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Parturient with meningeal signs—Not your average post-partum headache
Abstract Number: S5D-6
Abstract Type: Case Report/Case Series
22 year old at 34w6d with cerclage presented with preterm contractions and vaginal bleeding. Plan was for cerclage removal with CSE. Attempted CSE resulted in inadvertent dural puncture with 17g Tuohy. Epidural was placed successfully at different level. She remained for monitoring and steroid administration, but was discharged in morning when PTL stalled. She presented later in day with non-positional severe headache, mild leukocytosis, subjective fever at home (afebrile at time), altered sensorium, pain and weakness of buttocks and legs, and neck stiffness. Neurology was consulted and STAT brain and spine MRI ordered with concern for meningitis or epidural abscess. MRI showed extensive extra arachnoid fluid collection throughout the spine, trace blood at presumed site of dural puncture and clumping of the cauda equina nerve roots. In the setting of recent steroids, stable vitals and no fever, decision was made by neurology and anesthesia to forgo spinal tap for CSF examination. Infection was lower on the differential, which also included arachnoiditis, transient neurologic symptoms and atypical PDPH and she was admitted for monitoring and pain management. Given concern for inflammation and TNS, there was concern epidural blood patch would exacerbate symptoms. To treat a potential atypical PDPH, she received cosyntropin, caffeine and sphenopalantine ganglion block. She improved gradually and was discharged 2 days later on a Medrol dose pack, gabapentin and NSAIADs.
Although uncommon (2.6:100K), meningitis or abscess is possible1. Aseptic meningitis is characterized by apyrexia, headache, neck stiffness and photophobia typically within 1 day of dural puncture with recovery within 48 hours2. Bacterial meningitis typically presents between 24-96 hours after neuraxial. If concern for bacterial meningitis, prompt CSF examination is necessary1. Patient had mild leukocytosis and was afebrile, so this was lower on differential. Abscess can also be ruled out with MRI. Spinal arachnoiditis is an inflammatory process of the arachnoid membrane and is transient3. She received epidural lidocaine after dural puncture, which likely allowed lidocaine into the IT space4. Patient likely had atypical PDPH with a degree of arachnoiditis and/or TNS from intrusion of spinal lidocaine. Goal was to avoid further inflammation, which EBP may worsen. There is little data on EBP followed by neuraxial. In a case report, labor analgesia was achieved in a patient 3 days after an EBP. Others report higher failure rates due to potential scarring in the epidural space which may impede the spread of local5.
This case illustrates the importance of a thorough history and physical exam and wide differential when called to evaluate for a “post-dural puncture headache.”
1. Clin Micr inf. 2012 Apr; Vol: 18(4): 345-351.
2. Pan Afr Med J. 2017 Jul 13;27:192.
3. Acta Med Port 1998;2013:59–66.
4. Acta Anae Scand. 2003 Jan;47(1):3-12.
5. Anae Crit Pain. 2017; Vol 36 (17): 325-326.