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Post-Dural Puncture Headache in Obstetrics: Audiological, Clinical and Epidemiological studies
Örebro University, School of Health Sciences.
2016 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Post-dural puncture headache (PDPH) is the most common complication of obstetric epidural analgesia. The characteristic positional headache, often associated with visual, vestibular or cochlear symptoms, is severe and disabling for the parturient. The diagnosis is clinical without the possibility of confirmatory objective tests. Although epidural blood patch (EBP) is considered the gold standard for treatment of PDPH, many aspects of this treatment modality remain to be explored. This thesis was performed in order to improve our current knowledge of the diagnosis and the short and long-term consequences of PDPH. We found that the incidence of accidental dural puncture in labour epidural analgesia was 1% in the Nordic countries and 90% of these patients were managed with an EBP (study I). Auditory impairment related to PDPH was prospectively investigated in 21 parturients with PDPH treated with EBP (study II). A significantly greater number of parturients suffering from PDPH had hearing loss (> 20 dB) in the low frequency range compared to controls which improved spontaneously but independent of treatment with EBP. At 4 hours, 95% of subjects had a successful EBP but headache recurred in 24% at 24 hours. In study III, we investigated residual hearing deficit several years after PDPH treated with EBP. We found statistically significant long-term impairment of hearing but this was of minor clinical relevance. In study IV, 60 women with previous PDPH and treated with EBP responded to a validated questionnaire to determine the long-term effects of EBP on headache and backache. We found that subjects who had been treated with EBP had a significantly greater incidence and severity of headache compared to controls. The incidence of mild backache was also significantly higher but of limited clinical importance. In conclusion, PDPH after labour epidural analgesia is an important clinical problem. Parturients suffering from PDPH may have audiometric deterioration in the early postpartum period that recovers spontaneously over time and some long-term effects of PDPH on hearing may be evident but these are of minor clinical relevance. Clinically important headache, but not backache, may be present several years after PDPH.

Place, publisher, year, edition, pages
Örebro: Örebro university , 2016. , 80 p.
Series
Örebro Studies in Medicine, ISSN 1652-4063 ; 135
Keyword [en]
Accidental dural puncture, post-dural puncture headache, epidural blood patch, obstetrics
National Category
Anesthesiology and Intensive Care Surgery
Research subject
Anaesthesiology; Surgery
Identifiers
URN: urn:nbn:se:oru:diva-47475ISBN: 978-91-7529-124-6 (print)OAI: oai:DiVA.org:oru-47475DiVA: diva2:895008
Public defence
2016-04-08, Universitetssjukhuset, Wilandersalen, Södra Grev Rosengatan, Örebro, 09:00 (English)
Opponent
Supervisors
Available from: 2016-01-18 Created: 2016-01-18 Last updated: 2016-03-10Bibliographically approved
List of papers
1. Management of accidental dural puncture and post-dural puncture headache after labour: a Nordic survey
Open this publication in new window or tab >>Management of accidental dural puncture and post-dural puncture headache after labour: a Nordic survey
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2011 (English)In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 55, no 1, 46-53 p.Article in journal (Refereed) Published
Abstract [en]

Background: A major risk with epidural analgesia is accidental dural puncture (ADP), which may result in post-dural puncture headache (PDPH). This survey was conducted to explore the incidence of ADP, the policy for management of PDPH and the educational practices in epidural analgesia during labour in the Nordic countries.

Methods: A postal questionnaire was sent to the anaesthesiologist responsible for Obstetric anaesthesia service in all maternity units (n=153) with questions relating to the year 2008.

Results: The overall response rate was 93%. About 32% (22-47%) of parturients received epidural analgesia for labour. There were databases for registering obstetric epidural complications in 13% of Danish, 24% of Norwegian and Swedish, 43% of Finnish and 100% of hospitals in Iceland. The estimated incidence of ADP was 1% (n approximate to 900). Epidural blood patch (EBP) was performed in 86% (n approximate to 780) of the parturients. The most common time interval from diagnosis to performing EBP was 24-48 h. The success rate for EBP was > 75% in 67% (62-79%) of hospitals. The use of diagnostic CT/MRI before the first or the second EBP was exceptional. No major complication was reported. Teaching of epidurals was commonest (86%) in the non-obstetric population and 53% hospitals desired a formal training programme in obstetric analgesia.

