From the Guidelines
Epidural blood patch is not recommended at 12 days postpartum due to infection risks, and conservative management is the preferred approach at this stage. The risks associated with an epidural blood patch at this time include infection, which can lead to serious complications such as meningitis or abscess formation 1. Conservative management treatments are preferred and include:
- Bed rest in a flat position
- Increased fluid intake, especially caffeinated beverages
- Pain management with acetaminophen (up to 1000 mg every 6 hours) or ibuprofen (400-600 mg every 6 hours)
- Abdominal binder to increase intracranial pressure
- Hydration with IV fluids if oral intake is insufficient These measures help by promoting natural healing of the dural puncture, reducing intracranial hypotension, and managing pain. Most cases resolve within 1-2 weeks with conservative treatment, as postdural puncture headaches are typically self-limited, with most symptoms fully resolving within 1 week without any treatment 1. If symptoms persist beyond 2-3 weeks or are severely debilitating, reassess for a blood patch, as the infection risk is lower, and the procedure's benefits may outweigh the risks. It is essential to monitor for signs of meningitis or other complications, such as fever, neck stiffness, or altered mental status, which would require immediate medical attention. The initial management of postdural puncture headaches is conservative medical management, with consideration of epidural blood patch if symptoms are severe or not beginning to resolve by 2 to 3 days postdural puncture 1.
From the Research
Risks Associated with Epidural Blood Patch
- The risks associated with an epidural blood patch include pain, dural puncture, and infection 2, 3
- Severe coagulopathy, patient refusal, or infection at the intended site of entry are contraindications to epidural blood patch 2
- There is a high recurrence rate of symptoms after an initially successful epidural blood patch, and therefore patients should be provided with counseling and contact information 4
Timing of Epidural Blood Patch
- Epidural blood patch performed later than 48 h following lumbar puncture or accidental dural puncture is effective in parturients with postdural puncture symptoms 4
- The success rate of the first procedure was 89%, with permanent relief in 76% of patients 4
- A second procedure was performed for 22 parturients due to incomplete relief or recurrent symptoms, and all had complete resolution of symptoms 4
Conservative Management Treatments
- Conservative options for treating postdural puncture headache include hydration, caffeine, bedrest, and NSAID analgesics 2, 3
- Transnasal sphenopalatine ganglion block (SPGB) has been successfully used to treat postdural puncture headache in obstetric patients, and may be considered as an alternative to epidural blood patch 3
- The risks of a transnasal SPGB, which include bleeding and temporary discomfort, may be lower than those of an epidural blood patch, which include dural puncture, neurologic complications, bleeding, and infection 3
Considerations for Subsequent Neuraxial Procedures
- The timing of subsequent neuraxial procedures after an epidural blood patch is unclear, and the risks of disruption of the epidural blood patch, procedure failure, and infection must be considered 5
- The literature suggests that the time course of dural repair and the risks of subsequent neuraxial procedures after epidural blood patches are not well understood, and further study is needed to inform clinical management 5