A 29-year-old woman who had delivered a healthy infant at a different hospital 7 days earlier was admitted for suspicion of delayed postpartum preeclampsia with severe features, based on symptoms of severe headache and elevated blood pressure (150/90 mm Hg).
Magnesium sulfate infusion was started. During labor, she had a labor epidural placed with some difficulty, and she complained of residual localized back pain. Her headache was positional, consistent with a postdural puncture headache (PDPH). An epidural blood patch (EBP) was performed, resulting in immediate headache relief. However, after the procedure, the patient complained of increased back pain. Hours later, the patient’s headache returned, the back pain persisted, and she complained of new-onset leg weakness. An MRI scan of the lumbar spine was normal, and an MRI scan of the brain showed features consistent with posterior reversible encephalopathy syndrome (PRES). The patient’s leg weakness resolved when the magnesium infusion was discontinued, and she was discharged home with valproic acid to treat the PRES-induced headache, after failed treatment with butalbital/acetaminophen/caffeine (Fioricet, Par Pharmaceutical).
Our patient had a normal pregnancy and delivered her infant without complications (except for a difficult epidural placement, according to the patient). By the time she returned to the hospital with the complaint of a headache, she had become a complex postpartum patient. A headache in a peripartum woman has a broad differential diagnosis, including tension headache, migraine, subarachnoid hemorrhage, postdural puncture headache, meningitis, preeclampsia/eclampsia, cerebral infarct, brain tumor, and sinusitis, and should always be evaluated.1
Preeclampsia with severe features affects 25% of patients having preeclampsia, and is defined by the existence of one or more of the following conditions: marked increase in blood pressure (>160/110 mm Hg), cerebral or visual disturbances, impaired liver function, progressive renal insufficiency, pulmonary edema, and thrombocytopenia (<100,000/mcL).4 Our patient presented delayed postpartum preeclampsia. According to Al-Safi et al, approximately 70% of patients with delayed postpartum preeclampsia present with headache.5
Magnesium sulfate is the drug of choice to prevent seizures in severely preeclamptic patients and prevent recurrent seizures in eclampsia.4 It is thought to raise the seizure threshold by centrally antagonizing the N-methyl-d-aspartate receptor. Patients treated with magnesium sulfate should be monitored carefully to detect clinical signs of toxicity, which are sedation, absent deep tendon reflexes, respiratory distress, hypotension, and arrhythmias.
A Multifactorial Case
Because of the patient’s postural headache, we suspected a PDPH. In a meta-analysis, Choi et al showed an inadvertent puncture rate of 1.5% for epidural placements. Of patients with a dural puncture, 52% will develop PDPH.6 Although PDPHs often are multisymptomatic, some patients complain only of headache. The headache is defined as postural with relief in the supine position and pain while sitting or standing. PDPHs often are accompanied by neck stiffness, tinnitus, hypoacusia, photophobia, and nausea. Differential diagnosis also includes rare, severe complications such as cerebral venous thrombosis, subdural hematoma, and reversible encephalopathy.7 No other type of headache has a postural component, so this component of PDPH has great significance.
Expectant management with bed rest and hydration is largely ineffective in cases of moderate or severe PDPH.8 Caffeine temporarily ameliorates symptoms of PDPH. Another option for treating PDPH is IV administration of cosyntropin. According to Katz et al, cosyntropin can manage headache pain effectively, but the onset of headache relief is slow.8
An EBP is known to provide significant pain relief in PDPH. An early EBP, performed 24 to 48 hours after the dural puncture, has a lower success rate, so conservative measures are recommended during this period. When performed after the first 24 hours, an EBP has a success rate of about 70% in significantly decreasing or eliminating the PDPH. A second EBP can be performed if the first one is not effective, which has a higher rate of success of up to 95%.9
There are alternative treatments to the invasive EBP, but none is considered as effective. If a dural puncture is known to have occurred, an attempt to prevent PDPH can be made by leaving an intrathecal catheter in place for 24 hours.
After an EBP, our patient had persistent low back pain and tenderness—the most common complication after an EBP (80%-85% of patients)—but this is also a possible symptom of a lumbar epidural abscess.10
Lumbar epidural abscess is a rare complication of epidural placement, and is a purulent accumulation in the epidural space that mechanically compresses the spinal cord and/or the cauda equina. Symptoms are generally nonspecific, making diagnosis difficult. Fever, headache, lethargy, nausea, tenderness at the epidural needle insertion site, radiating spinal pain, loss of bowel or bladder control, and limb weakness are a few symptoms.11 Some of these symptoms overlap with those of PDPH, so epidural abscess should be considered in the care for an obstetric patient with a headache.12 Spinal epidural abscesses are more likely to occur after blunt trauma to the spine, bone/blood/spinal infections, or spinal surgery. Even though the incidence of lumbar epidural abscess is very low, at 2 in 10,000 hospital admissions, early diagnosis and treatment are of critical importance, because delayed treatment may result in irreversible neurologic damage, paralysis, or death. To successfully confirm this diagnosis and rule out others, neurologic consultation and immediate blood cultures should be ordered. MRI with gadolinium or CT with myelography are needed for diagnosis.13
With the ongoing nature of our patient’s headache, imaging of the head was needed to rule out subdural hematoma and PRES. Posterior reversible encephalopathy syndrome is a complex syndrome characterized by symptoms including headache, confusion, seizures, altered mental status, visual loss, and pain.14 PRES headaches may be indistinguishable from PDPH (except for the postural component), and should always be considered in the differential diagnosis in a patient with a possible PDPH.
