產婦剖腹生產使用全身麻醉與區域麻醉的關聯影響產後抑鬱症的發生風險之關聯性： 一個以臺灣人口為基礎的世代研究

Association of general anesthesia and neuraxial anesthesia in caesarean section affects the occurrence of maternal postpartum depression: A Population-Based Cohort Study

洪國訓(Kuo-Hsun Hung)

指導教授 ： 葉兆斌

共同指導教授 ： 周明智(Ming-Chih Chou)

中山醫學大學/醫學院/醫學研究所/碩士(2022年)

https://doi.org/10.6834/csmu202200079

摘要

研究目的
剖腹生產(CS: caesarean section)是世界上最常見的手術之一，全球平均率為18.6%。台灣過去十年的剖腹生產率均超過 30%。 [2] 剖腹生產是一項拯救生命的手術，可以保護母親和後代的生存或健康。隨著醫療技術的進步和社會風氣的改變，剖腹生產逐漸發展成為一種常見的分娩方式。然而，剖腹產也有副作用，例如增加產婦併發症的風險，包括感染、產後出血、輸尿管和膀胱損傷、子宮破裂、慢性盆腔疼痛、胃腸功能障礙和再次住院，並導致嬰兒出現醫療問題。產後抑鬱症 (Postpartum depression: PPD) 是分娩後最常見的孕產婦健康問題。產後抑鬱症的患病率因國家而異，從接近 0% 到 60% 不等。產後抑鬱症可能導致母嬰接觸和嬰兒餵養情況等對母親和兒童的不利影響，並增加自殘、自殺意念和殺嬰的風險。產後憂鬱是英國產後產婦死亡的主要原因。產後抑鬱症的症狀通常在分娩後一個月開始出現，是分娩後一年內形成的抑鬱發作。許多流行病學研究試圖解決過去三十年中，剖腹生產與產後抑鬱症發生之間的關聯。最近有兩項統合分析報告稱，與陰道分娩相比，剖腹生產與產後抑鬱症風險增加有關。然而，截至目前仍然無法得出令人信服的結果。到目前為止，只有少數研究檢查了剖腹生產麻醉方法對產後抑鬱症危害的影響。因此，本研究的目的是調查產後抑鬱症的發生與剖腹生產中選擇性全身麻醉或區域麻醉的麻醉方式之間的關係，該數據庫進行了台灣縱向健康保險數據庫。我們假設剖腹生產選擇全身麻醉將具有顯著高的產後抑鬱症風險。

研究方法及資料
我們使用健保資料庫當中2008-2017全國的母嬰檔案，納入從2008年1月1日至2017年12月31日當中有2034924 出生事件(每位小孩算1次)。第一階段: 出生通報資料不明的事件(n=34396) ，剩餘2000528出生事件，依照母親身份證號碼及出生年月歸戶口後的小孩檔案，共1968334次生產事件。

研究結果
經過排除條件篩選後(排除條件: 1.生產年在2008 或 2017; 2.自然產有任何麻醉，剖腹產無麻醉或同時兩種麻醉; 3. 母親生產後3個月內死亡 )，剩餘自然產1027146、剖腹產-全身麻醉 16234及剖腹產-半身麻醉(區域麻醉)535612。全身麻醉的產婦有相對較高的麻醉史、懷孕期間的共病比例、死產比例、較低的懷孕週數及嬰兒出生體重、子代一年內死亡率、嬰兒出生一個月內生命維持器及加護病房入住比例。相較於自然產的產婦，全身麻醉產婦的產後1年內憂鬱、睡眠障礙或使用安眠藥或抗憂鬱藥之調整後勝算對比為2.39 (95% CI=2.31-2.47)，半身麻醉產婦的勝算對比為1.71 (95% CI=1.70-1.73)。特別是生產後1年內使用安眠或抗憂鬱藥之勝算對比值，全身麻醉產婦為2.69(95% CI=2.60-2.78)，半身麻醉產婦的勝算對比為1.89 (95% CI=1.87-1.91)。

結論與建議
剖腹生產不論以半身麻醉或全身麻醉，產後1年內憂鬱、睡眠障礙或使用安眠藥、抗憂鬱藥之勝算比顯著高於自然生產者。關於剖腹產使用全身麻醉與區域麻醉比較，全身麻醉在產後1年內憂鬱、睡眠障礙或使用安眠藥、抗憂鬱藥之勝算比顯著高於區域麻醉。 特別是安眠或抗憂鬱藥的使用情形。

