The study was registered and approved by the Ethics Committee of the Kurdistan University of Medical Sciences (Ethical code: IR.MUK.REC.1397.6675/14). For this cross-sectional descriptive study, 80 women candidates for CS referring to Besat Hospital, Sanandaj, Iran, were recruited by convenient sampling in 2021. The researchers described the method of the study to women candidates for cesarean and provided that they were willing to participate in the study, they entered the research after being obtained informed consent. Exclusion criteria were women with a history of migraine headaches or other chronic headaches, women with a history of back pain or lumbar diseases, women being addicted to any drugs, women who had regularly taken antidepressants and painkillers preoperatively, and women who had frequent spinal punctures for reason except SA.
At the 12th week of gestation, demographic data were obtained. According to the BMI formula, BMI = kg/m2(kg is a person's weight in kilograms and m2 is their height in meters squared) [12], participants' BMI at the 12th week of pregnancy was calculated. Using the patient's medical file, BP at the first and second visits to the ward was recorded.
On the day of surgery, the participants’ FBS, BP, and BMI were measured. All participant women received 5-7cc / kg of intravenous normal saline fluid [13]. In the operating room, the patient was placed in an upright position, and the operating room nurse used 10% iodine to prep the back of the patient. Then, under sterile conditions, the anesthesiologist inserted a 25G-size Sprotte spinal needle into the dura at the L3-L4 or L4-L5 intervertebral space of the patient's back perpendicularly. After the cerebral fluid flowed, the anesthesiologist injected either 5% Lidocaine with a dose of 1.1 to 1.2mg/kg or Bupivacaine with a dose of 10-12mg/kg into the dural puncture[2]. After inducement of SA and maintaining its level, the intravenous fluid was calculated according to the 4/2/1 rule (4 cc/kg/hr. for the first 10 kg, 2 cc/kg/hr. for the second 10 kg, and 1 cc/kg/hr. for every kg above 20) and infused into the patients. The anesthesiologist prescribed Midazolam with a dose of 1-2mg/kg for all patients to sedate them during the surgery. Thepatient'svital signs were carefully monitored by a standard ECG monitor device, sphygmomanometer, and pulse oximeter. If the patient's blood pressure fell 30% below her baseline BP, 10mgof intravenous Ephedrine was injected into her to raise the patient's blood pressure. Bradycardia of fewer than 50 beats/min was treated with 0.5mg of intravenous Atropine [14].
After the CS, patients were kept in the supine position in the maternity ward. The researchers recorded the time taken for the patient to be in the supine position for her headache to be alleviated and recorded the recurrent headaches. If the PDPH was persistent, treatments included complete bed rest, adequate hydration, NSAID analgesics, and in the case of severe headaches (the scores 7, 8, 9, 10 according to NPRS), Epidural Patch was utilized. The researchers used the Numeric Pain Rating Scale (NPRS) to measure patients' headache severity. The NPRS is a segmented numeric version of the visual analog scale (VAS) in which a respondent selects a whole number from 0 to10 integers that best reflects the intensity of their pain. A score of zero indicates no pain and as the intensity of pain increases, the patient chooses a higher score. A score of five indicates average pain, and a score of ten means the worst possible pain [15].
The association between patients' BMI before pregnancy, BMI at the 12th week of the pregnancy, BMI, FBS, and BP on the day of surgery, and PDPH after CS was examined. To describe research results and indicate the frequency of each variable, information summary methods in descriptive (frequency table, mean, mode, standard deviation, range, median, and calculating the percentage) and inferential statistics were used. An independent t-test was used to investigate the association between headache and quantitative independent variables. To investigate the studied variables of the normal distribution, Kolmogorov–Smirnov test was used, and the two-tailed independent t-test was used to investigate the link between the two-level independent variable. If the data does not follow the normal distribution, the nonparametric t -value was used. The significance level of 5% was considered for all tests. For analyzing the data, SPSS software version 16 was used.