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Year : 2016  |  Volume : 60  |  Issue : 8  |  Page : 612-613  

Effective management of post-labour analgesia-post-dural puncture headache with mannitol

Department of Anesthesiology and Pain Management, D Y Patil Medical College, Kolhapur, Maharashtra, India

Date of Web Publication4-Aug-2016

Correspondence Address:
Kalpana Rajendra Kulkarni
"Chaitanya," A-5, 1168, Takala Square, Kolhapur - 416 008, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0019-5049.187820

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How to cite this article:
Kulkarni KR, Patil RR, Wadhawan AA. Effective management of post-labour analgesia-post-dural puncture headache with mannitol. Indian J Anaesth 2016;60:612-3

How to cite this URL:
Kulkarni KR, Patil RR, Wadhawan AA. Effective management of post-labour analgesia-post-dural puncture headache with mannitol. Indian J Anaesth [serial online] 2016 [cited 2021 Jul 30];60:612-3. Available from: https://www.ijaweb.org/text.asp?2016/60/8/612/187820


We read with great interest the case report on the management of post-dural puncture headache (PDPH) with mannitol and the letters in response to the same in the IJA. The authors have mentioned the postulated mechanism of action of mannitol- drawing fluid from neuronal glial cells, resulting in dehydration and reduction in brain volume, whereby it 'refloats', thus minimising the meningeal traction effects. [1],[2],[3] We would like to share our experience of PDPH in a parturient for labour epidural analgesia (LEA) managed with mannitol infusion successfully.

In our institute, we practice LEA regularly with 0.1% bupivacaine/ropivacaine with fentanyl 2 μg/ml as intermittent bolus doses of 10-15 ml one hourly. Recently, in one case, we encountered an inadvertent dural puncture twice at L3/4 and L2/3 intervertebral spaces at a distance of 2.7 cm (approximately) with the use of an 18-gauge Tuohy's needle. The parturient was gravid 2, moderately built, presenting with vertex lie of the foetus with no other comorbidity.

On per vaginal examination, the cervix was 5 cm dilated with 3-5 mild contractions for every 15 min. It was a dilemma to decide to attempt a third prick, but considering the demand of labour analgesia and threat of PDPH for which epidural catheter could further facilitate the injection of saline in achieving seal effect on the dural rents, a third attempt of epidural at L4/5 level was made. Loss of resistance was appreciated, but the catheter could not be negotiated. By then, the parturient became uncooperative, labour progressed to cervical dilatation of 6-7 cm with increasing intensity/frequency of contractions and the procedure was abandoned and analgesia was provided with tramadol intravenously.

The child was delivered vaginally at around 12 noon uneventfully. Immediately, oral analgesics containing caffeine, triptans and crystalloid infusions (ringer lactate/normal saline) 2 L/day along with strict bed rest and watch on the symptoms of PDPH started. Antibiotics and dexamethasone 8 mg BID were administered. Oral hydration was encouraged. The need of epidural blood patch for the managementof headache was explained to the parturient and relatives.

Meningism developed the next day morning and she complained of headache at around 12 noon i.e., at 24 h of delivery. It was again a dilemma to decide about epidural autologous blood patch, considering the failed epidural trials on the previous day. We administered 100 ml of 20% mannitol as infusion over 30 min twice 12 hourly. On the 3 rd day morning, there was a dramatic relief in her headache except local back pain. Subsequently, she was managed conservatively and was discharged on 8 th day. On weekly telephonic follow-up, she was fine and relieved of all her symptoms.

Occurrence of PDPH in parturient following inadvertent dural puncture with large bore needle during LEA is well known. [4],[5] Epidural autologous blood patch is performed within 24-48 h of dural puncture when PDPH is inevitable or has occurred.

Cochrane review shows the results with epidural blood patch to be controversial with a success rate of 65%. [6],[7] Our case responded well to mannitol infusion, and we could avoid the need of epidural blood patch.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Rizvi MM, Singh RB, Tripathi RK, Immaculate S. New approach to treat an old problem: Mannitol for post dural puncture headache! Indian J Anaesth 2015;59:260-1.  Back to cited text no. 1
Dhansura T, Shaikh T, Shaikh MA. Comments: New approach to treat an old problem: Mannitol for post dural puncture headache. Indian J Anaesth 2015;59:762.  Back to cited text no. 2
  Medknow Journal  
Rizvi MM, Singh RB, Tripathi R. New approach to treat an old problem: Mannitol for post-dural puncture headache. Indian J Anaesth 2016;60:229-30.  Back to cited text no. 3
[PUBMED]  Medknow Journal  
Bawdane KD, Magar JS, Tendolkar BA. Double blind comparison of combination of 0.1% ropivacaine and fentanyl to combination of 0.1% bupivacaine and fentanyl for extradural analgesia in labour. J Anaesthesiol Clin Pharmacol 2016;32:38-43.  Back to cited text no. 4
Reena, Bandyopadhyay KH, Afzal M, Mishra AK, Paul A. Labor epidural analgesia: Past, present and future. Indian J Pain 2014;28:71-81.  Back to cited text no. 5
Ghaleb A, Khorasani A, Mangar D. Post-dural puncture headache. Int J Gen Med 2012;5:45-51.  Back to cited text no. 6
Kotur PF. Evidence based management of post dural puncture headache. Indian J Anaesth 2006;50:307-8.  Back to cited text no. 7
  Medknow Journal  

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