Diagnosis and Treatment of Intrapartum Postdural Puncture Headache using a Normal Saline Bolus
Adam Wendling, MD, Michael Froelich, MD, DEAA,
Department of Anesthesiology, University of Florida, Gainesville, Florida
ABSTRACT
The incidence of postdural puncture headache (PDPH) in the obstetric
population after dural puncture with an epidural needle ranges between
76-85%.1 Onset of symptoms may take up to 72 hours after dural puncture.
Several measures to treat or prevent postpartum PDPH, including the
prophylactic administration of saline have been described. This report
describes a case in which injection of normal saline via a large bore (20
gauge) intrathecal catheter intrapartum served as a diagnostic maneuver and
theraputic measure for PDPH.
Case report: A 28 year old parturient requested epidural analgesia during
labor. An inadvertent dural puncture was made with an 18-gauge Touhy needle
on the third pass. A 20-gauge catheter was threaded into the intrathecal
space and she was started on an intrathecal infusion of 0.2% ropivicaine
with 2 mcg/mL of fentanyl at a basal rate of 3 mL per hour. The patient
noted an mild headache within one hour of the her dural puncture. Nine hours
later, her headache increased in severity to a visual analog scale score of
8 out of 10. At that time she was given a bolus with 10 mL of preservative
free normal saline via the intrathecal catheter. The patient’s headache
improved immediately. She continued to labor with continuous intrathecal
analgesia. She went on to have a spontaneous vaginal delivery.
Unfortunately, her headache recurred and on postpartum day one and she
required an epidural blood patch, that was successful.
Discussion: PDPH seems to be related to the loss of CSF. Several methods of
reducing the loss of CSF have shown a reduction in the incidence of PDPH.1,2
However, there are no reports in the literature of an intrathecal saline
bolus both to diagnose and treat intrapartum PDPH. In our patient, her
headache started immediately after the inadvertent dural puncture with an
18-gauge Touhy needle. Early, intrapartum headache may also be due to a
pneumoencephalus, which mandates a therapeutic approach different from that
for PDPH. Therefore, injection of normal saline served to both elucidate the
etiology of our patient’s peripartum headache as well as provide significant
immediate albeit temporary relief. This case suggests that the injection of
10 mL of normal saline into the intrathecal space may provide both
diagnostic information and at least temporary relief of early onset PDPH.
References:
1. Charsley MD, Abram SE. Reg Anesth Pain Med 2001; 26(4):301-5
2. Lybecker H, Djernes M, Schmidt JF. Acta Anaesthesiol Scand 1995;
39:605-12
