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For all procedures requiring general anesthesia, pregnant patients >18– 20 weeks gestation should receive a nonpartic­ulate antacid, an H2 blocker, and a gastric motility agent and a rapid sequence induction (RSI) is recommended. When the gestational age is >20 weeks, le uterine displacement (LUD) should also be maintained. Agents that increase ICP should be avoided (e.g., ketamine), and succinylcholine may produce transient increases in ICP. However, those increases may be abolished with IV lidocaine, adequate depth of anes­thesia, hyperventilation, or a defasciculating dose of a nonde­polarizing paralytic.29 An arterial line should be considered for close blood pressure monitoring and should be main­tained within 20% of baseline, with a mean arterial pressure of >70mmHg. Invasive blood pressure monitoring should also be considered for laboring patients with stroke/ intracra­nial hemorrhage if vasoactive medications are required for tight blood pressure control. A sodium nitroprusside drip can be used to lower blood pressure, but it crosses the pla­centa and may cause fetal cyanide toxicity (keep infusions to less than 0.5 mg/ kg/ h and minimize duration of time on infusion). Nitroglycerin can also be used to control blood pressure without adverse fetal eects, although experimen­tally, nitroglycerin is metabolized to nitrites, causing met­hemoglobinemia and cerebral vasodilation. Nicardipine infusion oers the advantage of easy titration and short duration of action if blood pressure control requires con­tinuous medication administration. Inhalation agents like isourane can also be used to lower blood pressure and even at greater than 1 MAC (minimum alveolar concentration), uteroplacental perfusion is maintained as long as maternal

should be equipped for an emergency cesarean section should the need arise.32 Continuous intraoperative fetal monitoring for a previable fetus should be performed to optimize placental blood ow in cases of fetal bradycardia and on a case- by- case basis.32 Loss of beat- to- beat vari­ability is normal during general anesthesia, but fetal heart rate decelerations are abnormal and should be corrected with increased blood pressure, increased oxygenation, or a change in position.

Since the sum of all structures (brain, CSF, blood vol­ume) in the cranium remains constant, according to the Monro- Kellie doctrine, the loss of CSF volume surround­ing the brain leads to compensatory cerebral venodilation. is results in increased cerebral blood volume, which is another contributing factor to the development of PDPH.6 Movements that commonly prevent cerebral venous drain­age, such as coughing, sneezing, and straining, may further exacerbate HA symptoms.

Since many PDPH do not rapidly improve with conserva­tive measures, many patients elect for the more invasive, “gold standard” treatment for PDPH: epidural blood patch (EBP). e EBP is the denitive treatment for PDPH, because it directly confronts the cause (CSF leak­age from the intrathecal space). e treatment was origi­nally devised from a casual observation that bloody “wet taps” were associated with a reduction of PDPH, since in these cases, autologous coagulation factors were intro­duced into the epidural space.6 e procedure requires two providers, one to draw the patient’s blood (commonly from the hand or arm), and the other to place a Tuohy needle into the epidural space, both under sterile condi­tions. e patient may be placed in the sitting or lateral position, but some providers prefer the lateral position, because this oers the patient additional comfort by min­imizing PDPH symptoms for extended periods of time during the procedure.

hours.