AUTHORS: Delgado, Carlos MD; Bollag, Laurent MD; Van Cleve, Wil MD, MPH
Anesthesia & Analgesia: November 21, 2019
Labor and delivery insurance claims from the Truven MarketScan Commercial Claims and Encounters database were analyzed. Mode of delivery, analgesic and/or operative anesthesia information, and EBP placement were identified using Current Procedural Terminology (CPT) codes. PDPH was identified using International Classification of Diseases, Ninth Revision (ICD-9) codes.
The analytic dataset consisted of 1,752,243 deliveries. Vaginal deliveries (VD) comprised 64.6% of the sample. Of these, 72.9% received NLA, with a PDPH incidence of 0.58% (95% confidence interval [CI], 0.57–0.60). Using VD with NLA as a referent, the risk ratio for PDPH following cesarean delivery (CD) without a prior NLA was 1.1 (95 CI, 1.05–1.15; P = .0001), while the risk ratio for PDPH following CD with a prior NLA was 0.81 (95% CI, 0.76–0.87; P < .0001). EBP placement was documented in 68.4% PDPH cases following VD with NLA, 67.2% of PDPH cases following CD with prior NLA, and 59.7% of PDPH cases following CD without prior NLA. The median number of days between delivery and first and EBP was 3. A second EBP was performed in 8.3% of initially patched patients, and a third in 0.1%. In patients who went on to receive a repeat EBP, the median interval between delivery and the first EBP was 1 day.
This analysis confirms findings of prior studies regarding the present utilization of neuraxial analgesia and the incidence of PDPH. When compared to patients undergoing VD with NLA, patients having CD without NLA had a higher incidence of PDPH, presumably due to intentional dural puncture. Women having CD with a prior NLA had a lower incidence of PDPH, possibly due to avoidance of pushing during the second stage of labor. EBP was a commonly pursued strategy for the treatment of PDPH and was more commonly pursued in patients with a history of NLA. Repeat EBP was rare.