NEUROLOGIC AND NEUROMUSCULAR DISEASE IN THE OBSTETRIC PATIENT

Postdural puncture headache

Postdural puncture headache (PDPH) has been a problem for patients, following dural puncture, since August Bier reported the first case in 1898. His paper discussed the pathophysiology of low-pressure headache resulting from leakage of cerebrospinal fluid (CSF) from the subarachnoid to the epidural space. Clinical and laboratory research over the last 30 years has shown that use of small-gauge needles, particularly of the pencil-point design, is associated with a lower risk of PDPH than traditional cutting point needle tips (Quincke-point needle). A careful history can rule out other causes of headache. A postural component of headache is the sine qua non of PDPH. In high-risk patients , for example, age < 50 years, postpartum, large-gauge needle puncture, epidural blood patch should be performed within 24–48 h of dural puncture. The optimum volume of blood has been shown to be 12–20 mL for adult patients. Complications of AEBP are rare.

Prognostic factors in obstetric patients admitted to an Indian intensive care unit

OBJECTIVES

Obstetric patients form a significant proportion of intensive care unit admissions in countries like India, where maternal mortality is high (440 per 100,000 deliveries). We studied the diseases requiring intensive care and prognostic factors in obstetric patients.

DESIGN

Retrospective chart review. Acute Physiology and Chronic Health Evaluation (APACHE) II data were prospectively collected.

SETTING

Multidisciplinary intensive care unit of a public hospital in Mumbai, India.

PATIENTS

Women admitted during pregnancy or 6 wks post-partum during a 5-yr study period (1997-2001).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Four hundred fifty-three obstetric patients (age 25.5 +/- 4.6 yrs [mean +/- SD], mean gestational age 31 wks) were admitted (548 intensive care unit admissions per 100,000 deliveries), 138 with single organ failure and 152 with multiple organ failure. Ninety-eight women died (mortality rate 21.6%). Mortality was comparable in antepartum (n = 216) and postpartum (n = 247) admissions but increased with increasing number of organs affected. There were 236 fetal deaths (52%), of which 104 occurred before hospital admission. Median APACHE II score was 16 (interquartile range, 10-24), and standardized mortality ratio (observed deaths/predicted deaths) was 0.78. Compared with pregnant patients admitted with obstetric disorders (n = 313), those with medical diseases (n = 140) had significantly lower APACHE II scores (median 14 vs. 17) but higher observed mortality rate (28.6% vs. 18.5%; odds ratio, 1.76; 95% confidence interval, 1.08-2.87) and standardized mortality ratio (1.09 vs. 0.66). On multivariate analysis, increased mortality rate was associated with acute cardiovascular (odds ratio, 5.8), nervous system (odds ratio, 4.73) and respiratory (odds ratio, 12.9) failure, disseminated intravascular coagulation (odds ratio, 2.4), viral hepatitis (odds ratio, 5.8), intracranial hemorrhage (odds ratio, 5.4), absence of prenatal care (odds ratio, 1.94), and >24 hrs interval between onset of acute symptoms and intensive care unit admission (odds ratio, 2.3).

CONCLUSIONS

Multiple organ failure is common in obstetric patients; mortality rate increases with increasing organ failure. APACHE II scores overpredict mortality rate. Standardized mortality ratio is lower in obstetric disorders than in medical disorders. Lack of prenatal care and delay in intensive care unit referral adversely affect outcome and are easily preventable.

Backache, headache, and neurologic deficit after regional anesthesia

Back pain, chemical backache, PDPH, and neurologic deficit all may be reported after regional anesthesia for childbirth. Back pain is common during pregnancy, but epidural analgesia during labor does not increase the incidence of long-term back pain. Chemical backache caused by 2-chloroprocaine is probably a result of hypocalcemic tetany of paraspinous muscles. The mechanism is presumed to be chelation of calcium by sodium bisulfite, an antioxidant present in nesacaine-MPF. PDPH after dural puncture is caused by leakage of CSF, which causes cerebral hypotension. Cerebral hypotension leads to traction on pain-sensitive intracranial structures and cerebral vasodilation. Initial therapy includes hydration, caffeine, and sumatriptan. EBP is the most effective treatment in severe PDPH. If the first EBP fails, a second blood patch can be performed. Neurologic deficits after regional anesthesia are rare. Meticulous technique and vigilance are the keystones in avoiding major neurologic complications of regional anesthesia. Rapid diagnosis and appropriate treatment are essential to optimize a successful outcome if complications do develop.