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e578 TUTDIBI et al
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Statistical Analyses
For statistical analyses, we used SPSS
15 (SPSS, Chicago, IL). Continuous vari-
ables were compared by using t tests
when data were distributed normally;
otherwise, the nonparametric Mann-
Whitney U test was used. Categorical
variables were analyzed by using Pear-
sons 2 test or Fishers exact test, as
appropriate. Correlation studies were
performed by using Pearsons correla-
tion coefcient. The statistical signi-
cance level was set at P .05 for all
analyses with 2-tailed comparisons.
Results of multivariate regression FIGURE 1
analyses (including the confounders Cohort design of study, with deliveries from 2001 to 2005 in the federal states of Hesse and Saarland
(Germany).
maternal age, parity, smoking, diabe-
tes mellitus, mode of delivery, GA, birth
weight, and gender) were expressed
as odds ratios (ORs) and 95% con- with maternal data. Variables within summarized in Table 1. Compared with
dence intervals (CIs). the maternal and neonatal data sets the national German perinatal data for
coincided for 6843 (73.2%) of those term singletons born between 2001
RESULTS 9352 infants. There were no signicant and 2005, study infants with TTN were
During the study period, the perinatal differences between all term infants more likely to have an inappropriate
birth registers included data for and those with matched perinatal data birth weight for GA (small for GA: 15.8%
275 459 deliveries, including 259 312 in sets, with respect to basic maternal vs 9.6%; large for GA: 13.5% vs 10.6%;
Hesse between 2001 and 2005 and and neonatal variables (data not P .001) and more often were male
16 147 in Saarland between 2004 and shown). Of the 9352 admitted neo- (60.3% vs 51.4%; P .001).
2005 (Fig 1). Among these deliveries, nates, postnatal respiratory problems The mode of birth was closely related
239 971 (87%) fullled the inclusion were found as leading causes for neo- to GA. Nearly 70% of all ECSs were per-
criteria of GA of 37 weeks and single- natal admission for a total of 2984 new- formed at GAs of 37 to 38 completed
ton live birth. Of these term newborns, borns (31.9%), including TTN (n weeks. The main indications for ECSs
13 346 (5.6%) were transferred to a 1423), meconium aspiration syndrome were as follows: previous CS (31.7%),
neonatal ward. After application of the (n 223), persistent pulmonary hy- breech presentation (17.6%), cephalo-
exclusion criteria (congenital anoma- pertension of the newborn (n 24), pelvic disproportion (13.8%), and ma-
lies affecting the cardiorespiratory and infection (n 1314). The overall ternal disorders (11.7%). For 11.6% of
system or chromosomal aberrations, incidence of TTN was 5.9 cases per ECSs, the indications for surgery in-
n 1871; asphyxia, n 1603; fetal hy- 1000 singleton live births in our study cluded other malpresentations, pla-
drops, n 8; mothers with alcohol or cohort. cental and umbilical cord complica-
drug abuse, n 512), data for the re- The main characteristics of the study tions, and pregnancy disorders. In
maining 9352 newborns were matched cohort and newborns with TTN are 13.6% of cases, however, the indication
e580 TUTDIBI et al
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ARTICLES
TABLE 2 Therapy and Outcomes of Infants With TTN and Role of Labor et al18 (5.7 cases per 1000 infants) and
All Infants With TTN Labor Group No-Labor Group P Riskin et al19 (7.2 cases per 1000 in-
(N 1423) (N 625) (N 456)
fants). The inclusion of neonates with
Oxygen supplementation, n (%) 580 (40.7) 258 (41.1) 208 (45.7) .141a
Duration of oxygen supplementation, 1.3 0.9 1.1 0.6 1.3 1.1 .02b
TTN with GAs of 35 weeks might ex-
mean SD, d plain the higher incidence of TTN in the
Mechanical ventilation, n (%) 60 (4.2) 22 (3.5) 36 (7.9) .01a study by Riskin et al.19
Continuous positive airway pressure 58 (4.1) 17 (2.7) 26 (5.7) .05a
therapy, n (%) We found that TTN risk was associ-
Pulmonary air leaks, n (%) 22 (1.5) 6 (1.0) 13 (2.8) .05a ated strongly with the mode of deliv-
Antibiotic therapy, n (%) 307 (21.6) 177 (28.3) 112 (24.5) NSa
Duration of hospital stay, median 5 (115) 5 (111) 5 (114) NSb
ery and GA. The overall rate of ECS
(5th to 95th percentile range), d was substantially higher in new-
Obstetric data were available for 76% of newborns with TTN (1081 of 1423 newborns) after maternal-neonatal data borns with TTN, compared with term
matching. NS indicates not signicant.
