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.

All women who developed a PDPH following an ADP between the years 2007-2017 at rabin medical center and at Assaf Harofeh Medical Center.