Epidural fever

Czech version

Authors: Hlinecká Kristýna ¹; Bartošová Tereza ²; Bláha Jan ²
Authors‘ workplace: Gynekologicko-porodnická klinika 1. LF UK a VFN v Praze ¹; Klinika anesteziologie, resuscitace a intenzivní medicíny 1. LF UK a VFN v Praze ²
Published in: Ceska Gynekol 2021; 86(5): 355-361
Category: Review Article
doi: https://doi.org/10.48095/cccg2021355

Overview

Epidural analgesia (EPA) is the most effective method of intrapartum pain relief and is considered to be very safe. Recently, it has been used in up to 34% of parturients with EPA and is also associated with maternal temperature elevations during labor. The mechanism of this epidural-associated fever remains incompletely understood. The most likely etiology seems to be non-infectious inflammation caused by an epidural catheter. However, some authors deny this association. They theorize it is caused by selection bias only, as EPA is more often required by women with more painful and prolonged or more complicated labor, where temperature elevation is due to other causes. They point out that in some studies, fever was correlated to EPA only with concurrent placental inflammation. Maternal fever, despite the cause, either infectious or non-infectious origin, carries important clinical and public health implications. Further research that evaluates maternal epidural status and its influence on maternal or neonatal fever could improve sepsis evaluation and lead to worldwide decrease of unnecessary antibiotic exposure.

Keywords:

epidural analgesia – epidural fever – thermoregulation

Sources

1. Blaha J. Moderní způsoby porodní analgezie. Postgrad Med 2016; 18 (5): 480–486.

2. Blaha J, Stourac P, Grochova M et al. Labor analgesia in Czech Republic and Slovakia: a 2015 national survey. Int J Obstet Anesth 2018; 35: 42–51. doi: 10.1016/j.ijoa.2018.04.001.

3. Šťourač P, Bláha J, Nosková P et al. Analgezie u porodu v České republice v roce 2011 z pohledu studie OBAAMA-CZ – prospektivní observační studie. Ceska Gynekol 2015; 80 (2): 127–134.

4. Segal S. Labor epidural analgesia and maternal fever. Anesth Analg 2010; 111 (6): 1467–1475. doi: 10.1213/ANE.0b013e3181f713d4.

5. Fusi L, Steer PJ, Maresh MJ et al. Maternal pyrexia associated with the use of epidural analgesia in labour. Lancet 1989; 1 (8649): 1250–1252. doi: 10.1016/s0140-6736 (89) 92341-6.

6. Herbst A, Wølner-Hanssen P, Ingemarsson I. Risk factors for fever in labor. Obstet Gynecol 1995; 86 (5): 790–794. doi: 10.1016/0029-7844 (95) 00254-o.

7. Lieberman E, Lang J, Richardson DK et al. Intrapartum maternal fever and neonatal outcome. Pediatrics 2000; 105 (1 Pt 1): 8–13. doi: 10.1542/peds.105.1.8.

8. Chan JJ, Dabas R, Han RN et al. Fever during labour epidural analgesia. Trends Anaesthesia Critical Care 2018; 20: 21–25. doi: 10.1016/j.tacc.2018.04.014.

9. Lieberman E, Cohen A, Lang J et al. Maternal intrapartum temperature elevation as a risk factor for cesarean delivery and assisted vaginal delivery. Am J Public Health 1999; 89 (4): 506–510. doi: 10.2105/ajph.89.4.506.

10. Jansen S, Lopriore E, Naaktgeboren C et al. Epidural-related fever and maternal and neonatal morbidity: a systematic review and meta-analysis. Neonatology 2020; 117 (3): 259–270. doi: 10.1159/000504805.

11. Mackowiak PA, Wasserman SS, Levine MM. A critical appraisal of 98.6 degrees F, the upper limit of the normal body temperature, and other legacies of carl reinhold august wunderlich. JAMA 1992; 268 (12): 1578–1580. doi: 10.1001/jama.1992.03490120092034.

12. Wunderlich CA. On the temperature in diseases: a manual of medical thermometry. Oxford: New Sydenham Society 1871.

13. Obermeyer Z, Samra JK, Mullainathan S. Individual differences in normal body temperature: longitudinal big data analysis of patient records. Bmj 2017; 359: j5468. doi: 10.1136/bmj.j5468.

14. Callaway E. Not so hot: US data suggest human bodies are cooling down. Nature 2020; 577 (7790): 306. doi: 10.1038/d41586-020-00 074-9.

