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Association Between Uterine Contractions Before Elective Caesarean Section and Transient Tachypnoea of the Newborn: a Retrospective Cohort Study

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Association Between Uterine Contractions Before Elective Caesarean Section and Transient Tachypnoea of the Newborn: a Retrospective Cohort Study Open access Original research BMJ Open: first published as 10.1136/bmjopen-2019-033154 on 16 March 2020. Downloaded from Association between uterine contractions before elective caesarean section and transient tachypnoea of the newborn: a retrospective cohort study Satoshi Shinohara , Atsuhito Amemiya, Motoi Takizawa To cite: Shinohara S, ABSTRACT Strengths and limitations of this study Amemiya A, Takizawa M. Objective We evaluated the association between the Association between uterine presence of predelivery uterine contractions and transient ► We used the findings of an objective test to evalu- contractions before elective tachypnoea of the newborn (TTN) in women undergoing an caesarean section and ate the risk of transient tachypnoea of the newborn, elective caesarean section. transient tachypnoea of the thus avoiding complicated or subjective patient Design A retrospective cohort study. newborn: a retrospective examinations. Setting National Hospital Organization Kofu National cohort study. BMJ Open ► Our study population was limited to women under- Hospital, which is a community hospital, between January 2020;10:e033154. doi:10.1136/ going an elective caesarean section, and our anal- 2011 and May 2019. bmjopen-2019-033154 ysis was adjusted for many known risk factors of Participants The study included 464 women who Prepublication history for transient tachypnoea of the newborn. ► underwent elective caesarean section. The exclusion this paper is available online. ► Our study was a retrospective, single- centre study. criteria were missing data, twin pregnancy, neonatal To view these files, please visit ► Our analysis did not control for maternal asthma, asphyxia, general anaesthesia and elective caesarean the journal online (http:// dx. doi. which is a known risk factor of transient tachypnoea section before term. org/ 10. 1136/ bmjopen- 2019- of the newborn. 033154). Primary and secondary outcome measures Patients were grouped according to the presence or absence of Received 23 July 2019 uterine contractions on a 40- min cardiotocogram (CTG) Revised 23 October 2019 performed within 6 hours before caesarean delivery. We birth and require invasive or non- invasive Accepted 24 February 2020 performed a multivariable logistic regression analysis respiratory support.7 8 to examine the association between predelivery uterine Several studies have demonstrated that http://bmjopen.bmj.com/ contractions and TTN. catecholamines play an important role in Results The incidence of TTN was 9.9% (46/464), and fetal alveolar fluid clearance,9–11 a process 38.4% (178/464) of patients had no uterine contraction. that begins before term birth and continues The absence of uterine contractions was significantly 1 associated with an increased risk of TTN (adjusted OR through labour and after delivery. The spon- 2.04; 95% CI 1.09 to 3.82) after controlling for gestational taneous surge in catecholamine secretion diabetes mellitus, small for gestational age, male sex and caused by uterine contractions is particularly 12 caesarean section at 37 weeks. important for fetal alveolar fluid clearance, on September 26, 2021 by guest. Protected copyright. Conclusions Accurate risk stratification using a CTG and previous studies found that elective could assist in the management of infants who are at risk caesarean section before the onset of labour of developing TTN. is a significant risk factor for TTN.3 13 14 The number of elective caesarean sections has increased in Japan over the last decades, and INTRODUCTION the caesarean section rate reached 11.5% in Transient tachypnoea of the newborn (TTN) 2013.15 The elective caesarean section rate is a parenchymal lung disorder character- is expected to continue to increase due to © Author(s) (or their ised by pulmonary oedema resulting from increased maternal age,16 multiple gesta- employer(s)) 2020. Re- use delayed resorption and clearance of fetal tions after fertility treatment17 and maternal permitted under CC BY-NC. No 1 18 commercial re- use. See rights alveolar fluid. Clinical characteristics appear request. Inevitably, the number of newborns and permissions. Published by shortly after delivery and include tachy- with TTN will also increase. Therefore, it is BMJ. pnoea, nasal flaring and grunting.1–3 TTN is important to completely understand the risk Obstetrics and Gynecology, Kofu a common cause of respiratory distress in late factors of TTN. National Hospital, Kofu, Japan preterm and term infants and is generally a Many reports indicate that caesarean Correspondence to benign disease treated with a brief course of