ROLE OF BODY MASS INDEX IN THE DEVELOPMENT OF POST-DURAL PUNCTURE HEADACHE IN OBSTETRIC ANESTHESIA DURING CESAREAN-SECTIONS

Pakistan Journal of Medical & Cardiological Review https://pakjmcr.com/index.php/1/about Online ISSN Print ISSN 3007-2387 3007-2379 Vol. 4 No. 4 (2025) Pakistan Journal of Medical & Cardiological Review Page 434 ROLE OF BODY MASS INDEX IN THE DEVELOPMENT OF POST-DURAL PUNCTURE HEADACHE IN OBSTETRIC ANESTHESIA DURING CESAREAN-SECTIONS Irfan Hussain Pain Therapist, Pain Relief with Professor Irfi, Rahman Diagnostic Center Timergara. Email: [email protected] Hazrat Bilal Lecturer Anesthesia, Faculty of Health Professional Technologies, Iqra National University Peshawar Zia Ur Rahman Student of MS Anesthesia Technology, Green International University, Lahore Said Ali Shah Anesthesia Department, Allied Health Sciences, Technologist, Iqra National University Peshawar Sajid Raza Anesthesia Technologist, Hayatabad Medical Complex, Peshawar Aneeqa Shahzad Lecturer, Department of Health Technologies, Faculty of Green International University, Lahore Post-Dural Puncture Headache (PDPH) is a prevalent complication in obstetric anesthesia, particularly following spinal anesthesia for cesarean sections, affecting patient recovery and quality of life due to CSF leakage and orthostatic symptoms. This cross-sectional descriptive study, conducted over four months at Rehman General Hospital, Samar Bagh, Dir, aimed to investigate the prevalence and determinants of PDPH among 370 obstetric patients aged 18-45 years undergoing elective cesarean sections under spinal anesthesia, focusing on factors like BMI, maternal age, needle characteristics, and comorbidities. Using simple convenient sampling, data were collected via a structured questionnaire and the StateTrait Anxiety Inventory (STAI), analyzed with SPSS version 23.0 employing descriptive statistics, paired t-tests, and Chi-square tests for significance (p < 0.05). Results revealed that 72.4% of patients were aged 18-30, 58.8% had normal BMI, 40.4% had prior spinal anesthesia exposure, and 41.7% reported headaches, with 34.8% experiencing posture-related aggravation; blunt-tip, fine-gauge needles (25-27G) were used in 82.1% and 71.4% of cases, respectively, and Abstract Author Details Keywords: Post-Dural Puncture Headache, Csf Leakage, Spinal Anesthesia, State-Trait Anxiety Inventory, Prior Exposure. Received on 15 Oct 2025 Accepted on 07 Oct 2025 Published on 17 Oct 2025 Corresponding E-mail & Author*: Irfan Hussain Pain Therapist, Pain Relief with Professor Irfi, Rahman Diagnostic Center Timergara. Email: [email protected] Page 435 anesthesia was administered in the sitting position for 98.4%. Discussion highlights that younger age, higher BMI, prior exposure, and procedural factors significantly increase PDPH risk, aligning with studies from Gambia, Ethiopia, and Nigeria, and underscoring gaps in training and guidelines. In conclusion, this research emphasizes the need for precision anesthesia to address modifiable risks, improving maternal outcomes and reducing PDPH burden in obstetric care. Introduction Post-Dural Puncture Headache (PDPH) remains one of the most prevalent and distressing complications following procedures involving a breach in the dura mater, such as spinal anesthesia or accidental puncture during epidural analgesia. As highlighted in recent literature (Uppal et al., 2024), (1) PDPH typically manifests within 5 days of the procedure and is characterized by orthostatic symptoms, including headaches that worsen upon standing and improve when lying down. This condition arises due to cerebrospinal fluid (CSF) leakage, leading to intracranial hypotension, and can significantly impair patient recovery, particularly in high-risk groups like pregnant women undergoing cesarean sections. With the global rise in cesarean deliveries, where spinal anesthesia is the preferred method due to its rapid onset and safety profile, understanding PDPH's etiology and risk factors is crucial for improving maternal outcomes (2). Patient-specific factors, including age, sex, body mass index (BMI), and pregnancy status, play a pivotal role in the incidence of PDPH. For instance, women, especially those who are overweight or obese, face heightened risks due to physiological changes such as elevated estrogen levels, which can alter cerebral artery tone and exacerbate CSF hypotension. In Ethiopia and other regions, the increasing adoption of spinal anesthesia for obstetric procedures has amplified these concerns, with reported PDPH rates ranging from less than 2% to 40%, influenced by procedural variables like needle size