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Post dural puncture headache in morbidly obese parturients
Abstract Number: 48
Abstract Type: Original Research
Introduction: Accidental dural puncture is a recognized complication of epidural insertion. Post dural puncture headache (PDPH) subsequently develops in approximately 81% of parturients(1). A low incidence (25%) of PDPH has been reported in morbidly obese parturients after (18G) epidural anesthesia(2). In this study we compared the incidence of PDPH in morbidly obese paturients with non-morbidly obese parturients.
Method: Approval was obtained for this study from the Local Research Ethics Committee. A prospective audit was carried out on all patients known to have had an accidental dural puncture with a 16G needle or complaining of PDPH after 16G epidural anesthesia over an eleven-year period at our institution. Data was collected prospectively using a standardized form. Demographic data included Body Mass Index (BMI), age and ASA status. Epidural details included reason for request, level of epidural placement, depth of epidural space, severity and associated signs and symptoms of PDPH and subsequent treatment.
Results: 116 patients were identified during the study period. Both groups were comparable in terms of age and ASA status. The incidence of dural puncture rate was significantly higher in morbidly obese parturients than non-morbidly obese parturients 7.8% (44/564) versus 1.1% (72/6540), respectively. There was a statistically significant lower incidence of severe PDPH (needing epidural blood patch) between morbidly obese (52.3%) and non-morbidly obese (83.8%) paturients.
Discussion: The combined risks of obesity and pregnancy are significant. Regional anesthesia is the safest approach for the morbidly obese obstetric patients, but may be technically challenging for the anesthesiologist. Morbidly obese patients have poorly defined anatomical landmarks that make the identification of the epidural space difficult and increase the possibility of dural puncture. The decreased incidence of PDPH in morbidly obese parturients may relate to the large abdominal panniculus that functions as the equivalent of an abdominal binder, elevating intraabdominal pressures and retarding spinal fluid leakage through the dural puncture site.
1.Paech M, banks S. An Audit of accidental dural puncture during epidural insertion of a Tuohy needle in obstetric patients. International Journal of Obstetric Anesthesia 2001;10:162-7.
2.Faure E, Moreno R. Incidence Postdural Puncture Headache in Morbidly Obese Parturients. Regional anesthesia 1994;19:361-3.