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* From the Sunnybrook & Women’s College Health Sciences Center; and
the University of Toronto School of Medicine, University of Toronto, Toronto, Ontario, Canada.
Address correspondence to: Dr. Pamela Angle, Department of Anesthesiology, Women’s College Hospital Campus, Sunnybrook and Women’s College Health Sciences Center, 76 Grenville Street, Toronto, Ontario M5S 1B2, Canada. Phone: 416-323-6008; Fax: 416-323-6307; E-mail: pamela.angle{at}sw.ca
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Abstract |
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Methods: After Ethics Committee approval, the hospital perinatal database was used to identify healthy parturients with recognized DP during labour epidural placement from 1996–2001. Women developing PDPH after expectant management were matched with women with uneventful epidurals and no evidence of PDPH, as well as by parity, delivery mode and admission date. All women delivered term singletons. The primary outcome was LOS (hours) from delivery to discharge. Secondary outcomes included: number (#) nights in hospital, #ER visits for PDPH, epidural blood patch (EBP) timing (pre vs post discharge), EBP location (ward vs ER) and blood volumes used.
Results: 26 cases and 26 controls were identified. Precise discharge times were found for 23 cases and 23 controls. In cases, the LOS was increased by a mean of 17 ± 23.8 (SD) hours; [95% conficence interval (CI) = 8, 26; P = 0.0012] and # nights in hospital was increased by a mean of 0.62 ± 0.94 nights (95% CI, 0.26, 0.98, P = 0.0027). Nineteen cases (73% 19/26) received at least one EBP. Sixteen cases received at least one EBP prior to discharge with 38% (6/16) returning to ER for re-assessment/repeat EBP. Forty-four percent (4/9) of cases without an EBP prior to discharge returned to ER for further assessment/EBP.
Conclusion: PDPH leads to a significant increase in hospital LOS and ER visits. Studies of preventive therapy are warranted.
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Introduction |
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While concerns related to the risks and effectiveness of prophylactic EBP limit its widespread use,12 expectant management is also likely to be associated with "costs." This matched retrospective cohort study examined hospital length of stay (LOS) and emergency room (ER) visits in healthy parturients developing PDPH after expectant management of recognized DP during labour epidural placement. Outcomes were compared with women receiving uneventful labour epidurals with no evidence of PDPH in the medical record. All women had uneventful vaginal deliveries (spontaneous or instrumental) and had healthy full-term singletons.
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Methods |
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Inclusion criteria were: absence of significant maternal medical illness, delivery of a healthy full-term (> 37weeks) singleton, and an uncomplicated vaginal (spontaneous or instrumental) delivery. Women with the following characteristics on the database that could increase LOS were excluded a priori: premature delivery, multiple gestation, neonatal intensive care admission, or antibiotic use in the postpartum period. Women with evidence of third or fourth degree perineal tears, urinary retention, noted difficulties with breastfeeding and excessive neonatal weight loss (> 10% birth weight) according to our lactation consultants on chart review were also excluded.
Selection of PDPH cases
The charts of women with recognized DP meeting study inclusion criteria were reviewed by two independent reviewers (P.A., S.T.) to ensure that DP had occurred, to determine whether PDPH had developed, and to confirm patient eligibility. Only patients receiving expectant management of recognized DP (usual hospital practice) were included. Prophylactic therapy involving use of the epidural space (normal saline, EBP) or intrathecal catheter placement were considered reasons for exclusion. PDPH was defined as the presence of a postural headache or neckache (with or without cranial nerve symptoms) present at > 24 hr after epidural placement and lasting at least an additional 24 hr, occurring within the first ten days of epidural placement.
