Clinical Assistant Professor, Anesthesiology, Perioperative and Pain Medicine
Chronic disabling postpartum headache after unintentional dural puncture during epidural anaesthesia: a prospective cohort study.
British journal of anaesthesia
2021; 127 (4): 600-607
BACKGROUND: Unintentional dural puncture with an epidural needle complicates approximately 1% of epidural anaesthetics and causes an acute headache in 60-80% of these patients. Several retrospective studies suggest an increased risk of chronic headache. We assessed the relationship between unintentional dural puncture and chronic disabling headache, defined as one or more functionally limiting headaches within a 2-week interval ending 2, 6, and 12 months postpartum.METHODS: In this prospective observational study, parturients who experienced unintentional dural puncture were matched 1:4 with control patients. Patients completed questionnaires regarding characteristics of headache and back pain pre-pregnancy, during pregnancy, immediately postpartum, and at 2, 6, and 12 months postpartum. The primary outcome was prevalence of disabling headache in the past 2 weeks, assessed at 2 months postpartum. Secondary outcomes included prevalence and characteristics of headache and back pain at these time points.RESULTS: We enrolled 99 patients. At 2 and 6 months postpartum, the prevalence of disabling headache was greater among patients with unintentional dural puncture than matched controls (2 months, 74% vs 38%, relative risk 1.9, 95% confidence interval 1.2-2.9, P=0.009; 6 months, 56% vs 25%, relative risk 2.1, 95% confidence interval 1.1-4.0, P=0.033). There was no difference in the prevalence of back pain at any time point.CONCLUSIONS: Our prospective trial confirms retrospective studies that chronic headache is more prevalent among women who experienced unintentional dural puncture compared with controls who received uncomplicated neuraxial anaesthesia. This finding has implications for the. patient consent process and recommendations for long-term follow-up of patients who experience unintentional dural puncture.
View details for DOI 10.1016/j.bja.2021.05.020
View details for PubMedID 34548152
Postpartum headaches after epidural or spinal anesthesia.
Current opinion in obstetrics & gynecology
2021; 33 (2): 94–99
PURPOSE OF REVIEW: Postpartum headache is a common occurrence with various obstetric, neurologic, and anesthetic etiologies. Post dural puncture headache (PDPH) after neuraxial anesthesia is a culprit that may be less familiar to obstetricians. In this review, authors will discuss the differential diagnosis and management of postpartum headache, review PDPH, and explore evidence suggesting that PDPH may have greater implications than previously considered.RECENT FINDINGS: Emerging evidence suggests that PDPH, previously believed to be benign and self-limited, is associated with significant acute and chronic sequelae. A recent large database study links PDPH to subdural hematoma and cerebral venous sinus thrombosis. The authors also identified associations between PDPH and bacterial meningitis, depression, and back pain. A growing body of literature also links PDPH or unintentional dural puncture with an epidural needle (UDP) with development of chronic headaches.SUMMARY: Patients who experience UDP or PDPH should be counseled to return for evaluation for new or worsening headache. In the immediate postpartum setting, clinicians assessing these patients should have a low threshold to obtain brain imaging. In addition, obstetricians should be alerted that patients who suffer UDP may be prone to develop chronic headache disorders and consider referral to pain specialists.
View details for DOI 10.1097/GCO.0000000000000685
View details for PubMedID 33620887
Superficial Cervical Plexus Block for Awake Large-Bore Central Line Placement in Parturients: A Case Series.
2021; 15 (3): e01429
Pregnant patients with high-risk conditions including abnormal placentation or severe cardiovascular disease may require large-bore central venous access at the time of delivery. Central lines are generally inserted while obstetric patients are awake, either because neuraxial anesthesia is planned or to minimize fetal exposure to anesthetic medications. Despite local infiltration, the procedure can cause significant patient discomfort. This case series describes use of a superficial cervical plexus block (SCPB) to facilitate line placement in 4 pregnant women with high-risk conditions. SCPB is technically straightforward with low reported complication rates and should be considered for pregnant patients requiring large-bore central lines.
View details for DOI 10.1213/XAA.0000000000001429
View details for PubMedID 33740791
Management of brain tumors presenting in pregnancy: a case series and systematic review
Management of brain tumors presenting in pregnancy: a case series and systematic review
2021; 3 (1)
View details for DOI 10.1016/j.ajogmf.2020.100256
Did she have an epidural? The long-term consequences of postdural puncture headache and the role of unintended dural puncture.
