Arterial bleed from an epidural puncture site: a case report

Abstract

This case highlights a rare complication of superficial arterial bleeding from an epidural puncture site.

A 27-year-old primigravida was admitted for induction of labour at 38 weeks' gestation due to obstetric cholestasis. An epidural for labour analgesia was inserted at spinal level L4-L5 with a 16G Tuohy needle. Blood-stained fluid was noted on aspiration, prompting its removal. Subsequently, there appeared to be arterial bleeding from the epidural site, which persisted despite prolonged pressure with epinephrine and tranexamic acid soaked swabs. The bleeding was ultimately controlled using a purse-string suture and subcutaneous epinephrine 20 μg on each side of the bleeding site, with a total estimated blood loss of 500 mL. There were no neurological concerns and no cardiovascular changes or evidence of formation of a superficial haematoma following the interventions.

Epidural related arterial bleeding is exceptionally rare and the primary concern is the risk of an epidural haematoma, especially if the source of the bleeding is unknown. There are only four case reports in the literature detailing superficial arterial bleeding following an epidural with differing management strategies including a purse-string suture or varying doses of subcutaneous epinephrine (30 μg−300 μg). Both techniques carry potential risks. In this case, a combination of a purse-string suture and low-dose subcutaneous epinephrine effectively controlled the bleeding, with no complications. We recommend using the lowest effective dose of subcutaneous epinephrine with vigilant maternal and fetal monitoring. Any lower limb neurological changes warrants urgent imaging and a neurosurgical evaluation to exclude an epidural haematoma.