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Intrathecal Hematoma after CSE for Labor Analgesia
Abstract Number: F-34
Abstract Type: Case Report/Case Series
Case: A 30 year old G1P0 at 39w3d was admitted in active labor. Due to antithrombin III deficiency, she was on Heparin 10,000U BID with the last dose being 6 hours prior to CSE. CBC was normal at admission, though a PTT was not checked. CSE placement was uneventful, labor analgesia was effective, and she delivered a healthy baby 4 hours later. She was discharged on postpartum day (PPD) 2 in good condition, and medications included enoxaparin 40mg BID. By PPD 4-5 she began to experience positional headaches, photophobia, meningismus, fever, lower back pain with radicular irritation, and mild subjective leg weakness. On PPD 6 she returned to the hospital and was thought to have postdural puncture headache (PDPH) in addition to possible meningitis or other infection, and thus IV antibiotics were started. As part of the infectious workup, lumbar puncture (LP) was done and revealed frank blood (RBC=82K). Notably, all of her symptoms were greatly exacerbated after the LP procedure. Anesthesia evaluation occurred after the LP and recommended immediate lumbar MRI, which revealed subarachnoid blood filling much of the lumbar cistern (up to L2). Neurosurgery and anesthesia agreed that her back pain and other symptoms were due to intrathecal hematoma and PDPH. Given that her symptoms were slowly improving, conservative management was recommended. She continued to slowly improve symptomatically and was discharged after 5 days (PPD 11). At her 1 month follow-up with neurosurgery she was noted to be asymptomatic. Repeat MRI done 11 months postpartum showed resolution of the hematoma.
Discussion: Intrathecal hematoma after neuraxial anesthesia is a very rare complication that may have an acute onset,(1) though may have a more gradual onset as it did as in this case.(2,3) Symptoms suggestive of spinal hematoma should prompt immediate lumbar MRI and neurosurgical evaluation, as timely diagnosis and treatment may be crucial in determining outcome.(1-3) Treatment may involve surgical decompression,(1,2) though conservative management may be recommended if symptoms are not severe or are improving.(3) The presence of fever and neck stiffness likely led to the initial focus on possible meningitis and performing an LP procedure prior to lumbar MRI. Fortunately, the delay in diagnosis did not lead to permanent neurologic injury.
1. Int J Obstet Anesth. 2012 Apr;21(2):181-5.
2. Anesthesiology. 2007 Nov;107(5):846-8.
3. Anaesthesia. 2008 Apr;63(4):423-7.