Post-partum+complications

toc Post operative follow up is perhaps nowhere more important than in the practice of obstetric anesthesiology, the unique physiology of the pregnant patient and the routine use of neuraxial anesthesia makes for a unique profile of complications following delivery.

=**Post Dural Puncture Headache**=

Epidemiology:
PDPH is actually quite rare, as dural puncture is a complication affecting between 0.19 and 3.6 percent of epidurals. Of those patients in whom the dura was punctured, however, the rate of PDPH is as high as 50%. Though rare, the number of epidurals placed in a busy obstetric unit make PDPH part of our clinical reality.

Diagnosis:
The hallmark of PDPH is postural headache in the setting of recent dural puncture. However, the differential is long and notably includes migraine, pregnancy induced hypertension (including pre-eclampsia), and pneumocephalus. The following is a complete differential.

(David Bezov, MD; Richard B. Lipton, MD; Sait Ashina, "Post-Dural Puncture Headache: Part I Diagnosis, Epidemiology, Etiology, and Pathophysiology"head_1699 1144..1152" MDHeadache 2010;50:1144-1152)

Unless there is suspicion of a more insidious process, imaging is rarely pursued in PDPH, however, it is possible to see changes in MRI in the presence of low pressure of the CSF, the brain parenchyma enhances diffusely with gadolineum dye. If severe, the presence of tonsillar herniation may be appreciated.

(David Bezov, MD; Richard B. Lipton, MD; Sait Ashina, "Post-Dural Puncture Headache: Part I Diagnosis, Epidemiology, Etiology, and Pathophysiology"head_1699 1144..1152" MDHeadache 2010;50:1144-1152)

= Treatment: = Typically treated first line with NSAIDS, Fiorocet, hydration, caffeine. If these measures do not work and the patient is still in pain 24-48 hours after the dural puncture, an epidural blood patch may be considered. A recent review and meta-analysis was published in the British Journal of Anesthesiology, on the various treatment and prophylaxis modalities for PDPH. Of note, early blood patch, saline injection, and the practice of keeping a spinal catheter in place once the dura is punctured, all turned out to be statistically insignificant. Intrathecal morphine, however may be a promising modality, worthy of more research. They conclude however that there is still sparse evidence due to a lack of large RCT's in this field of study.

=**Back Pain**= =**CNS Infections**= =**Spinal / Epidural Hematoma**=

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