Prophylactic vs therapeutic blood patch for obstetric patients with accidental dural puncture – a randomised controlled trial

Abstract

Summary Epidural blood patch is a standard treatment for obstetric patients experiencing a severe post‐dural puncture headache. Patients who sustained an accidental dural puncture during establishment of epidural analgesia during labour or at caesarean delivery were randomly assigned to receive a prophylactic epidural blood patch or conservative treatment with a therapeutic epidural blood patch if required. Eleven of 60 (18.3%) patients in the prophylactic epidural blood patch group developed a post‐dural puncture headache compared with 39 of 49 (79.6%) in the therapeutic epidural blood patch group (p < 0.0001). A blood patch was performed in 36 (73.4%) of patients in the therapeutic group. The number of patients who needed a second blood patch did not differ significantly between the two groups: 6 (10.0%) for prophylactic epidural blood patch and 4 (11.1%) for therapeutic epidural blood patch. We conclude that prophylactic epidural blood patch is an effective method to reduce the development of post‐dural puncture headache in obstetric patients.

Is prophylactic epidural blood patch the answer?

“…This phenomenon is supported in the authors' [1] study by the observation that six patients who received a second epidural blood patch in the prophylactic epidural blood patch group had a vaginal delivery. Prophylactic epidural blood patch -a reply I would like to thank Dr. Shah for these comments about our paper [1]. We did not perform a full neurological examination on our patients before placing an epidural blood patch.…”

“…We already know that women with unintentional dural puncture who push during labour have a high incidence of PDPH [2]. This phenomenon is supported in the authors' [1] study by the observation that six patients who received a second epidural blood patch in the prophylactic epidural blood patch group had a vaginal delivery. Prophylactic epidural blood patch -a reply I would like to thank Dr. Shah for these comments about our paper [1].…”

“…The survey by Howes et al [1] on postoperative morbidity, mortality and length of stay following emergency laparotomy is a valuable addition to our knowledge on an area with surprisingly little evidence, given its frequency around the world. Following the Lancet Commission's report on the importance of access to essential surgery and safe anaesthesia [2,3], patients requiring emergency laparotomy around the globe will become more likely to receive this operation, and validated tools such as the postoperative morbidity survey (POMS), which are relatively easy to implement in low-resource settings, will enable measurement and comparisons of the quality of care delivered.…”

The effect of serial in vitro haemodilution with maternal cerebrospinal fluid and crystalloid on thromboelastographic (TEG®) blood coagulation parameters, and the implications for epidural blood patching

“…Some authors have advocated prophylactic epidural blood patch after accidental dural puncture, and a number of reviews have looked at this area, concluding that previous studies were flawed in their methodology and further large studies were required [25,26]. One hundred and sixteen parturients were randomly assigned by Stein et al to receive either prophylactic or therapeutic epidural blood patch with 15-20 ml autologous blood after accidental dural puncture [27]. They found that prophylactic blood patch decreased the incidence of PDPH and also decreased the intensity of the headache and accompanying symptoms.…”

Accidental dural puncture: patch or wait?

“…I read with interest the paper by Stein et al [1] comparing prophylactic and therapeutic epidural blood patch administration for accidental dural puncture in the obstetric population. I noticed that the range of times between accidental dural puncture and administration of the prophylactic epidural blood patch varied from 5 h to 30 h. As postdural puncture headache (PDPH) can occur almost instantaneously [2], with symptoms beginning before 48 h in 66% of cases [3], I wondered if the authors could clarify whether any symptoms of PDPH had occurred in the patients who received their treatment towards 30 h after accidental dural puncture, effectively re-classifying their blood patch as therapeutic rather than prophylactic?…”