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National Trends In Post-Dural Puncture Headache (PDPH) And Epidural Blood Patch (EBP) Placement Following Neuraxial Labor Analgesia/Anesthesia
Abstract Number: S1A-2
Abstract Type: Original Research
Approximately 71% of pregnant women in the US receive labor epidural analgesia or neuraxial anesthesia for delivery(1). The incidence of PDPH is approximately 50% in patients with an inadvertent dural puncture after epidural placement(2). PDPH may increase the length of stay, hospital visits related to headache; and can interfere with activities of daily living and newborn care(3). An EBP is the most beneficial intervention to treat PDPH, but up to 17% of women require a second EBP(5). Data about incidence of PDPH and use of EBP is based on studies from single institutions(5) and academic centers, which may not describe national practices. This study uses 7 years of data from a national claims dataset to estimate the incidence of EBP/PDPH and to determine trends over time.
The Truven MarketScan® database contains de-identified inpatient and outpatient insurance claims. We undertook a retrospective analysis from Jan 1, 2008 to Sept 30, 2015. Vaginal and surgical deliveries, and EBP procedures were identified using CPT codes. PDPH was identified using ICD-9 codes. Outcomes included use of neuraxial labor analgesia, incidence of PDPH after neuraxial procedures, rate of EBP placement (single and multiple) following PDPH, time between neuraxial procedure and EBP; and 90-day incidence of follow up care (inpatient, outpatient and emergency room visits) related to PDPH.
A dataset of 1,753,439 deliveries was retrieved with 64.6% vaginal deliveries. Overall, 71.4% of these women received neuraxial analgesia, with an increase observed between 2008 (67.6%) and 2015 (73.7%) (p<0.001). The incidence of PDPH after neuraxial labor analgesia (vaginal births and cesarean deliveries with a prior labor analgesic) was 0.59%, decreasing from 0.64% in 2008 to 0.55% in 2015 (p < 0.001). Patients that delivered via cesarean section without a prior neuraxial had a 0.65% incidence of PDPH, decreasing from 0.73% in 2008 to 0.55% in 2015 (p<0.001). Among patients with PDPH, 56% were diagnosed prior to discharge after delivery. Of all patients with PDPH, 62.2% received an EBP with no change over time. The median number of days between neuraxial analgesic/anesthetic and EBP was 3. Repeat EBP was performed in 6.6% of patients receiving an initial patch and follow-up care for PDPH was documented in 10.6% of patients after their initial EBP.
To our knowledge, this dataset represents the largest series of obstetrical PDPH/EBP cases published to date. Our results support the previously estimated incidences of PDPH. We documented an increase in the use of neuraxial labor analgesia with a decrease in the incidence of PDPH, the reasons for which remain to be studied. Lower rates of repeat EBP and follow-up care for PDPH than previously described were observed, suggesting a potential bias from the academic settings in prior studies.
1.A&A 2016; 122: 1939-46
2.CJA 2003; 50: 460-9
3.CJA 2005; 52: 397-402
4.IJOA 2017; 29: 10-17