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An Epidural Hematoma in a Patient with a Normal Coagulation Profile Following Epidural Analgesia for Labor
Abstract Number: T 65
Abstract Type: Case Report/Case Series
A 28 year old G2P1 with a previous Ceaserean section at 40 weeks presented following a spontaneous rupture of membranes. Epidural analgesia was requested and a catheter was placed at the L3-4 level on the first attempt without any complications. No CSF or blood was withdrawn from either the needle or catheter. There was no paresthesia or any unusual pain during the procedure. Hemoglobin was 11.9 gm/dl and platelet count was 135 x 109/L before the procedure. The catheter was removed without any evidence of bleeding at the insertion site after vaginal delivery.
Five hours after removal of the catheter, the patient complained of bilateral lower extremity weakness and radiating pain. The neurologic examination indicated slightly depressed muscle motor tone of both lower extremities. No bleeding or swelling was noted at the insertion site of the catheter. Post delivery hemoglobin was 9.4 gm/dl and platelet count was 112 x 109/L. An emergency MRI revealed a posterior epidural hematoma at L4 approximately 12.8 x 5.1 mm in size. The hematoma displaced the thecal sac anteriorly with an associated severe central spinal canal compromise. Because the neurologic findings had stabilized for several days, the neurosurgeon recommended conservative therapy without surgical intervention. By post partum day 4, the pain in lower back and motor weakness of lower extremities had gradually improved. She was discharged home with instructions to continue physical therapy.
An epidural hematoma following an epidural catheter insertion is a rare but significant complication. The incidence of an epidural hematoma in a healthy parturient can be as low as 2.72 per million. Symptoms from an epidural hematoma include unusual back pain and local tenderness, persistent numbness or motor weakness, or sphincter dysfunction. Bilateral symptoms or symptoms not typical of obstetric neuropathy must be investigated by MRI whenever an epidural hematoma is suspected. While risks of hematomas are low, delay in diagnosis can cause severe and permanent neurologic dysfunction. Once imaging confirms the presence of a hematoma, neurosurgical consultation is required for possible decompression of the spine. Early diagnosis by MRI and surgical intervention if indicated remain the standard treatment for complete neurological restitution.
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