Selection of matched controls
By using the perinatal database, controls were matched with cases by parity (multiparous vs primiparous), mode of vaginal delivery (spontaneous vs instrumental) and date of admission within one year. Women with instrumental deliveries were matched for forceps vs vacuum extractions. A perinatal database programmer (not associated with the study) matched women with the closest possible admission dates using patient characteristics and eligibility criteria present in the database. Once matched, the charts of controls were reviewed by two independent reviewers to confirm study eligibility, the accuracy of matching and to exclude evidence of DP or PDPH. In the instance where controls were found to be ineligible, the data programmer then chose the next closest match by the next closest date of admission.
Outcomes were assessed only after patients were entered into the study and assigned to groups. The primary outcome was LOS (hours) from birth to patient discharge or last recorded time in the chart. Secondary outcomes included: 1) number of nights spent in the hospital; 2) number of ER visits after delivery; 3) EBP timing (pre vs post-discharge); 4) EBP effectiveness; and 5) EBP blood volume used. Length of hospital stay for women with recognized DP and PDPH was compared with matched controls without recognized DP or evidence of PDPH in the chart. LOS for women with recognized DP and no evidence of development of PDPH while in hospital is also reported.
Usual hospital practice
In our hospital, management of a recognized large gauge DP is usually expectant. Patients and staff are informed of the DP, the symptoms of PDPH are described as well as the spectrum of available therapies, and arrangements are made to follow the patient. Management includes opioid and non-opioid analgesics, non-steroidal anti-inflammatory drugs, caffeinated beverages, maintenance of normovolemia, stool softeners and instructions to avoid straining, and early ambulation to permit early detection. Therapeutic blood patches are usually performed for moderate to severe persistent PDPH and are given after discussion with the patient. Hospital discharge is based upon achievement of discharge-based criteria (rather than a set time). These include: stable vital signs, normal bladder function, the ability to manage the activities of daily living including breastfeeding and a neonatal weight loss within the accepted norm (< 10% birth weight). These criteria did not change over the study period.
Statistical analysis
The primary outcome, mean difference in length of hospital stay between matched pairs, was analyzed using paired t test with alpha, two-tailed, set at 0.05. Sample size calculation done a priori suggested that 23 matched pairs were required to achieve a power of 80% to detect a minimally clinically important difference of 12 hr between groups at a conventional significance level of less than 0.05. The secondary outcome, number of nights spent in hospital post-delivery, was analyzed using a paired t test with a two-tailed alpha set at 0.025 to correct for multiple testing.
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Results |
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). These 26 women met all of the study eligibility criteria and were included as cases. The remaining nine women with DP were excluded for the following reasons: three women experienced headaches lasting < 24 hr; one experienced a non-evolving non-postural headache; one had a fourth degree vaginal tear extending her stay; one delivered by Cesarean section; and three women had no evidence of PDPH in the chart. LOS was 52 ± 16 (SD) hours in women who developed PDPH as compared with 35 ± 13 (SD) hours in those with uncomplicated epidurals. In three women with recognized DP but no evidence of PDPH (who otherwise met study entry criteria), LOS was 33 ± 16 (SD) hours.
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). Hospital stay in PDPH cases was increased by a mean of 17 ± 23.8 (SD) hours [95% confidence interval (CI), 8, 26; P = 0.0012]. The number of nights spent in hospital post-delivery was increased by a mean of 0.62 ± 0.94 (SD) in women with PDPH (95% CI, 0.26, 0.98; P = 0.0027); (Table II). Figure 2 demonstrates the range of nights spent in hospital for both cases and controls. None of the controls visited the ER whereas 10 cases made a total of 14 visits to the ER, all of which were related to PDPH.
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Nine women with suspected PDPH symptoms while in hospital did not receive an EBP prior to discharge. Four of these women returned to the ER within six days of discharge for PDPH reassessment with 3/4 receiving their first EBP.