15. Ganong W. Přehled lékařské fyziologie. 20. vyd. Praha: Galén 2005: 495, 890.

16. Javorka K. Lekárska fyziológia: učebnica pre lekárske fakulty. 1. vyd. Martin: Osveta 2001: 337–346.

17. Varela M, Cuesta D, Madrid JA et al. Holter monitoring of central and peripheral temperature: possible uses and feasibility study in outpatient settings. J Clin Monit Comput 2009; 23 (4): 209–216. doi: 10.1007/s10877-009-9184-x.

18. O‘Grady NP, Barie PS, Bartlett JG et al. Guidelines for evaluation of new fever in critically ill adult patients: 2008 update from the American College of Critical Care Medicine and the Infectious Diseases Society of America. Crit Care Med 2008; 36 (4): 1330–1349. doi: 10.1097/CCM. 0b013e318169eda9.

19. Leon LR. Invited review: cytokine regulation of fever: studies using gene knockout mice. J Appl Physiol (1985) 2002; 92 (6): 2648–2655. doi: 10.1152/japplphysiol.01005.2001.

20. Tatro JB. Endogenous antipyretics. Clin Infect Dis 2000; 31 (Suppl 5): S190–S201. doi: 10.1086/317519.

21. Lim CL, Byrne C, Lee JK. Human thermoregulation and measurement of body temperature in exercise and clinical settings. Ann Acad Med Singap 2008; 37 (4): 347–353.

22. Sultan P, David AL, Fernando R et al. Inflammation and epidural-related maternal fever: proposed mechanisms. Anesth Analg 2016; 122 (5): 1546–1553. doi: 10.1213/ane.00000000000 01195.

23. Higgins RD, Saade G, Polin RA et al. Evaluation and management of women and newborns with a maternal diagnosis of chorioamnionitis: summary of a workshop. Obstet Gynecol 2016; 127 (3): 426–436. doi: 10.1097/aog.0000 000000001246.

24. Zhao BS, Li B, Wang QN et al. Time- and dose-dependent correlations between patient-controlled epidural analgesia and intrapartum maternal fever. BMC Anesthesiol 2021; 21 (1): 31. doi: 10.1186/s12871-021-01249-1.

25. Chan JJ. Fever during labour epidural analgesia. Trends Anaesthesia Critical Care 2018; 20: 21–25. doi: 10.1016/j.tacc.2018.04.014.

26. Wartzek T, Mühlsteff J, Imhoff M. Temperature measurement. Biomed Tech (Berl) 2011; 56 (5): 241–257. doi: 10.1515/bmt.2011.108.

27. 3M SpotON. 2012 [online]. Available from: https: //multimedia.3m.com/mws/media/878163O/spoton-system-brochure.pdf.

28. Arce DY, Bellavia A, Cantonwine DE et al. Average and time-specific maternal prenatal inflammatory biomarkers and the risk of labor epidural associated fever. PLoS One 2019; 14 (11): e0222958. doi: 10.1371/journal.pone.0222958.

29. Lieberman E, Lang JM, Frigoletto F Jr et al. Epidural analgesia, intrapartum fever, and neonatal sepsis evaluation. Pediatrics 1997; 99 (3): 415–419. doi: 10.1542/peds.99.3.415.

30. Committee opinion no. 712: intrapartum management of intraamniotic infection. Obstet Gynecol 2017; 130 (2): e95–e101. doi: 10.1097/aog.0000000000002236.

31. Li CJ, Xia F, Xu SQ et al. Concerned topics of epidural labor analgesia: labor elongation and maternal pyrexia: a systematic review. Chin Med J (Engl) 2020; 133 (5): 597–605. doi: 10.1097/cm9.0000000000000646.

32. Alexander JM, McIntire DM, Leveno KJ. Chorioamnionitis and the prognosis for term infants. Obstet Gynecol 1999; 94 (2): 274–278. doi: 10.1016/s0029-7844 (99) 00256-2.

33. Wendel GD Jr, Leveno KJ, Sánchez PJ et al. Prevention of neonatal group B streptococcal disease: a combined intrapartum and neonatal protocol. Am J Obstet Gynecol 2002; 186 (4): 618–626. doi: 10.1067/mob.2002.122970.

34. Towers CV, Yates A, Zite N et al. Incidence of fever in labor and risk of neonatal sepsis. Am J Obstet Gynecol 2017; 216 (6): 596.e1–596.e5. doi: 10.1016/j.ajog.2017.02.022.

35. Tita AT, Andrews WW. Diagnosis and management of clinical chorioamnionitis. Clin Perinatol 2010; 37 (2): 339–354. doi: 10.1016/j.clp.2010.02.003.