a Pearson 2 test.
singletons in the German population
b Nonparametric Mann-Whitney U test. (42.2% vs 9.2%; P .001). Other risk
factors for TTN were male gender
and inappropriate birth weight for
found not to be inuenced by con- factor in TTN.8,9 Defects in active pulmo- GA. Our results agree with previously
founders and mode of birth. nary epithelial sodium transport,10 reported studies that demonstrated
mild pulmonary immaturity and tran- the association of ECS with higher
DISCUSSION sient surfactant deciency,11 and myo- risk for neonatal respiratory mor-
The present study indicates the posi- cardial left-heart failure attributable bidity and the importance of timing
tive impact of labor on respiratory out- to asphyxia have been discussed as the of ECS to GA of 39 weeks, to de-
comes among infants with TTN, in main potential pathogenic factors op- crease the TTN risk.18,2025 In line with
agreement with previous studies; the erative in dysfunction of postnatal lung the report by Richardson et al,26 how-
absence of labor in infants with TTN liquid clearance and TTN pathophysio- ever, ECS performed even at a GA of
was associated with higher rates of logical processes.12 Studies on genetic 40 completed weeks was associated
continuous positive airway pressure risk factors for TTN demonstrated that with a signicant increase in the TTN
therapy, mechanical ventilation, and certain functional polymorphisms in rate in our study, which demon-
complications from pulmonary air the -adrenergic receptor encoding strates the benecial effects of labor
leaks and longer duration of oxygen genes are associated with higher TTN in the mechanisms mediating post-
supplementation, in comparison with risk.1315 Rapid clearance of fetal lung natal lung liquid clearance.
infants with TTN who were delivered uid during postnatal lung adaptation
after having been exposed to uterine Our study has several limitations.
is largely correlated with the onset of
contractions. Multivariate regression The main limitation is that the peri-
labor before birth.16 Labor enhances
analyses, with correction for perinatal natal registers used for this study
the release of catecholamines in ma-
confounders, established that the ab- may contain coding inaccuracies and
ternal and fetal circulation, resulting
sence of labor increased the duration in -adrenergic receptormediated data entry errors, which are inher-
of oxygen supplementation by a factor upregulation of surfactant synthesis ent in all population-based analyses.
of 2. The duration of labor was linked and transepithelial sodium ion trans- In our study, 26.8% of all data sets for
signicantly to the duration of oxygen port, with subsequent uid reabsorp- infants who were admitted to the
supplementation (r 0.151; P tion, in the neonatal lung. Infants deliv- neonatal ward could not be con-
.028). The length of hospital stay for ered through ECS often are deprived of nected with maternal data (for new-
infants presenting with TTN did not dif- this labor-related physiological stress borns with TTN, the matching rate
fer on the basis of labor. response pattern at birth and conse- was 76%). We are aware of the pos-
We suggest that both the incidence and quently experience failure of postnatal sibility that the results might be bi-
severity of TTN are affected by labor respiratory transition.17 According ased by the high loss rate. However,
before birth. TTN is the most common to our study results from a large, basic validation analyses of the main
cause of neonatal respiratory distress population-based, birth cohort, the maternal and neonatal characteris-
in term neonates. Delayed resorption rate of TTN was 0.59% (1423 cases per tics and outcome variables for all
of fetal lung uid after delivery is con- 239 971 infants), which is comparable 9352 neonates and the 6843 matched
sidered the main pathophysiological to the previous reports by Morrison newborns demonstrated no signi-
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22. Schuler Barazzoni M, Roth-Kleiner M. Re- vaginal delivery at term: comparison of elective repeat cesarean delivery at term
spiratory distress of the neonate and the newborn infant outcomes. Am J Obstet Gy- and neonatal outcomes. N Engl J Med. 2009;
rate of caesarean section have increased necol. 2006;195(6):1538 1543 360(2):111120
over the last 30 years: is there a link [in French]? 24. Ross MG, Beall MH. Cesarean section and tran- 26. Richardson BS, Czikk MJ, daSilva O, Natale R.
Rev Med Suisse. 2008;4(146):504508 sient tachypnea of the newborn. Am J Obstet The impact of labor at term on measures of
23. Kols T, Saugstad OD, Daltveit AK, Nilsen ST, Gynecol. 2006;195(5):1496 1497 neonatal outcome. Am J Obstet Gynecol.
ian P. Planned cesarean versus planned 25. Tita AT, Landon MB, Spong CY, et al. Timing of 2005;192(1):219 226
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