[Two cases of postpartum pubis diastasis mistaken for neurological complications of epidural analgesia]. / Dos casos de diástasis de pubis postparto interpretados como complicación neurológica de la analgesia epidural.

Two healthy 31- and 34-year-old parturients received uncomplicated epidural analgesia for labor and delivery using standard techniques. Twenty-four and 12 hours postpartum, respectively, they developed severe lower back pain and difficulty moving their lower extremities. At first the symptoms were attributed to neurological complications of epidural analgesia and for this reason the anesthetist was called. Although both women appeared healthy and the neurological examinations were normal, emergency computed tomography scans were performed to rule out spinal compression because of the severity of pain and difficulty of movement. The diagnosis was only established after suspecting pubis diastasis, confirmed by palpation of symphysis gaps of 3 and 2 cm, respectively. Pelvic dysfunction associated with pregnancy and labour is a complication whose incidence varies from 1 in 300 to 1 in 30,000. It presents with severe pain located in the areas supplied by pudendal and genitofemoral nerves. The pain may radiate to the sacroiliac joints and shoot down the buttocks and legs. In the most severe cases it may be accompanied by urinary dysfunction and inability to walk. If the clinical features are not recognized, it can be difficult to differentiate pubis diastasis from severe neurological complications in women who have received a central nervous system block. We report two cases of peripartum pubis symphysis diastasis that were both initially mistaken for neurological complications of epidural analgesia for labor.

El remifentanilo como amortiguadorde la respuesta al estrés en la cesáreabajo anestesia general / Remifentanil to attenuate the stress response of cesarean section performed under general anesthesia

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[Treatment of post-dural-puncture headache with intravenous cortisone]. / Tratamiento de la cefalea postpunción dural con hidrocortisona intravenosa.

Postdural puncture headache (PDPH) is the most frequent complication of procedures involving dural penetration for spinal anesthesia or following unintentional dural puncture during attempted epidural anesthesia or analgesia. PDPH causes serious problems for women who have just given birth, as they are unable to give adequate care to their infants. The causes of PDPH are poorly understood and treatments are therefore various and symptomatic; most are empirical and not all are effective. When conservative measures fail, an alternative that may be proposed is the blood patch, an invasive technique which is not without risk and which many patients reject. We report three cases of incapacitating PDPH in women after vaginal or caesarian delivery in which symptoms resolved with intravenous hydrocortisone treatment. Hydrocortisone treatment for PDPH has never been reported in the literature, but given our results, we consider that clinical trials are warranted to establish the efficacy of this treatment and to determine if there is a chance that it might offer an alternative to the blood patch.

Tratamiento de la cefalea postpunción dural con hidrocortisona intravenosa / Intravenous hydrocortisone treatment for postdural puncture headache

La cefalea postpunción dural (CPPD) es la complicación más frecuente de los procedimientos en los que se perfora la duramadre, incluyendo la anestesia subaracnoidea y la anestesia o analgesia epidural, con punción dural accidental. Constituye un cuadro especialmente grave en la puérpera, que no puede atender adecuadamente a su recién nacido. La etiología no se conoce completamente, por lo que los múltiples tratamientos propuestos son sintomáticos, en su mayoría empíricos y no siempre eficaces. Cuando las medidas conservadoras fracasan, se propone como alternativa el parche hemático, una técnica invasiva, no exenta de riesgos y que muchas pacientes rechazan. Presentamos 3 mujeres que en el puerperio inmediato desarrollaron un cuadro grave de cefalea postpunción dural, que remitió con hidrocortisona intravenosa. No está descrita la utilización de la hidrocortisona para tratar esta complicación, pero dados los resultados obtenidos, consideramos que se deberían llevar a cabo ensayos clínicos que nos permitieran establecer la efectividad de este tratamiento y precisar si, al menos en determinados casos, podría sustituir al parche hemático (AU)