The epidural space was approached at the level of the dural puncture or at a lower space, using loss of resistance to saline. EBP was performed for patients who reported a persistently severe headache after 48 h of conservative treatment. If nausea or vomiting was prominent, 10 mg metoclopramide orally every 8 h was allowed. For severe headache, 1 mg/kg meperidine was given by intramuscular injection, in addition, and could be repeated every 6 h as required. For mild-to-moderate headache, 1 g paracetamol and 400 mg ibuprofen orally every 6 h were prescribed. They were instructed to lie flat in a supine position and to drink plenty of fluids. All patients with PDPH were managed conservatively. Patients who developed PDPH after discharge would be readmitted. Discharged patients were contacted daily by phone for 14 days and were asked about symptoms suggestive of PDPH. Patients who did not develop PDPH for 48 h after ADP and who were ambulating normally were discharged from the hospital with the instruction to come back for reassessment if they experience any headache. Nurses and anesthesiologists involved in headache assessment were blinded as to the patients' groups. The highest score recorded on each day from the onset of headache until headache remitted completely was taken, and these scores were averaged and entered for analysis. Severity was assessed using a 5-point verbal rating scale as follows: no headache = 0, mild headache = 1, moderate headache = 2, severe headache = 3, and unbearable headache = 4. Patients reporting headache were asked about its time of onset, character, aggravating and alleviating factors, and severity. A resident anesthesiologist visited the patients twice a day, inquired specifically about headache, and reviewed the patients' charts. The staff nurse in charge was asked to inquire the patients whether they had any headache at 8-h intervals. The incidents were explained to the patients, who were informed to report any headache, and were encouraged to ambulate and to drink plenty of fluids, with prescription of stool softeners. Patients were admitted to hospital for 48 h during which they were managed expectantly. Injections were prepared by assistants not participating in the study, and both the patients and those involved in the study were blinded as to the patients' groups. In group II (control group), patients received an equal volume of normal saline. The reconstituted solution was injected intravenously over 5 min. Four vials of cosyntropin, each containing 0.25 mg of the drug, were reconstituted in 0.9% sodium chloride, using 1 ml of solvent for each vial. In group I (cosyntropin group), patients received a single intravenous injection of cosyntropin (Cortrosy®, Amphastar Pharmaceuticals Inc., Rancho Cucamonga, CA) in a dose of 1 mg. The list was created using the GraphPad StatMate version 1.01i software (GraphPad Software Inc., San Diego, CA) and was accessible to anesthesiologists attending to patients in labor through the computer database. Thirty minutes after delivery, the epidural catheter was removed, and patients were randomly assigned to one of two groups using a computer-generated random number list.
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