Effect of Altitude on Postdural Puncture Headache After Caesarean Delivery

Study Overview
=================
Brief Summary
-----------------
The aim of this study is to examine the effects of altitude (high altitude versus low altitude) on incidence and severity of postural puncture headache (PDPH) following spinal anaesthesia for caesarean delivery. The investigators hypothesized that the risk of PDPH would be higher in highlander parturients than in lowlander parturients.

Detailed Description
-----------------
This will be a prospective cohort study conducted in two different altitudes in Nepal. The high-altitude site is in Jumla, approximately 2514 m above the sea level, and a low altitude city is Dharan, located at 350 m from sea level. The investigators will screen the eligible participant admitted to the in-patient obstetric unit. The investigator will also record patient baseline characteristics, preoperative anxiety, antenatal depression, presence of chronic pain conditions or preexisting headache. Spinal anaesthesia will be administered in the sitting position at the L3-L4 or L4-L5 interspace using a 25-G pencil point spinal needle (Pencan® 25-gauge). The diagnosis of post-dural puncture headache will be based on the international headache society ICDH-3 criteria

Official Title
-----------------
Effect of Altitude on Postdural Puncture Headache After Caesarean Delivery: a Prospective, Multicentre Cohort Study

Conditions
-----------------
Post-Dural Puncture Headache

Participation Criteria
=================
Eligibility Criteria
-----------------
Inclusion Criteria: Parturient, aged more than or equal to 18 years American society of Anesthesiologist 2 and 3 Scheduled for elective and non-elective (category 2 & 3) caesarean delivery with spinal anesthesia Native to their resident altitude i.e., those born, raised, and have continuously lived at the same altitude, at least for the past 1 year. Exclusion Criteria: Hypertensive disorder Cerebrovascular disease Mental disorder (schizophrenia and other psychotic disorders) Known fetal anomalies Contraindication to spinal anaesthesia. Those requiring general anaesthesia for delivery due to failed spinal anesthesia Major post-delivery complications (severe haemorrhage, sepsis, or ICU admission) Those who migrate from their resident altitude (either low to high or vice versa) within 7 days post-delivery will also be excluded.

Ages Eligible for Study
-----------------
Minimum Age: 18 Years

Sexes Eligible for Study
-----------------
Female

Study Plan
=================
How is the study designed?
-----------------

Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| High-altitude group<br>Parturient who are native to their resident altitude, i.e. residing at the altitude above 2500 m from sea level will receive spinal anesthesia for caesarean section. | |
| Low-altitude group<br>Parturient who are native to their resident altitude, i.e. residing at the altitude below 500 m from sea level will receive spinal anesthesia for caesarean section. | |

What is the study measuring?
-----------------
Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Number of patients with postdural puncture headache | The diagnosis of post-dural puncture headache will be based on the international headache society ICDH-3 criteria: a headache that occurs within 5 days of a dural puncture, is located in the occipital and/or frontal areas, worsens within 15 min of sitting or standing and alleviates within 15 min after lying down, associated with at least one of the following features: neck stiffness, nausea, vomiting, photophobia, and tinnitus, and resolves either spontaneously within 1 week or within 48 h after effective treatment. | up to 7 days after spinal anesthesia | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Number of patients with severity of postdural puncture headache | using a numeric rating scale (NRS), with 0= NO pain 10=worst imaginable pain, and classified as none (NRS=0), mild (1-3), moderate (4-6), and severe (7-10) | up to 7 days after spinal anesthesia | 
| Pain assessed by PROMIS pain interference scale | 6-item PROMIS Pain Interference short form scale will be used to assess the self-reported consequences of PDPH on social, cognitive, physical, and recreational activities. Respondents will be asked to rate the interference of pain in each activity listed using a 1 to 5 scale, where 1 = Not at all. 2 = A little bit, 3 = Somewhat, 4 = Quite a bit, and 5 = Very much | 7 days after occurrence of postdural puncture headache | 
| Number of patients with non-postdural puncture headache | Headache that is not related to posture | up to 7 days after spinal anesthesia | 
| Number of patients who received treatment for postdural puncture headache | paracetamol, NSAID's, caffeine, opioids, glossopharyngeal nerve block, sphenopalatine ganglion block and epidural blood patch | up to 1 month after occurrence of PDPH | 
| Number of patient with chronic headache | Headache that is persistent after postdural puncture headache or after non-postdural puncture headache | At 1 and 3 months after occurrence of headache following spinal anesthesia | 
| Number of patients with chronic backache | Presence of backache after spinal anesthesia | At 1 and 3 months after spinal anesthesia | 
| Number of patients with chronic post surgical pain | Pain that develops or increases in intensity after cesarean section and persists at least 3 months after the surgery. The pain has to be localised to the surgical field or area of injury. Other causes of pain such as pre-existing pain conditions or infections, or malignancy etc. have to be excluded. | 3 month after caesarean section | 

 Terms related to the study
=================
Keywords Provided by Centre Hospitalier Valida
-----------------
Spinal Anesthesia, Cesarean Section