2024 FSA Podium and Poster Abstracts

P033: SUBARACHNOID HEMORRHAGE AFTER INADVERTENT DURAL PUNCTURE IN AN OBSTETRIC PATIENT UNDERGOING CESAREAN DELIVERY
Alexander W Hall, MD; Daria M Moaveni, MD; Selina D Patel, MD; University of Miami

Introduction/Background: Post-dural puncture headaches (PDPH) are a common complication after inadvertent dural puncture with wide-bore epidural needles, occurring in between 76-85% of cases [1]. Typical symptoms include: positional headaches improved with supine positioning, nausea, photophobia, and cranial nerve disturbances. PDPH commonly self-resolves with conservative therapy but may require epidural blood patching which may result in complete symptom resolution. In rare circumstances intracranial bleeding may occur. Here we describe the case of sub-arachnoid hemorrhage immediately following dural puncture and hemodynamic changes.

Case description: 34-year-old gravida 2 para 1, presented to the labor and delivery triage at 39 weeks gestation with painful uterine contractions. Her medical history included obesity (BMI 36 at time of delivery), and hyperlipidemia. She was not taking any anticoagulants at the time of delivery. The patient was brought to the operating room and prepped for combined spinal-epidural (CSE) anesthesia. The CSE was complicated by inadvertent dural puncture with a 17-gauge Tuohy needle. An intrathecal catheter was advanced and spinal medication was delivered. 11.25 milligrams (mg) of 0.75% hyperbaric bupivacaine, 15 micrograms (mcg) of fentanyl, and 100 mcg of preservative free morphine was administered intrathecally. Hemodynamic changes included bradycardia (43 bpm), hypotension (delta MAP of 25 mmHg) initially refractory to ephedrine, glycopyrrolate, and phenylephrine. 400 mcg of atropine was subsequently administered. Resulting blood pressure was MAP of 154 mmHg and heart rate of 143 bpm. She subsequently developed a severe 10/10 severity headache in the supine position. After cord clamping, IV fentanyl was administered with improvement to 4/10 in severity. The remainder of the case was unremarkable. The patient continued to complain of throbbing headache in the supine position. Given the clinical course, a head CT was ordered revealing sub-arachnoid bleeding the right fronto-parietal region. There were no interval changes on repeat imaging and no neurosurgical intervention was required. CT angiography revealed no vascular abnormalities and CT myelogram revealed lumbar CSF leak consistent with dural puncture. The headache was treated conservatively. Treatment of the CSF leak with blood patch was offered but the patient declined. The patient was discharged on post-operative day 9.

Discussion: Inadvertent dural puncture can result in intracranial hypotension often causing a positional severe headache. This complication resolves spontaneously, with conservative management, or with blood patching. Rare complications include subdural bleeding caused by a combination of downward traction of the brain stretching veins potentially leading to bleeding. By the same mechanism sub-arachnoid bleeding can occur. In this case, contributing factors likely include increased blood volume in pregnancy, and sudden hemodynamic fluctuations leading to greater stress on bridging veins. Practitioners should keep in mind these rare complications and inform judicious hemodynamic management. Close follow-up for patients with suspected inadvertent dural puncture and good headache history and physical examination is stressed.