36. Romero R, Miranda J, Kusanovic JP et al. Clinical chorioamnionitis at term I: microbiology of the amniotic cavity using cultivation and molecular techniques. J Perinat Med 2015; 43 (1): 19–36. doi: 10.1515/jpm-2014-0249.

37. Kasdorf E, Perlman JM. Hyperthermia, inflammation, and perinatal brain injury. Pediatr Neurol 2013; 49 (1): 8–14. doi: 10.1016/j.pediatrneurol.2012.12.026.

38. Curtin WM, Katzman PJ, Florescue H et al. Intrapartum fever, epidural analgesia and histologic chorioamnionitis. J Perinatol 2015; 35 (6): 396–400. doi: 10.1038/jp.2014.235.

39. Newton ER, Prihoda TJ, Gibbs RS. Logistic regression analysis of risk factors for intra-amniotic infection. Obstet Gynecol 1989; 73 (4): 571–575.

40. Sperling RS, Ramamurthy RS, Gibbs RS. A comparison of intrapartum versus immediate postpartum treatment of intra-amniotic infection. Obstet Gynecol 1987; 70 (6): 861–865.

41. Gibbs RS, Dinsmoor MJ, Newton ER et al. A randomized trial of intrapartum versus immediate postpartum treatment of women with intra-amniotic infection. Obstet Gynecol 1988; 72 (6): 823–828. doi: 10.1097/00006250-198812000-00001.

42. Baumgart S. Iatrogenic hyperthermia and hypothermia in the neonate. Clin Perinatol 2008; 35 (1): 183–197. doi: 10.1016/j.clp.2007.11.002.

43. Badawi N, Kurinczuk JJ, Keogh JM et al. Antepartum risk factors for newborn encephalopathy: the Western Australian case-control study. BMJ 1998; 317 (7172): 1549–1553. doi: 10.1136/bmj.317.7172.1549.

44. Impey L, Greenwood C, MacQuillan K et al. Fever in labour and neonatal encephalopathy: a prospective cohort study. BJOG 2001; 108 (6): 594–597. doi: 10.1111/j.1471-0528.2001.00145.x.

45. Kandel PF, Spoerel WE, Kinch RA. Continuous epidural analgesia for labour and delivery: review of 1.000 cases. Can Med Assoc J 1966; 95 (19): 947–953.

46. Department of health 2005 NHS maternity statistics, England: 2003–2004. Statistical bulletin 2005/10. London: Department of Health 2005.

47. Kamakshi G, Anju G, Tania S et al. Epidural analgesia during labor: attitudes among expectant mothers and their care providers. Anesth Essays Res 2018; 12 (2): 501–505. doi: 10.4103/aer.AER_48_18.

48. Gurung P, Malla S, Lama S et al. Caesarean section during second stage of labor in a tertiary centre. J Nepal Health Res Counc 2017; 15 (2): 178–181. doi: 10.3126/jnhrc.v15i2.18210.

49. Greenwell EA, Wyshak G, Ringer SA et al. Intrapartum temperature elevation, epidural use, and adverse outcome in term infants. Pediatrics 2012; 129 (2): e447–e454. doi: 10.1542/peds. 2010-2301.

50. Yancey MK, Zhang J, Schwarz J et al. Labor epidural analgesia and intrapartum maternal hyperthermia. Obstet Gynecol 2001; 98 (5 Pt 1): 763–770. doi: 10.1016/s0029-7844 (01) 01537-x.

51. Logtenberg S, Oude Rengerink K, Verhoe-ven CJ et al. Labour pain with remifentanil patient-controlled analgesia versus epidural analgesia: a randomised equivalence trial. BJOG 2017; 124 (4): 652–660. doi: 10.1111/1471-0528.14181.

52. de Orange FA, Passini R Jr, Amorim MM et al. Combined spinal and epidural anaesthesia and maternal intrapartum temperature during vaginal delivery: a randomized clinical trial. Br J Anaesth 2011; 107 (5): 762–768. doi: 10.1093/bja/aer218.

53. Riley LE, Celi AC, Onderdonk AB et al. Association of epidural-related fever and noninfectious inflammation in term labor. Obstet Gynecol 2011; 117 (3): 588–595. doi: 10.1097/AOG.0b013e31820b0503.

54. Bensal A, Weintraub AY, Levy A et al. The significance of peripartum fever in women undergoing vaginal deliveries. Am J Perinatol 2008; 25 (9): 567–572. doi: 10.1055/s-0028-1085624.

