Subdural Hematoma Associated with Labor Epidural Analgesia and Post-Dural Puncture Headache: A Case Series
Abstract Number: F-18
Abstract Type: Original Research
Background: Subdural hematoma (SDH) after labor epidural analgesia is rare with a quoted incidence of 1:250,000 to 1:500,000.1 The proposed mechanism of SDH following labor epidural is low cerebrospinal pressure following unintentional dural puncture that leads to traction and tear of thin-walled meningeal blood vessels.2,3 We report a series of 11 obstetrical patients with subdural hematomas (SDH) that were associated with the use of labor epidural analgesia at a single, high-volume tertiary teaching hospital.
Description: All patients developed headaches consistent with post dural puncture headache (PDPH) prior to the diagnosis of SDH. 5 patients (50%) had a recognized unintentional dural puncture, 1 patient (10%) had a combined spinal and epidural with a 24 gauge pencil-point needle, and 5 patients (40%) had no recognized dural puncture. The SDH was diagnosed in 10 patients (91%) with radiologic studies an average 5.4 days (range 1-8 days) after performance of labor epidural analgesia. 3 patients were found to have small amount of intraventricular air at time of diagnosis. All patients without severe symptoms had a second hospital stay ranging from 2 to 4 days (average 2.8 days) for observation of the SDH. One patient experienced loss of consciousness and required neurosurgical intervention. Over the time period, 42,969 labor epidurals were placed and 437 inadvertent dural punctures were observed. Thus the observed institutional rate of labor neuraxial anesthesia-associated SDH was 0.026% (approximately 1:5000). The observed rate of SDH was 1.3% (approximately 1:100) if a recognized dural puncture occurred during labor epidural catheter placement.
Conclusions: We conclude that SDH as a result of dural puncture during placement of labor epidural is rare, but potentially more common than historically thought. SDH after unintentional dural puncture is likely underdiagnosed, and may be appropriately managed expectantly without surgical intervention if no other serious associated neurological signs are present. In fact, SDH associated with PDPH appears to be a frequently clinically incidental finding, the detection of which has the potential to increase healthcare utilization and cost.
1. Palot M. Cah Anesthesiol. 1994;42:229-233.
2. Loo CC. Int J Obstet Anesth. 2000;9:99-124.
3. Vaughan DJA. Br J Anaesth. 2000;84:518-20.