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Intrapartum Fever, Epidural Analgesia and Histologic Chorioamnionitis

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Intrapartum Fever, Epidural Analgesia and Histologic Chorioamnionitis Journal of Perinatology (2015) 35, 396–400 © 2015 Nature America, Inc. All rights reserved 0743-8346/15 www.nature.com/jp ORIGINAL ARTICLE Intrapartum fever, epidural analgesia and histologic chorioamnionitis WM Curtin1,2, PJ Katzman3, H Florescue1, LA Metlay3 and SH Ural2 OBJECTIVE: Our objective was to determine whether epidural analgesia and histologic chorioamnionitis were independent predictors of intrapartum fever. STUDY DESIGN: This secondary analysis, retrospective cohort study included term parturients with placental examination during 2005. Logistic regression used fever (⩾38 °C) as the dependent variable. Significance was defined as P ⩽ 0.05. RESULT: There were 488 (76%) of 641 term parturients with placental examination and epidural. Independent predictors of intrapartum fever were epidural odds ratio (OR) = 3.4, confidence interval (CI): 1.70, 6.81, histologic chorioamnionitis OR = 3.18, 95% CI: 2.04, 4.95, birthweight OR = 2.07, 95%CI: 1.38, 3.12, vaginal exams OR = 1.15, 95% CI:1.06, 1.24, duration ruptured membranes OR = 1.03, 95% CI: 1.01,1.05, parity ⩾ 1 OR = 0.44: 0.29, 0.66 and thick meconium OR = 0.35: 95%CI: 0.24, 0.85. CONCLUSION: Epidural analgesia and histologic chorioamnionitis were independent predictors of intrapartum fever. Modification of labor management may reduce the incidence of intrapartum fever. Journal of Perinatology (2015) 35, 396–400; doi:10.1038/jp.2014.235; published online 12 February 2015 INTRODUCTION chorioamnionitis; other clinical signs include maternal and fetal Intrapartum fever has a variable incidence depending on how it is tachycardia, uterine tenderness, malodorous amniotic fluid and defined and upon the population studied. In women with term leukocytosis. The estimated intrapartum incidence of clinical pregnancies and spontaneous labor, fever, defined as temperature chorioamnionitis is 5 to 12%, similar to the incidence of intra- 7–9 ⩾ 38 °C, occurred in 2 to 10%.1,2 Intrapartum fever has been partum fever. Histopathology can be considered the gold standard in diagnosing infection of the fetal membranes, that is— associated with short-term complications in the newborn such as 10,11 lower 1 min Apgar scores, increased use of bag and mask resusci- chorioamnionitis. Histologic chorioamnionitis occurs at a tation, increased oxygen treatment in the nursery, and higher higher prevalence (10 to 57%) than intrapartum fever and, 2 although it is predictive of intrapartum fever, approximately frequency of hypotonia. Of greater concern is the association of 12 intrapartum fever with neonatal encephalopathy, which is 58% of the time fever is absent. Histologic chorioamnionitis, like intrapartum fever, has also been associated with cerebral estimated to occur in 1.9% of newborns exposed to intrapartum 13,14 3 palsy. fever and 12.5% if acidosis is also present. Long-term outcomes in fi children who had neonatal encephalopathy depend upon severity It is dif cult to distinguish whether an intrapartum fever is but may include cerebral palsy and mental retardation.4 Fusi and related to epidural analgesia, histologic chorioamniotitis or colleagues5 demonstrated that laboring women receiving epidural a combination of factors. Some authors have maintained that intrapartum fever is not associated with epidural anal- analgesia had a rise in vaginal temperature at a rate of 1 °C gesia in the absence of histologic chorioamnionitis.15,16 In a every 7 h versus women receiving intramuscular opioids whose previous study,12 we reported on the accuracy of intra- temperature remained constant. There was no evidence of infec- partum clinical signs, including fever, in prediction of histologic tion by bacterial investigation in the two groups. They hypo- chorioamnionitis in a population of term parturients with placental thesized that decreased dissipation of heat and consequent rise in examination. We observed, on univariate analysis, that epidural maternal temperature occurs by mechanisms such as sympathetic analgesia was associated with histologic chorioamnionitis, but on blockade leading to loss of sweating and reduced hyperventila- multivariate analysis, the relationship was no longer statisti- tion, the latter related to less pain in labor. Both observational cally significant. Using the data from this study, our hypothesis studies and randomized controlled trials of women with epidural 6 was that epidural analgesia and histologic chorioamnionitis analgesia in labor show an increased incidence of fever. These would contribute independently to the development of fi ’ ndings support Fusi s original observation that the incidence of intrapartum fever. intrapartum fever had increased in their labor unit with increasing use of epidural. Intrapartum fever, of course, may have other etiologies. The METHODS obstetrician will frequently diagnose clinical chorioamnionitis