产后抑郁与产妇无痛分娩是否如期施行的关系:前瞻性观察研究
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The Relationship Between Women’s Intention to Request a Labor Epidural Analgesia, Actually Delivering With Labor Epidural Analgesia, and Postpartum Depression at 6 Weeks: A Prospective Observational Study
背景与目的
产后抑郁（PPD）与分娩期及分娩后的疼痛相关，有研究表明硬膜外无痛分娩（LEA）可使得PPD发生率下降。我们作此假设：有硬膜外无痛分娩（LEA）意愿但实际未进行无痛分娩的产妇产后6周发生PPD的风险更高，主要有以下原因：分娩疼痛未得到合理控制、分娩期间产妇意愿未得到相应满足；
方 法
本研究共纳入1497名经阴道分娩的产妇，产后第一天记录产妇是否有进行LEA的意愿、是否行LEA、以及其对分娩期间疼痛处理的满意度。主要目的是将有LEA意愿却未进行LEA的产妇产后6周的PPD发生率与本研究中其余组别比较。主要结果为PPD的发生：使用EPDS评分表，评分≥10的产妇即为产后抑郁症患者。记录统计学及产科数据。组间比较用F检验。
结 果
1326名产妇中，共87名发生PPD。主要结果为：未进行LEA的产妇共439（29.3%）名，其中有LEA意愿的产妇共193（12.9%）名，PPD发生率为8.1%，与其余组别比较无显著性差异（OR=1.30；95%CI:0.72～2.38,P=0.41）;共1058（70.7%）名产妇行LEA，439（21.9%）名产妇未进行；共1169（78.1%）名产妇如愿进行无痛分娩，328（21.9%）名产妇分娩镇痛与其意愿不一致。评估其结果的差异性，未进行LEA与LEA施行组间有明显差别（差异=-8.6%，95%CI：16.2%～1.6%,P=0.014）,这一结果显示PPD发生与未进行LEA有关系。使用多重回归分析，有LEA意愿的产妇PPD发生率（OR=1.06,95%CI：1.01～1.11，P=0.029），进行LEA产妇PPD发生率（OR=1.07,95%CI：1.01～1.13，P=0.018），消除混杂因素后，其结果为（OR=0.92,95%CI：0.86～0.99，P=0.022）.
结 论
本研究结果表明：有LEA意愿但未进行LEA的产妇其产后6周PPD发生率并没有明显的增加；但我们发现有LEA意愿产妇及实际施行LEA产妇的PPD发生率有一定区别，未如其意愿进行LEA的产妇发生PPD风险增加；LEA施行与否与PPD发生率的关系可能与已下因素有关：生理性的分娩困难、未满足其意愿或个人挫败感所带来的消极情绪。因此，产后对产妇询问、及时的处理消极情绪对PPD的发生有重要意义。
原始文献摘要
Orbach-Zinger S, Landau R, Harousch AB, Ovad O, Caspi L, Kornilov E, Ioscovich A, Bracco D, Davis A, Fireman S, Hoshen M, Eidelman LA；The Relationship Between Women’s Intention to Request a Labor Epidural Analgesia, Actually
Delivering With Labor Epidural Analgesia, and Postpartum Depression at 6 Weeks: A Prospective Observational Study； Anesth Analg. 2017 Sep 19. doi:
10.1213/ANE.0000000000002501.
BACKGROUND: Postpartum depression (PPD) is associated with pain during and after delivery,
with studies showing reduced rates among women delivering with labor epidural analgesia (LEA).
We hypothesized that women who intend to deliver with LEA but do not receive it are at higher risk
for PPD at 6 weeks due to the combined experience of untreated labor pain and unmatched expectations
during labor, and evaluated the interaction between labor plans related to LEA, satisfaction
with pain control when actually delivering with LEA, and PPD at 6 weeks after delivery.
METHODS: A total of 1497 women with a vaginal delivery were enrolled into this prospective longitudinal
study. Women’s initial intention to deliver with or without LEA, how they subsequently delivered,
and satisfaction with pain relief were recorded on postpartum day 1. Primary aim was selected as
PPD at 6 weeks among women intending to deliver with but subsequently delivering without LEA
compared with the rest of the cohort. Primary outcome was PPD at 6 weeks using the Edinburgh
Postnatal Depression Scale; PPD was defined with a score ≥10 (scale from 0 to 30). Demographic
and obstetric data were recorded. Fisher exact test was used for comparisons between groups. The
interaction between intention and actual delivery with regard to LEA and PPD was tested.
RESULTS: Overall, 87 of 1326 women completing the study at 6 weeks had PPD (6.6%). For the
primary aim, 439 (29.3%) delivered without LEA, of which 193 (12.9%) had intended to deliver
with LEA; the PPD rate among these women was 8.1%, which was not statistically different from
the rest of the cohort (6.3%; odds ratio [OR], 1.30; 95% confidence interval [CI], 0.72–2.38;
P = .41). A total of 1058 women (70.7%) delivered with LEA and 439 (29.3%) delivered without;
therefore, 1169 (78.1%) delivered as intended and 328 (21.9%) did not (unmatched expectations).
Evaluating the interaction between effects, there was a strong negative additive interaction
between intending to deliver without LEA and actually delivering with LEA (risk difference
= −8.6%, 95% CI, 16.2%–1.6%; P = .014) suggesting that unmatched intention effect is significantly
associated with negative outcome. In multiple regression analysis, while intending to
deliver with LEA (OR, 1.06; 95% CI, 1.01–1.11; P = .029) and actually delivering with LEA (OR,
1.07; 95% CI, 1.01–1.13; P = .018) both increased the odds for PPD, the multiplicative interaction
was protective (OR, 0.92; 95% CI, 0.86–0.99; P = .022), after adjusting for cofactors.
CONCLUSIONS: Our study results did not demonstrate a significant increase in the odds for PPD
at 6 weeks among women who intended to deliver with LEA but subsequently delivered without.
However, we identified a protective interaction between intended LEA use and actual use on the
incidence of PPD. Our data suggest an increased risk when women do not deliver as intended,
particularly when not initially intending to deliver with LEA. The relationship between unplanned LEA
and PPD may be mediated by a physically difficult delivery rather than or in addition to negative emotions
related to unmet expectations or a sense of personal failure; therefore, counseling women
after delivery to address any negative perceptions may be useful.
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