關鍵字

剖腹生產 ； 全身麻醉 ； 區域麻醉 ； 產後抑鬱

並列摘要

Objective
Caesarean section (CS: caesarean section) is one of the most common surgeries in the world, with a global average rate of 18.6%. Caesarean section productivity in Taiwan has exceeded 30% over the past decade. A caesarean section is a life-saving surgery that protects the survival or health of the mother and offspring. With the advancement of medical technology and the change of social atmosphere, caesarean section has gradually developed into a common mode of delivery. However, C-sections also have side effects, such as an increased risk of maternal complications, including infection, postpartum hemorrhage, ureteral and bladder damage, uterine rupture, chronic pelvic pain, gastrointestinal dysfunction, and readmissions, and lead to medical problems in the baby. Postpartum depression (PPD) is the most common maternal health problem after childbirth. The prevalence of postpartum depression varies by country, ranging from nearly 0% to 60%. Postpartum depression may lead to adverse effects on mothers and children, including maternal contact and infant feeding, and increase the risk of self-harm, suicidal ideation, and infanticide. Maternal suicide is the leading cause of postpartum maternal death in the UK. Symptoms of postpartum depression usually begin one month after giving birth and are depressive episodes that develop within a year of childbirth. Numerous epidemiological studies have attempted to address the association between cesarean delivery and the incidence of postpartum depression over the past thirty years. Two recent meta-analyses reported that cesarean delivery was associated with an increased risk of postpartum depression compared with vaginal delivery. However, no convincing results could be drawn. To date, only a few studies have examined the effects of caesarean section anesthesia methods on the harms of postpartum depression. Therefore, the aim of this study was to investigate the relationship between the occurrence of postpartum depression and the mode of anesthesia in elective general or regional anesthesia during caesarean section, conducted with the Taiwan Longitudinal Health Insurance Database. We hypothesized that choosing general anesthesia for caesarean section would be associated with a significantly higher risk of postpartum depression.

Material and Methods
We used the national maternal and child records from 2008-2017 in the health insurance database, and included 2,034,924 birth events (one per child) from January 1, 2008 to December 31, 2017. The first stage: Incidents with unknown birth notification information (n=34396), the remaining 2,000,528 birth incidents, according to the mother's ID number and the date of birth, the child's file after the household registration, a total of 1,968,334 birth incidents.

Results
After screening for exclusion conditions (exclusion conditions: 1. The birth year was in 2008 or 2017; 2. Any anesthesia for natural birth, no anesthesia for caesarean section or both anesthesia at the same time; 3. The mother died within 3 months after giving birth), the remaining natural births 1027146, cesarean section - general anesthesia 16234 and cesarean section - semi-anesthesia (regional anesthesia) 535612. Maternal anesthesia with general anesthesia had a relatively higher history of anesthesia, comorbidity rates during pregnancy, stillbirth rates, lower gestational weeks and infant birth weight, offspring mortality within one year, and infant life support within one month of birth and ICU occupancy rates. The adjusted odds ratio for depression, sleep disturbance, or use of hypnotics or antidepressants within 1 year after delivery was 2.39 (95% CI=2.31-2.47) for women with general anesthesia compared to women with natural labor, and the odds ratio for women with partial anesthesia was 1.71 (95% CI=1.70-1.73). In particular, the odds ratio of using hypnotics or antidepressants within 1 year after delivery was 2.69 (95% CI=2.60-2.78) for women with general anesthesia and 1.89 (95% CI=1.87-1.91) for women with regional anesthesia.

Conclusion and Suggestion
We found that using general anesthesia in CS delivery is associated with significantly higher risks of depression, sleep disturbance, and use of sleeping pills and antidepressants within 1 year after caesarean section, compared with using regional anesthesia in CS delivery. This is especially the case with hypnotic or antidepressant use. Our study also shows the significant relationship between CS and PPD, compared with vaginal birth.

並列關鍵字

Cesarean section ； general anesthesia ； regional anesthesia ； postpartum depression

參考文獻

1. Maki Yokoyama, Cesarean section is associated with increased risk of postpartum depressive symptoms in Japan: the Kyushu Okinawa Maternal and Child Health Study, Journal of Affective Disorders 278 (2021) 497–501

2. Shao HH, Lee SC, Huang JP, Hwang LC. Prevalence of Postpartum Depression and Associated Predictors Among Taiwanese Women in a Mother-Child Friendly Hospital. Asia Pac J Public Health. 2021 May;33(4):411-417.

3. Pearlstein T, Howard M, Salisbury A, Zlotnick C. Postpartum depression. Am J Obstet Gynecol. 2009 Apr;200(4):357-64.

4. Slomian J, Honvo G, Emonts P, Reginster JY, Bruyère O. Consequences of maternal postpartum depression: A systematic review of maternal and infant outcomes. Womens Health (Lond). 2019 Jan-Dec;15:1745506519844044.

5. Jean Guglielminotti, Exposure to General Anesthesia for Cesarean Delivery and Odds of Severe Postpartum Depression Requiring Hospitalization, Anesthesia and analgesia, 2020 Nov;131(5):1421-1429