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A Multidisciplinary Care Pathway for the Evaluation of Postpartum Headache
Abstract Number: T-71
Abstract Type: Case Report/Case Series
Anesthesiologists play an important role in the diagnosis and management of postpartum headaches. While the cause of headache may seem obvious in the setting of a dural puncture, there are other serious etiologies of postpartum headache. We present two cases of cerebral venous sinus thrombosis that have initiated the development of a multidisciplinary care pathway in the evaluation of postpartum headache at our institution.
A 29 year-old G1 at term received an epidural for labor analgesia complicated by a dural puncture. The epidural was successfully placed on the second attempt and provided analgesia for an uncomplicated spontaneous vaginal delivery.
The patient developed a postural frontal headache, and an epidural blood patch (EBP) was performed on postpartum day (PPD) 1. She had complete resolution of her symptoms and was discharged home. She returned on PPD 4 with the same PDPH symptoms and was offered a repeat EBP, but the patient elected for conservative management.
She returned on PPD 8 with a 10/10 frontal headache and neck pain not relieved by laying supine. This prompted a CT scan of the head which showed an area of SAH. A MRI/MRV was then obtained, revealing a thrombus in the superior sagittal sinus.
The following week, a 24 year old G1 at term also received a labor epidural complicated by a dural puncture. She received an epidural blood patch on PPD 1 and immediate relief was noted. Her headache returned, and on PPD 3 neurology was consulted. An MRI/MRV was obtained based on their recommendation which showed a thrombus in the posterior sagittal sinus and parasagittal cortical veins. Both patients made a full recovery after starting anticoagulation.
Postpartum headache has an incidence of almost 40% among all parturients. While typically benign, these two cases illustrate that there are serious etiologies of postpartum headache that must be evaluated fully. These two patients eventually received imaging and further neurology consultation, but the events leading to these decisions were different in each case. We realized our peripartum caregivers had no formal guidelines to evaluate postpartum headache, which led to the development of a care pathway for the evaluation of postpartum headache. The care pathway modifies an existing pathway available in the literature, and continues to be modified with input from all of our peripartum caregivers.