and type (Uppal et al., 2024). This variability underscores the need for targeted interventions, as PDPH not only affects immediate postoperative comfort but also extends to long-term health implications, such as delayed mobility and reduced quality of life (3,4). Globally, the intersection of obesity and pregnancy has emerged as a critical factor in anesthetic complications. According to the World Health Organization (WHO), obesity (BMI ≥ 30 kg/m²) is rising among women of reproductive age, with studies indicating adverse outcomes like postpartum hemorrhage and fetal macrosomia in obese patients (Zheng et al., 2024). In the context of spinal anesthesia, these factors can complicate procedures, such as lumbar punctures, due to anatomical challenges like increased abdominal circumference and altered CSF dynamics (Bisht et al., 2025). As cesarean sections become more common, addressing these risks through refined anesthetic techniques is essential to mitigate PDPH and enhance overall patient safety (5,6). A study conducted in Istanbul, Turkey, from February 2024, by Akyol et al. investigated the impact of spinal needle types on PDPH incidence in 886 patients undergoing elective cesarean sections. The research compared 25-gauge pencil-point needles, 26-gauge atraumatic needles, and 27-gauge pencil-point needles, revealing a mean PDPH incidence of 3.2%. Notably, the 26-gauge atraumatic needle group experienced a higher rate (6.8%) compared to the others, emphasizing that noncutting, smaller needles may reduce CSF leakage and subsequent headaches (Akyol et al., 2024). This finding aligns with broader evidence that procedural factors, such as needle design and size, significantly influence PDPH outcomes, particularly in obstetric settings (7). In contrast, a systematic review by Alatni et al. from Qassim University, Saudi Page 436 Arabia, analyzed 345 articles published between 2013 and 2023 on PDPH prevention and treatment. The review, adhering to PRISMA standards, included 38 studies and highlighted the efficacy of interventions like oral pregabalin, intravenous aminophylline, and minimally invasive nerve blocks (e.g., sphenopalatine ganglion blocks) in managing PDPH. It also noted that patient positioning during procedures— such as lateral decubitus over sitting—could lower incidence rates, though evidence for epidural dexamethasone remains inconclusive (Alatni et al., 2024). These insights underscore the variability in PDPH management across institutions and the need for standardized protocols, especially in regions with rising obesity rates among pregnant women (8). One key benefit of advancing spinal anesthesia techniques is the potential to reduce PDPH through targeted procedural modifications, such as the use of ultrasound guidance. For instance, a study by Anand et al. (2025) compared pre-procedure ultrasound-guided combined spinal-epidural (CSE) with real-time ultrasound-guided CSE in obese patients, demonstrating that real-time guidance required fewer attempts and shorter times for catheter insertion, thereby minimizing dural trauma and associated complications. This approach not only enhances success rates in anatomically challenging cases, like those involving obesity or degenerative spinal changes, but also supports faster recovery, as seen in its application for cesarean sections (9). Additionally, spinal anesthesia offers broader benefits in obstetric care by addressing patient-specific factors like BMI and abdominal circumference, which influence CSF dynamics and drug diffusion. Research indicates that hypobaric local anesthetics, such as bupivacaine, can be optimized with adjuvants to improve efficacy and reduce side effects like intraoperative hypotension (Li et al., 2025). In pregnant women, these techniques lower the risk of thromboembolic events and perioperative blood transfusions, promoting safer outcomes and greater maternal satisfaction, as evidenced by studies showing no significant differences in anesthesia administration between BMI groups (10). In conclusion, PDPH represents a significant challenge in spinal anesthesia, particularly for cesarean sections in high-risk populations like obese pregnant women, with incidence rates influenced by a complex interplay of procedural and patientspecific factors. The literature highlights effective strategies for prevention and management, while further benefits of refined techniques underscore their potential to enhance safety and efficacy. This research aims to investigate the prevalence and determinants of PDPH in a specific context, such as Ethiopia or similar settings, to inform evidence-based guidelines