This narrative literature review examines the long-term impact of postdural puncture headache (PDPH) in postpartum women following an unintended dural puncture (UDP) with a large bore needle commonly used for epidural catheter placement. It seeks to bridge the knowledge gap for the neurologist as to the mounting body of obstetric anesthesia literature on the development of chronic headache after PDPH with this unique needle.Headache is the most common complication of dural puncture, and the risk is greatest in the parturient population. Preexisting risk factors for this population include youth and sex, and after UDP with a large bore needle, almost 70%-80% report a headache. Additionally, there appears to be a significant cohort who experience long-term, persistent headache after UDP.We performed a narrative review of literature using PubMed, searching terms that included long-term follow-up after UDP with a large bore needle in the postpartum population.In women who had UDP with a large bore needle used for epidural catheter placement at delivery, the rate of chronic debilitating headache is around 30% in the months following delivery and may persist for up to a year or longer.Based on the existing literature, we have mounting evidence that UDP with the large bore needle used to place an epidural catheter should be understood as a high-risk inciting event for the development of long-term headaches not simply a high risk of acute PDPH. Additionally, consideration should be given to stratifying the etiology of PDPH, based on needle type, and recognizing the entity of chronic PDPH, thus allowing for improvements in research and diagnosis.
View details for DOI 10.1111/head.14221
View details for PubMedID 34570902
- Confounders Not General Anesthesia Likely Explain Greater Postpartum Depression. Anesthesia and analgesia 2020; 131 (6): e248–e250
Bicuspid Aortic Valve and Ascending Aortic Aneurysm in a Twin Pregnancy.
JACC. Case reports
2020; 2 (1): 96-100
Bicuspid aortic valve with ascending aortic aneurysm is a common condition encountered in pregnancy. There are limited data on how to manage these patients. To our knowledge, we report the only case of a bicuspid aortic valve and aortic aneurysm with twin gestations. (Level of Difficulty: Intermediate.).
View details for DOI 10.1016/j.jaccas.2019.12.012
View details for PubMedID 34316973
A Bun in the Oven How to Use TIVA in Obstetrics
TAKING ON TIVA: DEBUNKING MYTHS AND DISPELLING MISUNDERSTANDINGS
View details for Web of Science ID 000648922100019
- Transesophageal Echocardiographic Observation of Caval Thrombus Followed by Intraoperative Placement of Inferior Vena Cava Filter for Presumed Pulmonary Embolism During Cesarean Hysterectomy for Placenta Percreta: A Case Report A & A PRACTICE 2019; 12 (2): 37–40
Transesophageal Echocardiographic Observation of Caval Thrombus Followed by Intraoperative Placement of Inferior Vena Cava Filter for Presumed Pulmonary Embolism During Cesarean Hysterectomy for Placenta Percreta: A Case Report.
During a cesarean hysterectomy for placenta percreta, transesophageal echocardiography was used to monitor volume status and guide resuscitation. After delivery of the neonate but before massive surgical hemorrhage, a thrombus appeared in the inferior vena cava. Roughly 3 hours later, the patient had hemodynamic changes consistent with an intraoperative pulmonary embolism. Boluses of epinephrine stabilized the patient. An inferior vena cava filter was placed via an in situ internal jugular central venous cannula to prevent further embolic events. We believe transesophageal echocardiography is a useful monitor during surgery for placenta percreta.
View details for PubMedID 30020106
Pharmacokinetics and Pharmacodynamics of Drugs Commonly Used in Pregnancy and Parturition.
Anesthesia and analgesia
2016; 122 (3): 786-804
The majority of pregnant women will be treated with a medication other than a vitamin supplement during their pregnancy. Almost half of these medications will be category C or D according to the former US Food and Drug Administration classification system, indicating a lack of human studies with animal studies suggesting adverse fetal effects (category C) or evidence of risk in humans (category D). Changes in maternal physiology alter drug bioavailability, distribution, clearance, and thus the drug half-life in often unpredictable ways. For many drugs, good pharmacokinetic and pharmacodynamic data in pregnancy and parturition are lacking. For other drugs, recent studies demonstrate major pharmacokinetic or pharmacodynamic changes that require dose adjustment in pregnancy, but current dosing guidelines do not reflect these data. In this review, we address the principles that underlie changes in pharmacology and physiology in pregnancy and provide information on drugs that anesthesiologists commonly encounter in treating pregnant patients.
View details for DOI 10.1213/ANE.0000000000001143
View details for PubMedID 26891392