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Discussion |
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Our study examined length of hospital stay and ER visits attributable to expectant management of PDPH in women with recognized DP during epidural placement. The overall incidence of PDPH was 75% (19/26) in women with DP and is consistent with the incidence found in the greater literature.11,15 The small number of cases identified over the study period reflect the low institutional DP rate (0.5%; epidural analgesia is provided only by staff anesthesiologists and senior anesthesia residents and fellows) and the stringent criteria necessary for study entry. The stringent eligibility criteria used were constructed to avoid confounding of the primary outcome of interest, hospital LOS, by other factors such as air headache, maternal co-morbidities, neonatal prematurity, or complications of delivery in each group. We chose to measure LOS only in women with both recognized DP and PDPH (rather than all parturients with recognized DP) since this approach allowed a more precise estimation of the "true costs" of expectant management related to LOS and ER visits. We excluded women with PDPH symptoms lasting less than the first 24 hr after DP since these self-limiting headaches were likely to represent headache related to air used as part of loss of resistance technique rather than cerebral spinal fluid leak.16
Women with recognized DP (meeting study entry criteria) but no evidence of PDPH stayed in hospital around the same amount of time as women with uncomplicated epidurals [33 ± 16 (SD) vs 35 ± 13 (SD) hours respectively]. We found that patients who developed PDPH stayed in hospital longer (17 hr on average), that the added time usually involved an extra overnight stay, and that both women with treated and untreated headache prior to discharge had a high rate of return to the ER for assessment and treatment.
Information related to the added LOS in those with recognized DP and PDPH also provides an estimate of the maximal potential benefit (reduction in hospital stay, ER visits) possible by using prophylactic EBP. Ultimately these "costs", among others associated with expectant management, must be weighed against the potential benefits and risks of prophylactic EBP. No attempt was made to place a monetary value on the use of these resources. Since prophylactic EBP is not commonly used in our institution (only one patient was identified as having received a prophylactic EBP in our review), no attempt was made to assess the value of this modality.
Overall, our results suggest that parturients developing PDPH following expectant management of recognized DP with a large gauge epidural needle have a high rate of EBP utilization (73%, 19/26) and is consistent with the literature. We found that approximately 40% of parturients receiving an EBP for moderate to severe PDPH prior to discharge returned to the ER for reassessment/treatment. Similarly, around 40% of patients discharged with milder PDPH symptoms (and no EBP) were also found to have returned to the ER for further assessment/treatment.
Recent work suggests that delayed EBP, given more than four days after DP, may be associated with a lower failure rate than EBP given within the first four days of DP.17 It should be noted that the authors of this study took great care in the interpretation of their results, noting that their findings may simply reflect the more refractory nature of more severe headaches, which are more likely to be associated with larger gauge needles, more likely to be treated earlier and probably more likely to fail therapy, rather than evidence to suggest that one should delay EBP to improve the odds of success following large gauge punctures. We believe that this carefully noted observation applies to the results found in our study and would not recommend delaying EBP in symptomatic patients following DP except in the cases where air headache is possible or alternative causes of PDPH-like symptoms are being entertained (for example, sagittal sinus thrombosis in pre-eclampsia). Since most of the women in our study receiving an EBP prior to discharge did so within the first four days of DP and information on the success rates of EBP administered in the ER is not available, we cannot comment on the role of timing of EBP on success rate in our study.
While acknowledging the limitations inherent in retrospective research, we believe that our results provide a reasonable estimate of the added length of hospital stay attributable to PDPH in women managed expectantly. Further, the results presented must be viewed as a conservative estimate of resource utilization since any additional visits to other health care providers for interim assessment of headache (e.g., family practitioners) would not have been captured.
In summary, our results suggest that PDPH, managed expectantly, extends hospital LOS compared with women without PDPH and increases the number of ER visits in the immediate postpartum period compared with women without PDPH. We would suggest that, in the absence of contraindications, clinicians treat moderate to severe PDPH symptoms with EBP prior to discharge and provide parturients with information necessary for further follow-up/reassessment should this become necessary. We also believe that additional studies related to prophylactic therapy are warranted.
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Acknowledgments |
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Footnotes |
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Accepted for publication May 5, 2004. Revision accepted January 19, 2005.
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References |
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