > Ensure the patient lies flat for two hours.

> > Advise no lifting of weight heavier
than her own baby for two weeks.

> > Written discharge summary for GP,
community midwife and woman to
include issues that should prompt
re-attendance at the hospital and
contact details of the anaesthesia team.

Question 5

b) What features in this patient
would lead you to consider
a serious underlying cause?
(7 marks)

Answer 5

History:
» Drowsiness, confusion, vomiting.
» Focal neurology.
» Seizures.
» Significant neck stiffness and photophobia (although photophobia may also be present in PDPH).

Examination:
» Focal neurology.
» Papilloedema.
» Hypertension.
» Hypotension and tachycardia.
» Fever.
» Reduced conscious level.
» Meningism: positive Kernig and Brudzinski’s signs.
» Petechial rash.

Investigations (that may already be available):
» Features of infection:
elevated CRP, raised or depressed white cell count.
However, CRP and white cell count tend to be elevated after delivery anyway, so this must be viewed in the overall context.

> > Features of pre-eclampsia:
deranged transaminases and bilirubin, low
platelets, haemolysis, elevated uric acid, proteinuria.

Question 6

c) You diagnose a PDPH and
arrange treatment by epidural
blood patch (EBP). What are the
described risks of EBP? (5 marks)

Answer 6

> > Local bruising on the back.

> > Backache and stiffness, which can last a few days (no risk of long-term back pain).

> > Another accidental dural puncture.

> > Nerve damage, infection or bleeding.

> > Seizure at the time of performing the EBP.

> > Failure to treat headache: 30%–40%.