Postpartum Headache

Question 1

A 32-year-old female presents 2 days postpartum with a headache. She has a body mass index of 40 but no other medical conditions. She had an epidural inserted during labour and a forceps delivery with no complications.

What are the possible causes of a headache in this patient?

Answer 1

Obstetric causes:

• Hypertensive disorders of pregnancy.
• Lactation headache/hormonal changes in oestrogen and
  progesterone levels.
• Post-dural puncture headache.
• Cerebral vein thrombosis, haematoma or infarct.

Non-obstetric causes:

• Common causes: dehydration, tension headache or migraine.
• Infective: meningitis/encephalitis/sinusitis.
• Cerebrovascular: haemorrhage, haematoma, infarct or thrombosis.
• Malignancy.
• Illicit drug use.
• Domestic violence.

Question 1

How would you manage this patient initially?

Answer 1

• An ABCDE assessment of this patient should be carried out to include a history and neurological examination to determine the cause and rule out any sinister pathology.
• Ensure multidisciplinary team management to involve the appropriate individuals.
• Monitoring, observations and investigations should be done as directed by the initial assessment.

Question 2

What is posterior reversible leucoencephalopathy syndrome?

Answer 2

• A syndrome characterised by headache, seizures, altered mental state and visual loss with vasogenic oedema of the white matter affecting the posterior occipital and parietal lobes of the brain. It was first diagnosed in 1996.
• The pathophysiology of PRES is not fully understood, but it is thought to be due to the effects of hypertension on the posterior circulation in the brain. Disruption of auto-regulation and local cellular damage are
  thought to play a part, leading to cerebral oedema.
• In pregnancy, PRES is a rare but serious complication of eclampsia,
  and management is largely supportive while the underlying cause is
  treated.
• Diagnosis is by MRI.
• There is a 15% risk of mortality or permanent nerve injury.
• Treatment is with blood pressure control, anticonvulsants and renal
  replacement therapy if required.

Question 3

What are the typical findings in the history and examination of a patient with a post-dural puncture headache?

Answer 3

History:
* A dural puncture may have been identified at the time of the procedure (although in ~40% of PDPH following an epidural, the dural puncture was not recognised at the time of insertion).

• May be associated with multiple or diffcult epidural insertion attempts, and with a low or high BMI.
• Commonly, the headache is fronto-occipital, worse on sitting or standing and improves when lying down (although in 5% of cases there is no postural element).
• Tinnitus, muffled hearing, photophobia and neck stiffness may be present.

Examination:
* Nerve palsies (most commonly VIth and VIIIth cranial nerves).

• In equivocal cases, circumferential squeezing of the abdomen may alleviate the headache (caval compression causes expansion of epidural venous circulation, which in term compresses the dural sac, producing an increase in CSF pressure and temporary alleviation of
  the headache).

Investigations:
* Observations and baseline blood tests are usually normal.

Question 4

What is the initial management of a patient with a PDPH?

Answer 4

• Conservative management should be attempted initially, to include:
• Hydration (ideally oral).
• Analgesia (paracetamol and ibuprofen are safe in breastfeeding).
• Bed-rest is no longer recommended; patients should mobilise as
  they feel able.
• Monitoring and assessment either at home or on the postnatal ward.
• If the above measures fail to work, an epidural blood patch should be considered. If tinnitus or other cranial nerve palsies develop, a blood patch should be encouraged.

Question 5

You are asked to insert an epidural for a patient in labour ward while on call, and note clear fluid profusely leaking from the Tuohy needle.

What your immediate management?

NB depends on experience of the anaesthetist, the staffing on the labour ward and the status of the patient

Answer 5

Intrathecal catheter insertion:
* The epidural catheter can be inserted into the intrathecal space and top-ups administered by an anaesthetist only, with no infusions attached.

• The catheter must be very clearly labelled and handed over to the senior midwifery and anaesthetic teams.
• Expect tachyphylaxis as labour progresses.
• This technique is likely to achieve good analgesia initially, but there is
  an increased risk of analgesic failure because of a lack of familiarity among the anaesthetic and midwifery staff, and the catheter may also be pulled out of the intrathecal space.