and improve clinical practices, ultimately reducing the burden on patients and healthcare systems (11). METHODOLOGY Study Design: This study was Cross-sectional descriptive. Study Settings: The study was conducted Rehman General Hospital Samar Bagh Dir L. Study Duration: The study was done in 4 months after synopsis approval. Sample Size: The study included a sample of 370 obstetric patients undergoing cesarean delivery under spinal anesthesia to evaluate PDPH prevalence and its associations with BMI, Page 437 maternal age, and spinal needle characteristics, calculated for adequate statistical power with a 5% margin of error at 95% confidence to ensure reliable estimates and robust comparisons. It was obtained using the formula (12). Sample Technique: Simple convenient sampling Sample Selection: Inclusion Criteria Obstetric Patients those women undergoing Cesarean-sections (Elective C-Section). Patients aged 18–45 years. All BMI categories (underweight, normal, overweight and obese) to assess the association (13) Patients receiving spinal anesthesia Patients who provide written informed consent to participate in the study ASA (American Society of Anesthesiologists) Physical Status I or II, Patients without severe systemic diseases. Exclusion Criteria Woman which undergoing emergency C-Section) Patients which receive epidural anesthesia (14) Patients ASA (American Society of Anesthesiologists) Physical Status III or IV Patients which have severe systemic disease Patients who do not provide consent to participate in the study. Data collection procedure After obtaining necessary approvals from the Institutional Research Committee, Iqra National University Peshawar, and Rehman General Hospital, data was collected over three months from patients undergoing elective surgeries under general anesthesia, using a structured questionnaire and the State-Trait Anxiety Inventory (STAI) to assess anxiety changes before and after an educational session. Data analysis procedure: Data were analyzed using SPSS version 23.0, employing descriptive statistics for demographics, with anxiety level as the dependent variable and preoperative education as the independent; a paired t-test (or Wilcoxon Signed-Rank if nonnormal) compared preand post-education scores, Chi-square (with Fisher's Exact as needed) for categorical comparisons, and p < 0.05 as significant (15) RESULTS The study population was predominantly composed of younger obstetric patients. with almost three-quarters (72.4%) of the study population being between the ages of 18 and 30. Just 5.3% of women were 39 years of age or older, compared to 21.1% of women aged 32 to 38. Women of early reproductive age are more likely to undergo cesarean sections under spinal anesthesia, which is consistent with standard obstetric practice. Given that age-related physiological changes including decreased tissue elasticity, vascular reactivity, and changed pain sensitivity may affect anesthetic effects, the modest percentage of older parturient is significant. The results of this study on post-Dural puncture headache (PDPH) predominantly represent individuals Page 438 in their peak reproductive years, as indicated by the overall preponderance of younger women. Table 1: Age of the patients Figure 1: age of the patients Figure 1 The majority of patients (58.8%) had a normal BMI (18.5-24.9 kg/m²), whereas 37.4% were obese (30-34.9 kg/m²). A tiny percentage were either very overweight (>35, 1.6%) or underweight (<18.5, 1.1%). this distribution reveals that the research sample was mostly made up of women with normal to moderately high BMI, which provides a solid foundation for assessing the influence of body mass on post-Dural puncture headache (PDPH). The large percentage of obese individuals is especially important since higher BMI might change spinal structure, boost intra-abdominal pressure, and impact cerebrospinal fluid dynamics, thereby altering PDPH risk. In contrast, the small number of underweight and highly overweight individuals limits generalization for these populations. Table 2: Patient body mass index (BMI) Frequency Percent Valid Percent Cumulative Percent Valid 18 to 24 158 42.2 42.2 43.3 25 to 31 113 30.2 30.2 73.5 32 to 38 79 21.1 21.1 94.7 39 to 45 20 5.3 5.3 100.0 Total 370 100.0 100.0 Page 439 Figure 2: Patient body mass index (BMI) Figure 2 In this study of 370 obstetric patients, 219 women (59.6%) had no prior experience with spinal anesthesia, whereas 151 (40.4%) had received spinal anesthesia during previous births. This distribution indicates that a considerable number of individuals had prior anesthetic exposure, which is