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Postpartum Headache: When An Epidural Blood Patch Is Not Enough
Abstract Number: SUN-35
Abstract Type: Case Report/Case Series
Headache is a common occurrence in the postpartum period. While the etiology of postpartum headache may be benign, a full differential diagnosis must be elicited to rule-out life-threatening processes. The incidence of cerebral venous sinus thrombosis (CVST) is 8.9 per 100,000 deliveries and can carry a 7% mortality. The pathophysiology is thought to occur from a two-hit phenomenon. First, damage to venous sinuses due to intracranial hypotension. Second, increased thrombotic tendency such as the hypercoagulable state of pregnancy as well as hereditary disorders of coagulation are thought to contribute to this process.
25-year-old G3P2002 parturient received an epidural for labor analgesia. The placement required two attempts, but was successfully placed at the L3-L4 level. There were no complications noted during the placement and good analgesia was achieved. The remainder of the patient’s labor was uneventful and vaginal delivery ensued.
On postpartum day 1, the patient complained of a positional headache. An anesthesiology consultation was obtained and post-dural puncture headache was diagnosed. Management included caffeine pills and cosyntropin. Additionally, an epidural blood patch (EPB) was offered, but was declined and she was subsequently discharged home.
The patient returned to the emergency department on postpartum day 3 with complaints of positional headache. An EBP was performed with resolution of headache and the patient was discharged home. During the follow-up phone call the next day, the patient endorsed return of the positional headache. She returned to the hospital where a second EBP was performed, but with unsuccessful relief of headache. Additionally, during this second admission, the patient’s blood pressure was noted to be elevated. Magnesium was administered to address possible pre-eclampsia.
An MRI was obtained, the preliminary results of which were interpreted as normal; however, the final result of the MRI was subsequently significant for CVST. The patient’s neurological status had worsened as a syncopal vs seizure event occurred. The patient was transferred to ICU and was started on a heparin infusion. Over next two days, the patient improved and she was discharged home on warfarin.
Although rare, CVST should be considered in any postpartum patient presenting with headache due to the high morbidity and mortality if left untreated. A thorough clinical evaluation coupled with a high degree of suspicion should arise for patients presenting with refractory postpartum headache following epidural blood patch.
1. Lanska DJ, Kryscio RJ. Peripartum stroke and intracranial venous thrombosis in the National Hospital Discharge Survery. Obstet Gynecol 1997; 89: 418-18
2. Kate M, Thomas B, Sylaja P. Central venous thrombosis is post-lumbar puncture intracranial hypotension: case report and review of literature. F1000 Research. 2014. 3:41.