Predicting severe pain after cesarean section: prospective cohort study

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Abstract

BACKGROUND: Severe and unbearable pain after abdominal delivery is recorded in 20% of cases, indicating the limitations of the applied methods of postoperative pain relief and the need for a personalized approach. Tests assessing preoperative pain threshold and anxiety have the greatest sensitivity and specificity as predictors of intense postoperative pain. The informative value of these tests in the Russian obstetric population has not been assessed.

OBJECTIVE: This study aimed to determine the optimal method for predicting severe pain after cesarean section (CS).

MATERIALS AND METHODS: This prospective cohort study included 212 women who underwent elective CS under spinal anesthesia. The Hospital Anxiety and Depression Scale (HADS) anxiety rating scale, pressure algometry, and cutaneous infiltration anesthesia pain intensity assessment were used as predictors of high-intensity pain. Postoperative pain intensity was assessed using a 10-point Numeric Rating Scale (NRS). The maximum level of pain according to the central pain level at rest (NRSr) and during movement (NRSa) was recorded 24 hour postoperatively. The number of requests for “rescue analgesia” was recorded. The predictive value of the studied methods was determined based on ROC curve analysis.

RESULTS: Median (interquartile range) NRSa was 5 [4–5]. Severe pain was recorded in 14% of the patients. The area under the ROC-curve (AUC), reflecting the relationship between severe postoperative pain and pressure-pain threshold, was 0.91±0.03 with 95% confidence interval (CI) of 0.84–0.97 (p <0.001). The relationship between pain intensity during infiltration anesthesia and postoperative pain severity had AUC=0.88 ± 0.04 with 95% CI of 0.81–0.96 (p <0.001). The HADS anxiety score demonstrated the lowest predictive ability (AUC=0.69±0.06; 95% CI, 0.81–0.96; p <0.001). When all three techniques were used together, the AUC was 0.924±0.024 with 95% CI 0.88–0.97 (p=0.001).

CONCLUSION: Preoperative pressure-pain threshold and pain severity during infiltration anesthesia are reliable predictors of severe pain after CS. Assessment of preoperative anxiety using HADS has low sensitivity and specificity. However, its use in conjunction with methods for assessing the pain threshold increases the predictive value of the combined model compared with the results of using the methods separately.

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About the authors

Nataliya V. Shindyapina

Razumovsky Saratov State Medical University

Author for correspondence.
Email: schindyapinan@yandex.ru
ORCID iD: 0000-0002-7124-3697
SPIN-code: 6186-5930
Scopus Author ID: 57223182289

MD, department assistant

Russian Federation, Saratov

Dmitry V. Marshalov

Razumovsky Saratov State Medical University

Email: marshald@mail.ru
ORCID iD: 0000-0002-8774-0700
SPIN-code: 4682-2711
Scopus Author ID: 8860392900

MD, Dr. Sci. (Medicine), associate professor

Russian Federation, Saratov

Efim M. Shifman

Vladimirsky Moscow Regional Research Clinical Institute

Email: eshifman@mail.ru
ORCID iD: 0000-0002-6113-8498
SPIN-code: 4582-8494
Scopus Author ID: 58399983600

MD, Dr. Sci. (Medicine), professor

Russian Federation, Moscow

Alexander V. Kuligin

Razumovsky Saratov State Medical University

Email: avkuligin@yandex.ru
ORCID iD: 0000-0001-5705-215X
SPIN-code: 1651-8142
Scopus Author ID: 57190874563
ResearcherId: AAD-9401-2021

MD, Dr. Sci. (Medicine), department head

Russian Federation, Saratov

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Supplementary files

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2. Fig. 1. ROC curves characterizing the relationship between the occurrence of high-intensity pain and pain scores at the time of performing lidocaine injection, anxiety and depression indicators according to HADS.

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3. Fig. 2. ROC curves characterizing the relationship between the occurrence of severe pain and the pain pressure threshold and pain tolerance.

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4. Fig. 3. ROC curve for predicting severe pain on movement in the first 24 hours after surgery for models including all 5 covariates (pressure pain threshold, pain tolerance, HADS anxiety and depression, pain at the time of lidocaine injection).

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