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When Postpartum Headaches are not Benign
Abstract Number: SA-76
Abstract Type: Case Report/Case Series
Introduction: Our parturient developed a headache in the postpartum period following a difficult epidural placement and uneventful spontaneous vaginal delivery. Diagnosed as a postdural puncture headache (PDPH), she received a blood patch with a worsening of symptoms prompting further work-up.
Case Description: MA, a 31 y.o. G4P3A1 Hispanic female at 39 weeks gestation presented in active labor. Upon request for analgesia, a CSE was planned. During the first attempts by the resident, loss of resistance was achieved using air, a 25-g spinal needle was introduced, but we were unable to obtain CSF. The procedure was reattempted by faculty again no return of CSF. An epidural catheter was threaded without resistance, there was negative aspiration and a negative test dose. The patient was comfortable throughout her labor course & had an uneventful delivery. She developed a frontal headache and neck pain on postpartum day 1. She opted for conservative management, but on postpartum day 3, the headache worsened. With the presenting symptoms and the possibility of an undetected dural puncture, a diagnosis of PDPH was made and she requested an epidural blood patch. Immediately following injection of 16 mL of autologous blood, she reported that the headache had increased in intensity and was accompanied by new onset nausea, vomiting, photophobia, and phonophobia. On further work-up, a CT scan of the brain was performed and revealed a pituitary macroadenoma measuring 1 cm anterior-posterior X 1.5 cm transverse x 1.4 cm craniocaudal. Endocrinology was consulted and the patient was discharged on postpartum day 4.
Discussion: This case highlights that not all postpartum headaches are benign and sometimes further work-up is required. While a PDPH was the primary diagnosis, the presence of a pituitary tumor complicated the picture. Etiology distribution of severe postpartum headache is tension (39%), preeclampsia or eclampsia (24%), PDPH (16%), migraines (11%), and hemmorrhage/thrombosis/vasculopathy (10%)1. It is unclear why we were unable to obtain CSF, but repeated dural punctures were the likely reason for the PDPH.
The presence of the pituitary adenoma was likely unmasked by the epidural blood patch, and timing of symptoms in relation to it being performed supports this theory. Injection of blood into the epidural space causes an immediate rise in pressure in the CSF2. We are of the opinion that this transmitted to the brain causing an increase in intracranial pressure producing a “pseudo” mass effect. The parturient exhibited classic symptoms of PDPH, but it is a reminder that we must be diligent of other possible causes of postpartum headache as the aforementioned distribution suggests.
1 Stella CL, Jodicke CD, How HY, Harkness UF, Sibai BM. Postpartum headache: is your work-up complete? Am J Obstet Gynecol. 2007;196(4):318.e1–e7
2 Chestnut, D. H. (2014). Chestnut's obstetric anesthesia: Principles and practice. Philadelphia: Mosby/Elsevier