What Would You Do?: Postpartum Headache

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You are working in your Emergency Department in the middle of Wisconsin because they pay really great moonlighting money. A 29 y female presents to you complaining of headache. She had just delivered 4 days ago by C-section. She developed signs suggestive of elevated blood pressure and an increase in her urine protein per the discharge instructions she received from the hospital. Prior to C-section, anesthesia placed an epidural. Patient stayed only 2 days in the hospital with a slight headache, treated by the morphine she was receiving post-operatively. Now her headache was pounding and the worst in her life. The nurse practitioner had given Reglan and Benadryl which only improved her pain from a 11/10 to a 10/10. Her LFTs shows a slight bump above normal AST: 87 ALT: 76. Neurologic examination demonstrates no abnormalities. How do you proceed with this case? Do you get a head CT? Does she need a lumbar puncture? Is this a postpartum issue or your regular run of the mill headache case? Let’s let the discussion begin.


  • alvarezzy

    I’d give Mag given concern for pre-eclampsia, maybe hellp. drop the BP with hydralazine/labetalol. what’s the platelet? send dic panel. call OB. yes CT. i’ve seen cavernous sinus thrombosis present like this, too, so low threshold for CTV/MRV. admit. not sure if jacobi still has IV caffeine (given national shortage), though i’d rule out other things first before tossing this up as post LP headache and getting anesthesia to put a blood patch. did i say admit?


  • edpcd

    I agree. I think we will get a diagnosis with the above plan but a blood patch can’t hurt and may make the headache go away within minutes so it is worth a try.

  • mmegue01

    I would give Magnesium as well, but what if Magnesium was already given intrapartum and OB says that the patient has already been treated. Does that change our management? I definitely think cavernous sinus or any type of dural sinus thrombosis needs to be considered. Does the patient get admitted to OB for them to manage?

    This was indeed my case…the patient’s blood pressure was 150/90 and the patient had normal coagulation panel as well as platelets. I do agree that is definitely of concern when considering progression to HELLP syndrome. Any other thoughts?

  • siuf

    For residents, they should know the ddx here for the headache is: nada, post-epidural (post-LP) headache, eclampsia and its cousins, central venous thrombosis, and the other usual causes of headache.

    The best way to ddx central venous thrombosis is mri / mra / mrv. Make sure you order each and every test. They don’t automatically do the mrv. You can see thrombosis of the cns venous system on a non-con CT or contrast CT sometimes.

    There is no answer to the question “when should i get an mri on a post-partum headache?” The usual answer is “when the headache seems bad and doesn’t go away”. There are no studies that i know of (research project!).

    We had a case recently where a post-LP headache led to a 6th nerve palsy. Apparently you can make this dx on an mri because you can see missing csf.

    Eclampsia and its cousins are sort of easy. If this patient is eclamptic, she will probably try to drop dead soon enough. There was no stated BP on the initial case, so it’s hard to tell if this should be seriously considered (aside from the LFTs). The patient is 4 days postpartum, so it’s a real possibility.

    If there’s no caffeine. Give the patient two Mountain Dews.

    Mg does not treat eclampsia. Mg treats the complications of eclampsia. Mg does not make eclampsia go away (whether is antepartum or postpartum).

    There’s a reason why I love aLAi when he was a resident. A simple way to deal with this patient is to dump it off on Ob. You have enough items here to say that post-partum eclampsia is a real concern. They can sort it out. Don’t keep the patient in the ER for 20 hours trying to get an mri. I’d be upset getting this sign-out.

    If the scale goes from the 0 to 10, the patient can’t say 11. This isn’t Spinal Tap. Send the patient over to psych.

    You don’t have to go all the way to Wisconsin to make a lot of money moonlighting.

    “The NP gave the patient reglan and benadryl”. If that isn’t a patient marked for death, I don’t know what is.

  • Andrew Shannon

    for shi-giggles, pituitary apoplexy/hemorrhage causing HA could also be in the DDX, but the management is the same as you’re all describing– get a picture/OB consult.

  • alvarezzy

    i’d admit to OB definitely. #1, it’s their patient until 2 weeks out =) The only thing is if they’re use the “too sick for OB floor” ticket, and recommends ICU admission. If that’s the case, I’d kindly ask them to talk to the medicine team.

    If mag was given, still would give mag until the DTR’s are decreased (vaguely remember that from medical school) and may even start mag gtt. somewhat agree with siuf although mag DOES prevent seizure in pre-eclamptic patients, i thought.
    Uptodate says NNT to prevent seizure in mild pre-eclampsia is 100, and to prevent seizure in severe pre-eclampsia is 60. TheNNT.com says “For the mother:
    98.8% saw no benefit, 1.2% were helped by preventing a seizure.” I’d personally give Mag.

    i’d try reglan/benadryl, though we know that reglan lowers seizure threshold, and i don’t know if this would increase likelihood for seizures in severe pre-eclamptic patients.
    if MRI is hard to get (or if the patient is unstable), CTV is fine. it has to be protocoled right. I’d get CT head, as well, though, in case this is, as shannon points out, pituitary apoplexy… don’t they get hypotensive?

    if negative, then the other stuff can be ruled out later in the course of admission.

    Would anyone LP in case this was a sentinel bleed for that aneurysm?

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