Long Term Outcomes Following a Post Dural Puncture Headache
Long Term Outcomes Following a Post Dural Puncture Headache
Epidural analgesia is considered a gold standard method for treatment of labor pain. One of
 the major risks with epidural analgesia is an accidental dural puncture, which leads to a
 post dural puncture headache. This headache is associated with significant maternal morbidity
 and can result in severe maternal consequences.

 Post traumatic stress disorder (PTSD) is defined as an anxiety syndrome, resulting from a
 traumatic experience. Postpartum PTSD, is a form of PTSD that can occur in relation to a
 traumatic birth experience. As PDPH is unexpected and can cause severe maternal sequele, PDPH
 can exhibit a posttraumatic stress response. Therefore we hypothesize that parturients who
 suffered from a PDPH are at higher risk for developing PP-PTSD.

 To date, very few reports have examined the long term outcomes of parturients suffering from
 a PDPH. As a follow up to the national survey of PDPH management in Israel the investigators
 aim, in this prospective multi center, observational study, to evaluate the long term
 outcomes of parturients suffering from a PDPH, including chronic headache, backache,
 postpartum depression, decreased breastfeeding and the development of PP PTSD.
Introduction:

 Epidural analgesia is considered a gold standard method for treatment of labor pain . However
 one of the major risks with epidural analgesia is an accidental dural puncture, a common
 complication occurring in 0.4-6% of the obstetric population . ADP increases the risk of
 developing a post dural puncture headache (PDPH) in 50% of parturients. PDPH is defined as a
 postural headache that worsens within fifteen minutes of standing and is relieved in the
 supine position . PDPH results from a CSF leakage from the intrathecal space, causing a
 decrease in CSF volume and pressure .

 PDPH is associated with significant maternal morbidity, prolonging hospital stay, preventing
 ambulation and impairing maternal neonatal bonding . Less frequently PDPH can cause severe
 maternal complications resulting in posterior reversible encephalopathic syndrome ,
 pneumocephalus , or a subdural hematoma .

 Treatment protocols for PDPH vary greatly, with numerous existing conservative/ invasive
 treatment options . Conservative treatment includes bed rest, fluids administration,
 non-steroidal anti-inflammatory drugs and caffeine intake. The most standard invasive method
 for treatment of PDPH with a reported success rate of 70-90% includes the epidural blood
 patch (EPD) which is applied by injecting autologous blood epidurally .

 Several factors have been found to increase the risk for developing a PDPH and increasing the
 duration of a PDPH including young age, low BMI and previous history of anxiety or depression
 .

 Posttraumatic stress disorder is classified as an anxiety syndrome one may develop in
 response to a traumatic experience. Clinical manifestations include persistent re-experience,
 avoidance of traumatic memories, hyperarousal and emotional numbing . In a retrospective
 analysis war related PTSD was not associated with increased risk of PDPH.

 Post partum (PP) PTSD is a form of PTSD occurring in the postpartum period in relation to a
 traumatic birth . As PDPH is unexpected and can cause severe maternal sequele, PDPH can
 exhibit a posttraumatic stress response. Therefore the investigators hypothesize that
 parturients who suffered from a PDPH are at higher risk for developing PP-PTSD.

 To date very few reports have examined the long term outcomes of parturients suffering from a
 PDPH associated with epidural analgesia. In a prospective, case control trial Webb et al
 demonstrated an increased risk for developing a chronic headache and backache in 40
 parturients who suffered an accidental dural puncture with a large gauge needle . In a five
 year follow-up study examining long term consequences of PDPH, PDPH was associated with
 persistent headache and backache in the obstetric population. In a case control trial
 evaluating long term auditory function following EBP treatment for PDPH, a minor hearing loss
 was detected in the PDPH group . However, these studies had a small sample size.

 As a follow up to the national survey of PDPH management in Israel the investigators aimed in
 this study to evaluate the long term consequences of PDPH including chronic headache,
 backache, postpartum depression (PPD), decreased breastfeeding and the development of PP
 PTSD.

 Study Objective:

 In this study the investigators intend to evaluate the long term sequelae of parturients who
 suffered from an accidental dural puncture and a subsequent PDPH.

 Primary Aims:

 This study's primary objective is to examine whether parturients suffering from a PDPH are at
 higher risk long-term for developing PP-PTSD than their counterparts.

 Secondary aims:

 Secondary aims include long term outcomes of parturients who suffered from PDPH:

 -  Chronic headache

 -  Chronic backache

 -  Comparing long term outcomes of parturients suffering from a PDPH with conservative
 treatment verses epidural blood patch treatment.

 -  PPD

 -  Breastfeeding outcomes including duration of breastfeeding

 -  Women will also be questioned about other labor experiences including analgesic
 consumption, breastfeeding outcome.

 Study Design This study is a prospective multi center cohort, study. Following obtaining
 approval from the local Institutional Review Board at each center, all women who developed a
 PDPH following an ADP between the years 2007-2017 will be contacted by phone and verbal
 consent will be obtained for participation in the study. Each participant will be compared to
 two women receiving epidural analgesia on the same day as those women who suffered an ADP.
 All participants will be requested to answer an IRB approved telephone script. Parturients
 will be assed for postpartum depression using the Edinburgh Postnatal Depression Scale
 (EPDS)translated into Hebrew . They will also be assed for PTSD using the validated PTSD
 questionnaire . Additionally in order to examine long term risk for chronic pain and backache
 parturients will be assed for persistent pain using the validated Brief Pain Inventory
 questionnaire ,and the validated Oswestry low back pain questionnaire . Parturients will also
 be asked about other labor experiences including analgesic consumption and breastfeeding
 outcome, in cases of breastfeeding cessation women will be asked an open-ended question about
 the reason for discontinuation.

 Data collection:

 Additional data will be collected from an electronic medical file database. Data collection
 will include; parturient's demographic data, obstetric data, in case of EBP treatment
 procedural data (level of injection, volume of blood injected, loss of resistance technique-
 air/saline, anesthesiologist experience, time of procedure, duration of procedure, technical
 difficulties, visual analogue score (VAS) upon lying down/ upon sitting up - before the EBP
 and upon release
Inclusion Criteria:

 - All cases of parturients suffering from a PDPH during the years 2007-2017.

 Exclusion Criteria:

 - Women unable to be answer a questionnaire in Hebrew. Women under the age 18 Women
 suffering from a PDPH following spinal anesthesia for cesarean section.