What is the management of postpartum subdural hematoma?

Management of Postpartum Subdural Hematoma

Postpartum subdural hematoma requires immediate neurosurgical consultation and management based on clinical presentation, with surgical evacuation indicated for symptomatic patients with significant mass effect or neurological deterioration.

Etiology and Risk Factors

Postpartum subdural hematoma (SDH) is a rare but potentially life-threatening complication that can occur in the postpartum period. Common causes include:

• Neuraxial anesthesia (epidural or spinal) leading to cerebrospinal fluid (CSF) leak and intracranial hypotension 1, 2, 3
• Vascular changes during pregnancy and postpartum period
• Coagulopathy or hypercoagulable state in the postpartum period
• Straining during labor and delivery 4

Clinical Presentation

Patients with postpartum subdural hematoma may present with:

• Headache (often mistaken for post-dural puncture headache)
• Altered mental status or confusion
• Seizures 1
• Visual disturbances including diplopia 3
• Focal neurological deficits
• Signs of increased intracranial pressure

Diagnostic Approach

1. Neuroimaging is essential:

   • CT scan of the brain is the first-line imaging modality to diagnose acute SDH
   • MRI may be indicated for subacute or chronic SDH, or when CT findings are equivocal

2. Clinical assessment:

   • Evaluate for signs of increased intracranial pressure
   • Perform detailed neurological examination
   • Monitor vital signs for signs of Cushing's triad (hypertension, bradycardia, irregular breathing)

Management Algorithm

Immediate Management:

1. Stabilize the patient:

   • Secure airway, breathing, and circulation
   • Elevate head of bed to 30 degrees to reduce intracranial pressure
   • Administer anticonvulsants if seizures are present

2. Neurosurgical consultation:

   • Immediate consultation is mandatory for all postpartum SDH cases

3. Surgical intervention indications:

   • SDH thickness >5mm with midline shift >5mm 5
   • Neurological deterioration
   • Uncontrolled intracranial hypertension
   • Mass effect with significant symptoms

Surgical Options:

• Craniotomy for evacuation of acute SDH
• Burr hole drainage for subacute or chronic SDH
• Decompressive craniectomy for refractory intracranial hypertension 5

Non-surgical Management:

For small, asymptomatic SDH without significant mass effect:

• Close neurological monitoring
• Serial neuroimaging
• Corticosteroids may be beneficial in selected cases 6
• Avoid epidural blood patch if SDH is suspected or confirmed 1

Intracranial Pressure Management:

• External ventricular drainage for persistent intracranial hypertension 5
• Osmotic diuretics (mannitol or hypertonic saline) for acute management of increased intracranial pressure
• Sedation and mechanical ventilation with end-tidal CO2 monitoring to maintain normocapnia 5

Special Considerations

1. Avoid epidural blood patch in patients with suspected or confirmed subdural hematoma, as this may worsen the condition 1

2. Recognize warning signs that differentiate SDH from simple post-dural puncture headache:

   • Altered mental status
   • Seizures
   • Focal neurological deficits
   • Headache that worsens despite lying flat
   • Confusion or fatigue that may represent postictal state 1

3. Monitor closely for at least 24-48 hours after diagnosis, as neurological status can deteriorate rapidly

Follow-up Care

• Serial neuroimaging to monitor hematoma resolution
• Neurological assessment at regular intervals
• Thromboprophylaxis with low molecular weight heparin once bleeding risk has stabilized 5
• Avoid activities that increase intracranial pressure

Prevention

• Careful technique during neuraxial anesthesia
• Early recognition and management of post-dural puncture headache
• Prompt diagnosis and treatment of coagulopathies in the postpartum period

By following this management approach, the morbidity and mortality associated with postpartum subdural hematoma can be significantly reduced.