Subdural hematoma following dural puncture epidural anesthesia for labor analgesia: two case reports

Abstract

BackgroundNeuraxial anesthesia is widely used for labor analgesia in the USA, such as epidural, combined spinal–epidural, and dural puncture epidural (DPE). Post-dural puncture headache (PDPH) is a well-known complication of neuraxial anesthesia. However, a rare yet more serious complication is subdural hematomas. Untreated subdural hematomas can result in permanent disability and death, hence the need to better understand their development in the obstetric population receiving DPE.Case presentationCase one: A 34-year-old G6P3 female at 39-week gestation received a DPE for labor analgesia and underwent a cesarean section for arrest of descent. On postoperative day two, the patient developed a PDPH but opted for conservative treatment. Ten days post-discharge, the patient presented with a large subacute to chronic subdural hematoma with midline shift. The patient underwent a right fronto-temporal craniectomy, evacuation of subdural hematoma, and placement of a subdural drain. Case two: A 31-year-old G1P0 female at 41-week gestation with a past medical history of a chronic right parietal hemangioma and malaria at 29-week gestation received a DPE for induction of labor. She subsequently underwent a primary cesarean section for failure to progress and persistent category-two fetal heart rate tracing. On postoperative day 11, she experienced a severe non-positional right-sided headache. Imaging revealed a subdural hematoma overlying the right frontal temporal and parietal lobes, which was observed and managed non-operatively. On postoperative day 14, the patient received an epidural blood patch for symptomatic intracranial hypotension.ConclusionPDPH, a complication of neuraxial anesthesia, is typically benign and often self-resolves with conservative measures. However, to avoid increased morbidity and mortality, monitoring in patients with PDPH at a higher risk for development of subdural hematomas (especially those with known preexisting intracranial pathologies) is critical for prompt diagnosis. As exemplified by our second case, epidural blood patches continue to be effective and may be considered in patients with symptomatic intracranial hypotension.