Association between early systemic hypotension after spinal anesthesia and post-dural puncture headache: a prospective observational cohort study

Aim Post-dural puncture headache (PDPH) remains an important complication after spinal anesthesia for cesarean delivery. Although cerebrospinal fluid leakage is central to its pathophysiology, systemic hemodynamic changes may also contribute. This prospective observational cohort study evaluated the association between early post-spinal hypotension and PDPH. Methods Pregnant women undergoing elective or semi-elective cesarean delivery under spinal anesthesia were prospectively followed. Systolic blood pressure (SBP), mean arterial pressure, heart rate, ephedrine requirement, and perioperative variables were recorded. The primary exposure was the percentage decrease in SBP at 5 minutes after intrathecal injection. PDPH was assessed during the first 5 postoperative days according to International Classification of Headache Disorders-3 criteria. Logistic regression and receiver operating characteristic (ROC) analyses were performed. Results A total of 353 patients were included, and PDPH occurred in 10 patients (2.83%). Baseline hemodynamic variables were similar between patients with and without PDPH. Patients who developed PDPH had lower 5-minute SBP and a greater percentage decrease in SBP from baseline. Severe hypotension (SBP decrease ≥20%) was associated with higher odds of PDPH (Firth OR 7.62, 95% CI 2.21–32.01; P = .002). The percentage decrease in SBP showed good discrimination for PDPH (AUC 0.880, 95% CI 0.807–0.937); an exploratory Youden-derived threshold of an 18.85% decrease was identified but requires external validation. In Firth penalized multivariable logistic regression, percentage SBP decrease remained independently associated with PDPH. Conclusion In parturients undergoing cesarean delivery under spinal anesthesia, greater early post-spinal systolic hypotension was independently associated with subsequent PDPH. These findings support further investigation of hemodynamic stability as a potentially relevant factor in PDPH prevention.