The etiology of PRES remains controversial, with hypertension being the most frequent factor despite the 20% of PRES cases that occur without hypertension. PRES is associated with a variety of conditions: malignant hypertension, eclampsia, septic shock, autoimmune disorders, renal disease, and transplants (bone and stem cells).14 An MRI scan will show edema in areas of the parietal and occipital lobes in the initial stages. Swelling then spreads to other lobes and brain structures.15 Delayed diagnosis and treatment of PRES may result in irreversible severe neurologic impairment and even death. Once again, early diagnosis is important. The most effective treatment for PRES is withdrawal of the trigger.16
Our patient’s headache was likely multifactorial, caused by preeclampsia with severe features, PRES, and a dural puncture. Full workup took nearly two days due to the array of evolving symptoms. Headache in a peripartum woman can result from multiple etiologies, ranging from a “simple” migraine to life-threatening causes, such as an epidural abscess or preeclampsia and PRES. A correct diagnosis is imperative.
Dr Feinstein is an assistant professor and section chief for obstetric anesthesia, Department of Anesthesiology; and Dr Hauck is an associate professor and associate vice chair for research, Department of Anesthesiology, Lewis Katz School of Medicine at Temple University, in Philadelphia, Pennsylvania.
Dr Vaida is a professor of anesthesiology, obstetrics, and gynecology; the vice chair for research; and the director of obstetric anesthesia at Penn State Health Milton S. Hershey Medical Center, in Hershey, Pennsylvania.
The authors and reviewer reported no relevant financial disclosures.
- Sabharwal A, Stocks GM. Postpartum headache: diagnosis and management. Continuing Education in Anaesthesia Critical Care & Pain. 2011;11(5):181-185.
- Duckitt K, Harrington D. Risk factors for pre-eclampsia at antenatal booking: systematic review of controlled studies. BMJ. 2005;330(7491):565.
- Rebelo I, Bernardes J. Can we predict preeclampsia? In: Yogev Y, Sheiner E, eds. Controversies in Preeclampsia. Hauppauge, NY: Nova Science Publishers; 2014: 194-195.
- Lambert G, Brichant JF, Hartstein G, et al. Preeclampsia: an update. Acta Anaesthesiol Belg. 2014;65(4):137-149.
- Al-Safi Z, Imudia AN, Filetti LC, et al. Delayed postpartum preeclampsia and eclampsia: demographics, clinical course, and complications. Obstet Gynecol. 2011;118(5): 1102-1107.
- Choi PT, Galinski SE, Takeuchi L, et al. PDPH is a common complication of neuraxial blockade in parturients: a meta-analysis of obstetrical studies. Can J Anaesth. 2003;50(5):460-469.
- Kwak KH. Postdural puncture headache. Korean J Anesthesiol. 2017;70(2):136-143.
- Katz D, Beilin Y. Review of the alternatives to epidural blood patch for treatment of postdural puncture headache in the parturient. Anesth Analg. 2017;124(4):1219-1228.
- Davies J. Neurologic complications of neuraxial analgesia/anesthesia: postdural puncture headache. www.clinicalpainadvisor.com/ home/ decision-support-in-medicine/ anesthesiology/ neurologic-complications-of-neuraxial-analgesia-anesthesia-postdural-puncture-headache/ . Accessed March 28, 2019.
- Gaiser RR. Postdural puncture headache: a headache for the patient and a headache for the anesthesiologist. Curr Opin Anaesthesiol. 2013;26(3):296-303.
- Rosc-Bereza K, Arkuszewski M, Ciach-Wysocka E, et al. Spinal epidural abscess: common symptoms of an emergency condition. A case report. Neuroradiol J. 2013;26(4):464-468.
- Doherty H, Hameed S, Ahmed I, et al. Post-dural puncture headache and posterior reversible encephalopathy syndrome: a misdiagnosis or co-presentation? Int J Obstet Anesth. 2014;23(3):279-282.
- Mackenzie AR, Laing RB, Smith CC, et al. Spinal epidural abscess: the importance of early diagnosis and treatment. J Neurol Neurosurg Psychiatry. 1998;65(2):209-212.
- Hobson EV, Craven I, Blank SC. Posterior reversible encephalopathy syndrome: a truly treatable neurologic illness. Perit Dial Int. 2012;32(6):590-594.
- Brady E, Parikh NS, Navi BB, et al. The imaging spectrum of posterior reversible encephalopathy syndrome: A pictorial review. Clin Imaging. 2018;47:80-89.
- Sudulagunta SR, Sodalagunta MB, Kumbhat M, et al. Posterior reversible encephalopathy syndrome (PRES). Oxf Med Case Reports. 2017;2017(4):omx011.