This was a secondary analysis of a retrospective cohort study of all based on fever alone and begin treatment with appro- singleton term livebirths, ⩾37 weeks’ gestation, with placental examination priate antibiotics. Fever is the main manifestation of clinical at Strong Memorial Hospital in 2005. The original objective of this study 1Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, University of Rochester School of Medicine & Dentistry, Rochester, NY, USA; 2Division of Maternal- Fetal Medicine, Department of Obstetrics & Gynecology, Pennsylvania State University College of Medicine, Hershey, PA, USA and 3Department of Pathology & Laboratory Medicine, University of Rochester School of Medicine & Dentistry, Rochester, NY, USA. Correspondence: Dr WM Curtin, Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology & Department of Pathology, Penn State Milton S. Hershey Medical Center, 500 University Dr., PO Box 850, Hershey 17033-0850, PA, USA. E-mail: [email protected] Received 15 October 2014; revised 24 November 2014; accepted 25 November 2014; published online 12 February 2015 Independent predictors of intrapartum fever WM Curtin et al 397 Table 1. Epidural analgesia vs no epidural comparisons Variablea Epidural N = 487 No epidural N = 154 OR (95% CI) P-value Maternal age 28.0 ± 6.3 29.0 ± 6.6 0.107 Gestational age 39.3 ± 1.2 39.1 ± 1.3 0.063 Parity ⩾ 1 202 (41.5) 117 (76) 0.22 (0.15, 0.34) o.001 Caucasian 357 (73.3) 97 (63) 1.61 (1.1, 2.4) 0.014 Induction of labor 226 (46.4) 37 (24.0) 2.74 (1.82, 4.12) o0.001 Six or more vaginal exams 266 (54.6) 38 (24.7) 3.67 (2.44, 5.52) o0.001 Internal monitoring 302 (62) 42 (27.3) 4.35 (2.92, 6.49) o0.001 Meconium, thick 36 (7.4) 22 (14.3) 0.48 (0.27, 0.84) 0.009 GBS+ 109 (22.4) 46 (29.9) 0.68 (0.81, 1.01) 0.059 ROM, duration (h) 11.4 ± 12.7 4.7 ± 12.5 o0.001 Labor, duration (h) 15.3 ± 11.8 9.17 ± 11.5 o0.001 Intrapartum amp/gent 139 (28.5) 11 (7.1) 5.19 (2.73, 9.89) o0.001 Cesarean delivery 169 (34.7) 34 (22.1) 1.88 (1.23, 2.89) 0.003 Birthweight (kg) 3.43 ± 1.02 3.26 ± 0.53 0.052 Observed for sepsis—newborn 182 (37.4) 23 (14.9) 3.40 (2.10, 5.49) o0.001 Intrapartum fever 180 (37) 11 (7.1) 7.62 (4.02, 14.45) o0.001 Histologic chorioamnionitis 302 (62) 65 (42) 2.24 (1.55, 3.23) o0.001 Abbreviations: CI, confidence interval; GBS, group B streptococcus; OR, odds ratio; ROM, rupture of membranes. aResults expressed in mean ± s.d. or number (%). was to determine the accuracy of clinical signs of chorioamnionitis for RESULTS 12 predicting histologic chorioamnionitis. The study was approved by the Out of a total of 2700 births in 2005, there were 713 term singleton research subjects review board at the University of Rochester Medical births with placental examination. We excluded 72 births whose Center. We used the birth certificate registry to identify all term livebirths and cross reference with the pathology database to identify which births mothers were not laboring, leaving a total of 641 study subjects. also had placental examination. Only singleton pregnancies, in labor or Given that the total number of term parturients was 2124, the undergoing induction of labor at term, with a pathologic placental percentage of placentas examined from term parturients was 30%. examination were included as subjects of the study. Patients undergoing Epidural analgesia was utilized by 1459 (68.7%) term parturients elective primary or repeat cesarean section in the absence of labor were and 487 (76%) of the study subjects. Intrapartum fever occurred in excluded. 191 (29.8%) of the study subjects. Histologic chorioamnionitis was The decision to submit the placenta for pathologic examination was present in 367 (57.3%) and absent in 274 (42.7%). made by the delivery provider. Placentas had been processed according to The comparisons of the cohorts with and without epidural standard guidelines.17 Placental slides were evaluated for histologic 18 analgesia are given in Table 1. Maternal age and gestational age chorioamnionitis according to the criteria of Redline at al. Histologic fi chorioamnionitis was considered to be any stage and grade of maternal were not signi cantly different between the two groups. The inflammatory response that fulfilled the criteria. epidural group was more likely to be Caucasian and less likely to Maternal, intrapartum and newborn data were obtained from the be parous. There was no significant difference in group B intrapartum electronic record (QS; GE Healthcare, Barrington, IL, USA). streptococcus colonization. Labor management in the epidural Computerized hospital medical records were reviewed for discharge group was more likely to include induction of labor, internal fetal summaries, operative reports, placental pathology reports and discharge monitoring and more vaginal examinations. The duration of labor coding summaries. Paper charts were obtained if more data were needed. and ruptured membranes was significantly longer in the epidural We collected the following maternal data: age, parity, race/ethnicity, group.
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