Conclusion: We found the incidence of ADP to be approximately 1%. EBP was the commonest method used for its management, and the success rate was high in most hospitals. Formal training in epidural analgesia was absent in most countries and trainees first performed it in the non-obstetric population.

Place, publisher, year, edition, pages
The Acta Anaesthesiologica Scandinavica Foundation, 2011
National Category
Surgery
Research subject
Surgery
Identifiers
urn:nbn:se:oru:diva-49012 (URN)10.1111/j.1399-6576.2010.02335.x (DOI)000284898500008 ()21039355 (PubMedID)2-s2.0-78650009807 (Scopus ID)
Available from: 2016-03-07 Created: 2016-03-07 Last updated: 2017-03-24Bibliographically approved
2. The effect of Epidural Blood Patch on Auditory Function following Accidental Dural Puncture in the Parturient: a prospective cohort study
Open this publication in new window or tab >>The effect of Epidural Blood Patch on Auditory Function following Accidental Dural Puncture in the Parturient: a prospective cohort study
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(English)Manuscript (preprint) (Other academic)
National Category
Surgery
Identifiers
urn:nbn:se:oru:diva-49015 (URN)
Available from: 2016-03-07 Created: 2016-03-07 Last updated: 2016-12-16Bibliographically approved
3. Auditory function following post-dural puncture headache treated with epidural blood patch: a long-term follow-up
Open this publication in new window or tab >>Auditory function following post-dural puncture headache treated with epidural blood patch: a long-term follow-up
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2015 (English)In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 59, no 10, 1340-1354 p.Article in journal (Refereed) Published
Abstract [en]

Background: Epidural analgesia is commonly used for pain management during labor. Sometimes, accidental dural puncture (ADP) occurs causing severely debilitating headache, which may be associated with transient hearing loss. We investigated if auditory function may be impaired several years after ADP treated with epidural blood patch (EBP).

Methods: Sixty women (ADP group) without documented hearing disability, who received EBP following ADP during labor between the years 2005-2011 were investigated in 2013 for auditory function using the following tests: otoscopic examination, tympanometry, pure tone audiometry, and transient-evoked otoacoustic emissions. Additionally, they responded to a questionnaire, the Speech, Spatial and Qualities (SSQ) of hearing, concerning perceived hearing impairment. The results were compared to a control group of 20 healthy, non-pregnant women in the same age group.

Results: The audiometric test battery was performed 5.2 (1.9)years after delivery. No significant differences were found between the ADP and the control groups in tympanometry or otoacoustic emissions. Pure tone audiometry revealed a significant but small (<5dB) difference between the ADP and control groups (P<0.05). The ability to hear speech in noise as measured by SSQ was significantly reduced in the ADP group compared to the control group (P<0.05).

Conclusions: A minor hearing loss was detected in the ADP group compared to the control group in pure tone audiometry in some women and during speech-in-noise component several years after accidental dural puncture treated with an epidural blood patch. This small residual hearing loss has minor clinical significance.

Place, publisher, year, edition, pages
Wiley-Blackwell, 2015
National Category
Anesthesiology and Intensive Care
Research subject
Anaesthesiology
Identifiers
urn:nbn:se:oru:diva-46393 (URN)10.1111/aas.12566 (DOI)000362589100014 ()26105531 (PubMedID)2-s2.0-84943362300 (Scopus ID)
Available from: 2015-11-04 Created: 2015-11-04 Last updated: 2016-12-16Bibliographically approved
4. Persistent headache and backache following accidental dural puncture in the parturient: a matched cohort study
Open this publication in new window or tab >>Persistent headache and backache following accidental dural puncture in the parturient: a matched cohort study
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(English)Manuscript (preprint) (Other academic)
National Category
Surgery
Identifiers
urn:nbn:se:oru:diva-49018 (URN)
Available from: 2016-03-07 Created: 2016-03-07 Last updated: 2016-03-07Bibliographically approved

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