Department of Medical Informatics, Amsterdam University Medical Center, Amsterdam, the Netherlands.
Department of Obstetrics and Gynecology, Amsterdam University Medical Center, Amsterdam, the Netherlands.
Acta Obstet Gynecol Scand. 2020 Sep;99(9):1155-1162. doi: 10.1111/aogs.13837. Epub 2020 Mar 20.
The associations of epidural analgesia and low Apgar score found in the Swedish Registry might be a result of confounding by indication. The objective of this study was to assess the possible effect of intrapartum epidural analgesia on low Apgar score and neonatal intensive care unit (NICU) admission in term born singletons with propensity score matching.
This was a propensity score matched study (n = 257 872) conducted in a national cohort of 715 449 term live born singletons without congenital anomalies in the Netherlands. Mothers with prelabor cesarean section were excluded. Main outcome measures were 5-minute Apgar score <7, 5-minute Apgar score <4 and admission to a NICU for at least 24 hours. First, an analysis of the underlying risk factors for low Apgar score <7 was performed. Multivariable analyses were applied to assess the effect of the main risk factor, intrapartum epidural analgesia, on low Apgar score to adjust the results for confounding factors. Second, a propensity score matched analysis on the main risk factors for epidural analgesia was applied. By propensity score matching the (confounding) characteristics of the women who received epidural analgesia with the characteristics of the control women without epidural analgesia, the effect of possible confounding by indication is minimized.
Intrapartum epidural analgesia was performed in 128 936 women (18%). Apgar score <7 was present in 1.0%, Apgar score <4 in .2% and NICU admission in .4% of the deliveries. The strongest risk factor for Apgar score <7 was epidural analgesia (adjusted odds ratio [aOR] 1.9, 95% confidence interval [CI] 1.8-2.0). The propensity score matched adjusted analysis of women with epidural analgesia showed significant adverse neonatal outcomes: aOR 1.8 (95% CI 1.7-1.9) for AS <7, aOR 1.6 (95% CI 1.4-1.9) for AS <4 and aOR 1.7 (95% CI 1.6-1.9) for NICU admission. The results of epidural analgesia on AS <7 were also significantly increased for spontaneous start of labor (aOR 2.0, 95% CI 1.8-2.1) and for spontaneous delivery.
Intrapartum epidural analgesia at term is strongly associated with low Apgar score and more NICU admissions, especially in spontaneous deliveries. This association needs further research and awareness.
瑞典登记处发现硬膜外镇痛与低 Apgar 评分之间的关联可能是混杂因素造成的。本研究的目的是通过倾向评分匹配评估产程中硬膜外镇痛对足月单胎无先天性畸形新生儿低 Apgar 评分和新生儿重症监护病房（NICU）入院的可能影响。
这是一项在荷兰一项全国队列中进行的匹配倾向评分的研究（n=257872），其中包括 715449 例足月活产无先天性畸形的单胎。排除了产前剖宫产的母亲。主要结局测量值为 5 分钟 Apgar 评分<7、5 分钟 Apgar 评分<4 和至少 24 小时入住 NICU。首先，对低 Apgar 评分<7 的潜在风险因素进行了分析。多变量分析用于评估主要风险因素（产程中硬膜外镇痛）对低 Apgar 评分的影响，以调整结果以适应混杂因素。其次，对硬膜外镇痛的主要风险因素进行了倾向评分匹配分析。通过倾向评分匹配接受硬膜外镇痛的女性与未接受硬膜外镇痛的对照组女性的特征，将指示性混杂的影响降到最低。
128936 名女性（18%）接受了硬膜外镇痛。分娩中出现 Apgar 评分<7 的占 1.0%，Apgar 评分<4 的占 0.2%，NICU 入院的占 0.4%。Apgar 评分<7 的最强风险因素是硬膜外镇痛（调整后的优势比[aOR]1.9，95%置信区间[CI]1.8-2.0）。接受硬膜外镇痛的女性的倾向性评分匹配调整分析显示新生儿不良结局显著增加：AS<7 的 aOR 为 1.8（95%CI 1.7-1.9），AS<4 的 aOR 为 1.6（95%CI 1.4-1.9），NICU 入院的 aOR 为 1.7（95%CI 1.6-1.9）。自发性分娩中自发性临产（aOR 2.0，95%CI 1.8-2.1）和自发性分娩中 AS<7 的硬膜外镇痛效果也显著增加。
足月时产程中硬膜外镇痛与低 Apgar 评分和更多 NICU 入院密切相关，尤其是在自发性分娩中。这种关联需要进一步研究和关注。