section before the onset of labour is a risk 4–6 3 13 14 Dr Satoshi Shinohara; oxygen. However, some patients develop factor for TTN. However, another study shinohara617@ gmail. com severe respiratory distress immediately after found conflicting results.3 The problem Shinohara S, et al. BMJ Open 2020;10:e033154. doi:10.1136/bmjopen-2019-033154 1 Open access BMJ Open: first published as 10.1136/bmjopen-2019-033154 on 16 March 2020. Downloaded from appears to be the lack of consensus on the definition contraction, is typically used to assess fetal well- being. In of labour onset between these studies and worldwide.19 this study, CTG data were recorded using an actocardio- Furthermore, the different definitions of labour onset are graph (Toitu MT- 516GE; Tofa Medical, Malvern, Penn- based on various features, including cervical dilatation, sylvania). The prepregnancy body mass index (BMI) was cervical effacement and uterine contractions.19 There- calculated according to the WHO standard (body weight/ fore, these studies are still open for further consideration. height squared (kg/m2)). Maternal weight gain during Given the ambiguity surrounding the onset of labour, pregnancy was calculated by subtracting the patient’s we examined the relationship between the presence of prepregnancy body weight from her body weight at the uterine contractions before caesarean section alone and last prenatal visit before delivery. We defined SGA as a TTN rather than considering all features of the onset of weight below the 10th percentile in each gestational labour. Furthermore, no study to date has used the pres- week.22 The diagnosis of GDM was made if there was at ence of uterine contractions to identify newborns at risk least one abnormal plasma glucose value (≥92, 180 and of developing TTN. Therefore, we aimed to examine the 153 mg/dL for fasting, 1- hour and 2- hour plasma glucose association between the presence of uterine contractions concentration, respectively) after a 75 g oral glucose toler- before an elective caesarean section and TTN. ance test.23 Neonatal asphyxia was defined as an Apgar score remaining less than 7 at 5 min after birth or as an arterial METHODS blood pH of less than 7.00.24 A diagnosis of TTN, which Study design was the outcome of interest in this study, required each of We performed a retrospective observational cohort study the following: respiratory rate >60 breaths/min, constant of women who underwent an elective caesarean section tachypnoea for ≥12 hours, prominent central pulmonary with spinal and epidural anaesthesia between January vessels or thickened interlobar fissures on a chest X-ray 2011 and May 2019 at the National Hospital Organi- and exclusion of other causes of respiratory distress, such zation Kofu National Hospital, which is a community as surfactant deficiency, pneumonia, meconium aspira- 25 hospital. We excluded women with multiple pregnan- tion, congenital heart disease or metabolic disorder. A cies, missing data and those who underwent an elective neonatologist diagnosed TTN based on the above diag- caesarean section before a term delivery. In addition, nostic criteria in the first few hours after a baby was born. we excluded cases in which the infant had neonatal Moreover, when the neonatologist diagnosed TTN, all asphyxia. The Human Subjects Review Committee of the infants were treated in the neonatal intensive care unit. National Hospital Organization Kofu National Hospital reviewed and approved the study protocol and waived Statistical analyses 2 the need for informed consent because of the retrospec- The Mann- Whitney U test and χ test (or Fisher’s exact test http://bmjopen.bmj.com/ tive study design. However, patients were provided the when the expected frequency was <5) were used to eval- opportunity to refuse the usage of their data through uate the effects of potential confounding factors of TTN. the hospital’s website. All procedures were performed in The Mann- Whitney U test was used to analyse continuous 2 accordance with the 1964 Helsinki Declaration and its variables such as maternal age, and the χ test (or Fisher’s later amendments. exact test when the expected frequency was <5) was used for categorical variables such as incidence of obstetric Data collection complications. A multiple logistic regression model was We collected obstetric data from medical and operative used to identify the variables significantly associated with records. We recorded maternal age, parity, gestational TTN. The logistic regression models were adjusted by on September 26, 2021 by guest. Protected copyright. age at delivery, prepregnancy weight status and maternal uterine contraction, GDM, SGA infants, infant sex and weight gain. Additionally, we assessed the presence of gestational age at delivery. All analyses were performed gestational diabetes mellitus (GDM), small for gesta- using the Bell Curve for Excel (Social Survey Research tional age (SGA), infant
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