55. Reilly DR, Oppenheimer LW. Fever in term labour. J Obstet Gynaecol Can 2005; 27 (3): 218–223. doi: 10.1016/s1701-2163 (16) 30513-8.

56. Zhang TN, Wu QJ, Liu YS et al. Environmental risk factors and congenital heart disease: an umbrella review of 165 systematic reviews and meta-analyses with more than 120 million participants. Front Cardiovasc Med 2021; 8: 640729. doi: 10.3389/fcvm.2021.640729.

57. Sharma SK, Alexander JM, Messick G et al. Cesarean delivery: a randomized trial of epidural analgesia versus intravenous meperidine analgesia during labor in nulliparous women. Anesthesiology 2002; 96 (3): 546–551. doi: 10.1097/00000542-200203000-00007.

58. Lucas MJ, Sharma SK, McIntire DD et al. A randomized trial of labor analgesia in women with pregnancy-induced hypertension. Am J Obstet Gynecol 2001; 185 (4): 970–975. doi: 10.1067/mob.2001.117970.

59. Impey LW, Greenwood CE, Black RS et al. The relationship between intrapartum maternal fever and neonatal acidosis as risk factors for neonatal encephalopathy. Am J Obstet Gynecol 2008; 198 (1): 49.e1–49.e6. doi: 10.1016/j.ajog.2007.06.011.

60. Shmueli A, Salman L, Orbach-Zinger S et al. The impact of epidural analgesia on the duration of the second stage of labor. Birth 2018; 45 (4): 377–384. doi: 10.1111/birt.12355.

61. Anim-Somuah M, Smyth RM, Cyna AM et al. Epidural versus non-epidural or no analgesia for pain management in labour. Cochrane Database Syst Rev 2018; 5 (5): CD000331. doi: 10.1002/14651858.CD000331.pub4.

62. Zeng H, Guo F, Lin B et al. The effects of epidural analgesia using low-concentration local anesthetic during the entire labor on maternal and neonatal outcomes: a prospective group study. Arch Gynecol Obstet 2020; 301 (5): 1153–1158. doi: 10.1007/s00404-020-05511-8.

63. White A, Olson D, Messacar K. A state-wide assessment of the association between epidural analgesia, maternal fever and neonatal antibiotics in Colorado, 2007–2012. Arch Dis Child Fetal Neonatal Ed 2017; 102 (2): F120–F125. doi: 10.1136/archdischild-2015-309985.

64. Kaul B, Vallejo M, Ramanathan S et al. Epidural labor analgesia and neonatal sepsis evaluation rate: a quality improvement study. Anesth Analg 2001; 93 (4): 986–990. doi: 10.1097/00000539-200110000-00038.

65. Goetzl L, Cohen A, Frigoletto F Jr et al. Maternal epidural use and neonatal sepsis evaluation in afebrile mothers. Pediatrics 2001; 108 (5): 1099–1102. doi: 10.1542/peds.108.5.1099.

66. Alexander VN, Northrup V, Bizzarro MJ. Antibiotic exposure in the newborn intensive care unit and the risk of necrotizing enterocolitis. J Pediatr 2011; 159 (3): 392–397. doi: 10.1016/j.jpeds.2011.02.035.

67. Penders J, Thijs C, Vink C et al. Factors influencing the composition of the intestinal microbiota in early infancy. Pediatrics 2006; 118 (2): 511–521. doi: 10.1542/peds.2005-2824.

68. Tanaka S, Kobayashi T, Songjinda P et al. Influence of antibiotic exposure in the early postnatal period on the development of intestinal microbiota. FEMS Immunol Med Microbiol 2009; 56 (1): 80–87. doi: 10.1111/j.1574-695X.2009.00553.x.

69. Dinsmoor MJ, Viloria R, Lief L et al. Use of intrapartum antibiotics and the incidence of postnatal maternal and neonatal yeast infections. Obstet Gynecol 2005; 106 (1): 19–22. doi: 10.1097/01.AOG.0000164049.12159.bd.

70. Goetzl L, Rivers J, Evans T et al. Prophylactic acetaminophen does not prevent epidural fever in nulliparous women: a double-blind placebo-controlled trial. J Perinatol 2004; 24 (8): 471–475. doi: 10.1038/sj.jp.7211128.

71. Goetzl L, Zighelboim I, Badell M et al. Maternal corticosteroids to prevent intrauterine exposure to hyperthermia and inflammation: a randomized, double-blind, placebo-controlled trial. Am J Obstet Gynecol 2006; 195 (4) : 1031–1037. doi: 10.1016/ j.ajog.2006.06.012.