clinically significant for determining the risk of post-Dural puncture headache (PDPH). Prior spinal surgeries may increase the risk of complications if the punctures were technically challenging or included many Dural injuries, but they may also educate patients with PDPH symptoms, allowing for more accurate reporting. Overall, the presence of almost 40% with prior spinal anesthesia highlights the importance of past anesthetic history as a possible moderator of PDPH development in later cesarean procedures. Table 3: Patients had no prior experience with spinal anesthesia Frequency Percent Valid Percent Cumulative Percent Valid NO 219 59.6 59.6 59.6 YES 151 40.4 40.4 100 Total 370 100 100 Patient body mass index (BMI) Frequency Percent Valid Percent Cumulative Percent Valid Normal weight 18.5_24.9 220 58.8 58.8 59.9 Obese 30_34.9 140 37.4 37.4 97.3 overweight >35 6 1.6 1.6 98.9 Underweight < 18.5 4 1.1 1.1 100.0 Total 370 100.0 100.0 Page 440 Figure 3: Among the 370 obstetric patients evaluated, 214 (58.0%) reported no headache after spinal anesthesia, but 156 (41.7%) had headache during or after the cesarean section. This very high frequency of headache is significant because it represents the high prevalence of post-Dural puncture headache (PDPH) in the obstetric population. The study reveals that approximately two out of every five women suffered headaches consistent with PDPH symptoms, emphasizing its clinical importance despite the widespread use of fine-gauge and pencil-point spinal needles in current practice. These findings underscore the need of precautionary measures, careful technique, and early detection of PDPH in obstetric anesthesia, since headaches after cesarean birth can have a substantial influence on maternal comfort and recovery in the immediate postpartum period. Table 4: Reported no headache after spinal anesthesia Table 4 Figure 4: Frequency Percent Valid Percent Cumulative Percent Valid NO 214 58 58 58 YES 156 41.7 41.7 100 Total 370 100 100 Page 441 The current study of 370 obstetric patients, 240 women (64.2%) reported no posturerelated pain aggravation, whereas 130 patients (34.8%) had headaches that increased in sitting or standing and relieved when laying down. this pattern is clinically noteworthy since posture-dependent headaches are a distinguishing characteristic of post-Dural puncture headache (PDPH). The fact that more than one-third of patients had this characteristic presentation gives strong evidence that PDPH accounted for a significant proportion of the postoperative headaches observed. Such positional features separate PDPH from other nonspecific postpartum headaches and support the role of BMI and anesthetic variables in its development. These findings emphasize the significance of meticulous spinal technique and close monitoring in obstetric anesthesia to minimize and immediately resolve PDPH. Table 5: reported no posture-related pain aggravation Figure 5: Frequency Percent Valid Percent Cumulative Percent Valid NO 240 64.2 64.2 65.2 YES 130 34.8 34.8 100 Total 370 100 100 Page 442 Out of 370 obstetric patients, the majority (219; 58.6%) reported no comorbidities. Among individuals with comorbidities, hypertension was the most common (55; 14.7%), followed by diabetes (45; 12.0%). A smaller proportion had both hypertension and diabetes (31, 8.3%). Less prevalent conditions were hypotension (10; 2.7%), renal dysfunction (5; 1.3%), and diabetes-hypertension. Only 0.8% reported further mild problems. this distribution reveals that while most patients were otherwise healthy, a significant number had chronic conditions, including hypertension and diabetes. These variables are important because they can change vascular dynamics, pain thresholds, and recovery profiles, thereby impacting the perception and severity of post-Dural puncture headache (PDPH). Table 6: Reported no comorbidities Figure 3: Frequency Percent Valid Percent Cumulative Percent Valid Diabetes 45 12.0 12.0 13.1 Hypertensions 55 14.7 14.7 28.3 Hypertensions, Diabetes 31 8.3 8.3 36.6 Hypotension 10 2.7 2.7 39.3 No Comorbid 5 1.3 1.3 40.1 None of these 219 58.6 58.6 98.7 Renal dysfunction 5 1.3 1.3 100.0 Total 370 100.0 100.0 Page 449 Punchuklang W, Nivatpumin P, Jintadawong T. Total failure of spinal anesthesia for cesarean delivery, associated factors, and outcomes: A retrospective casecontrol study. Medicine (Baltimore). 2022;101(27): e29813. Sakova V, Varjola E, Pepper J, Jernman R, Vaananen A. Are labor epidural catheters after a combined spinal epidural (CSE) technique more reliable than after a traditional epidural? 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