Major Neurologic Complications Associated With Postdural Puncture Headache in Obstetrics: A Retrospective Cohort Study

Abstract

Background: Increased risks of cerebral venous thrombosis or subdural hematoma, bacterial meningitis, persistent headache, and persistent low back pain are suggested in obstetric patients with postdural puncture headache (PDPH). Acute postpartum pain such as PDPH may also lead to postpartum depression. This study tested the hypothesis that PDPH in obstetric patients is associated with significantly increased postpartum risks of major neurologic and other maternal complications.

Methods: This retrospective cohort study consisted of 1,003,803 women who received neuraxial anesthesia for childbirth in New York State hospitals between January 2005 and September 2014. The primary outcome was the composite of cerebral venous thrombosis and subdural hematoma. The 4 secondary outcomes were bacterial meningitis, depression, headache, and low back pain. PDPH and complications were identified during the delivery hospitalization and up to 1 year postdelivery. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were estimated using the inverse probability of treatment weighting approach.

Results: Of the women studied, 4808 (0.48%; 95% CI, 0.47-0.49) developed PDPH, including 264 cases (5.2%) identified during a readmission with a median time to readmission of 4 days. The incidence of cerebral venous thrombosis and subdural hematoma was significantly higher in women with PDPH than in women without PDPH (3.12 per 1000 neuraxial or 1:320 vs 0.16 per 1000 or 1:6250, respectively; P < .001). The incidence of the 4 secondary outcomes was also significantly higher in women with PDPH than in women without PDPH. The aORs associated with PDPH were 19.0 (95% CI, 11.2-32.1) for the composite of cerebral venous thrombosis and subdural hematoma, 39.7 (95% CI, 13.6-115.5) for bacterial meningitis, 1.9 (95% CI, 1.4-2.6) for depression, 7.7 (95% CI, 6.5-9.0) for headache, and 4.6 (95% CI, 3.3-6.3) for low back pain. Seventy percent of cerebral venous thrombosis and subdural hematoma were identified during a readmission with a median time to readmission of 5 days.

Conclusions: PDPH is associated with substantially increased postpartum risks of major neurologic and other maternal complications, underscoring the importance of early recognition and treatment of anesthesia-related complications in obstetrics.

Figure 1:

Definitions of history and of new post-dural puncture headache (PDPH) or complication. History of PDPH or complication refers to a diagnosis of PDPH or complication recorded during the year preceding the delivery hospitalization or present on admission (POA) of the delivery hospitalization. New PDPH or complication during the delivery hospitalization refers to a diagnosis of PDPH or complication recorded during the delivery hospitalization among parturients without history of PDPH or complication. New PDPH or complication during a readmission refers to a diagnosis of PDPH or complication recorded during a readmission, up to 1 year after discharge from the index delivery hospitalization, among parturients without history of PDPH or complication and without a new PDPH or complication during the index delivery hospitalization.

Figure 2:

Flowchart of the study (CI: confidence interval; ZIP: zone improvement plan)