RevBrasAnestesiol.2015;65(1):82---83
REVISTA
BRASILEIRA
DE
ANESTESIOLOGIA
OfficialPublicationoftheBrazilianSocietyofAnesthesiology www.sba.com.brLETTER
TO
THE
EDITOR
Postdural
puncture
headache
after
caesarean
section:
are
preventive
strategies
worse
than
the
cure?
Cefaleia
pós-punc
¸ão
dural
para
cesárea:
as
estratégias
preventivas
são
piores
do
que
a
cura?
DearEditor,
Postduralpunctureheadache(PDPH)wasdescribed
immedi-atelyafterthefirstspinalanesthesia(SA),whenBierhimself
sufferedfromadebilitatingheadacheandattributeditto
cerebrospinalfluid leakage throughthe dural rent.1 With
betterunderstandingofthepathophysiologyofPDPH,and
useofsmallerboreneedlesfor SA,theincidencetoPDPH
hasgonedown.
Numerous risk factors for PDPH have been described.
Theseincludethepatient’sage,sexandbodymassindex,
thesizeandtypeofthespinalneedle,theneedleorientation
andeventheoperator’sskill.1,2Theincidenceofheadache
is higher in parturient undergoing caesareansection (CS)
under SA. This may be because of the increased
elastic-ityof theduralfibres,whichmaintains apatentdefectin
thesepatients.2The incidenceis muchhigherin anevent
of accidental dural puncture (ADP) during epidural
inser-tion(76---85%).2This is unfortunateaslowermaternaland
infantphysiologicalalterationsjustifypreferentialpractice
ofregionaltechniques(SAandepiduralanesthesia)inmost
caesarean sections. PDPH after CS is distressing for the
mothersastheyexpecttofeelgoodafter delivery ofthe
baby,andwanttotakecareofthenewborn.
Manycenters advise recumbency asthe prophylaxis of
PDPH, with some hospitals not evenallowing a pillow or
lateralpositionfor aslong as24h afterthe SA. However,
lyingdownflatforlonghourscausespainanddistresstothe patients.Mothersareunabletofeedornursethenewbornin thisposition.Boththemotherandchildneedtolearn breast-feedingatthisstage,andearlyinitiationofbreast-feeding
isimperativetopromotebondingbetweenthemotherand
the child.However,nursing the newbornis madedifficult
in this awkwardposition, which adds tothe stress of the
motherandthechild.
Supinerecumbencydoes notpreventtheoccurrenceof
PDPHafterduralpuncture.2---4EvenafterADP,the
manage-mentofPDPHismainlyexpectant,andprophylacticbedrest
isof limitedbenefit.Contrarytothepopularbelief,some
studies have described higher risk of PDPH if the patient
is not immediately mobilized after surgery.2 In spite of
evidenceagainstthebenefitsofsupinerecumbence,
physi-cianscontinuetoadviseitroutinelyafterlumbarpuncture.4
Especiallyinparturients,suchalimitationinmobility and
positioningisanobstacletobreast-feedthenewborn.5
PDPH,ifitoccurs,isdebilitatingandshouldbetreated
promptly.Themajorityoftheseheadacheswillresolve
spon-taneouslyormaybetreatedconservatively.Fewcasesmay
requireepiduralbloodpatch.However,keepingthepatient
supine for prolonged periods after spinal anesthesia, in
anticipation of PDPH,causes moreagonyand miserythan
thediseaseitaimstoprevent.Notonlyisthispracticehighly
uncomfortableforthemotherandhernewborn,ithasbeen
proventobeofquestionablebenefit.Inviewofthe
litera-tureagainstprophylacticbedrestforpreventionofPDPH,
theprotocolofabsoluterecumbencyafterSAforCScanbe
madelenientbytheanesthesiologistsandobstetricians,to
increasethecomfortofthemotherandhernewborn.
References
1.Turnbull DK, Shepherd DB. Post-dural puncture headache: pathogenesis, prevention and treatment. Br J Anaesth. 2003;91:718---29.
2.GhalebA,KhorasaniA,MangarD.Post-duralpunctureheadache. IntJGenMed.2012;5:45---51.
3.Jacobus CH. Does bed rest prevent post-lumbar puncture headache?AnnEmergMed.2012;59:139---40.
4.StendellL,FomsgaardJS,OlsenKS.Thereisroomfor improve-mentinthepreventionandtreatmentofheadacheafterlumbar puncture.DanMedJ.2012;59:A4483.
5.Tully KP, Ball HL. Maternal accounts of their breast-feeding intentandearlychallengesaftercaesareanchildbirth.Midwifery. 2014;30:712---9.
http://dx.doi.org/10.1016/j.bjane.2014.04.002
LETTERTOTHEEDITOR 83
PrakharGyanesha,∗,RadhikaK.a,ManjuSinhab,
RudrashishHaldara,c
aGlobalHospitals,Chennai,India
bDepartmentofObstreticsandGynaecology,Nishant
Hospital,Gaya,India
cDepartmentofAnaesthesia,GianSagarMedicalCollege,
Banur,Patiala,India
∗Correspondingauthor.
E-mails:prakhargyan@gmail.com,pgyan@yahoo.com (P.Gyanesh).
