The Heat Is On

The Heat is on

A hot topic Intra partum fever

 Intrapartum fever is an important predictor of neonatal morbidity & infection related morbidity. Obstet Gynecol.2001;98(1)20-7 Diurnal Temperature

Volunteers Parturients

Low: 0600 hrs – 36.8’C Low:Noon – 34.6’C

Peak : 1700 hrs – 37.7’C Peak: 0100 hrs – 37.6’C Intrapartum Fever

 Definition

Temperature > 38’C

Incidence up to 10% all pregnancies Aetiology

 Non infectious 11%

 Infectious 2-4% Chorioamnionitis at Term Intrapartum Fever

Risk factors Nulliparity Prolonged labour Prolonged Latent phase Prolonged ROM >24 hours Frequent vaginal exams Herbst et al 1995. Intrapartum fever – causes:

 Epidural analgesia  Overheated room  Normal physiologic change  Infection  Dehydration

Low risk asymptomatic intra-partum fever, infection is the least common explanation. Maayon-Metzger.Fetal Pediatric Path.2006.May- Jun;25(3)169-170 Fever in labour at Term

 Epidural analgesia nd  Longer 2 stage

 Longer duration of ROM

 Increased meconium in amniotic fluid

 Interventions for non-reassuring EFM

 Interventions for failure to progress

 NICU admissions Fever in women at Term with less than 24 hours ROM JOGC.Dan Reilly.Ottowa.March.2005 Fever in labour at Term

 Epidural : 5 fold risk of non-infectious fever in nullips

 Longer labour: 15% increased risk of fever for each hour of 1st Stage 18% increased risk of fever for each hour of 2nd stage Fever in labour at Term

 3 fold risk of intervention for failure to progress

 5 fold risk of intervention for non reassuring fetal heart rate

 70% increased risk of mec

 4 fold increased risk of early unexplained seizures in newborn Risks for Neonates

 Low Apgars

 Hypotonia

 Bag & mask ventilation

 Seizures Risk for Neonates

 Admission to NICU

 Septic workup

 IV antibiotics

 Separation Intrapartrum fever

 Sepsis evaluation of 416 neonates Only 4 babies had confirmed sepsis Lieberman et al Pediatrics 99:415-419 Epidurals

 Epidural use increased from 1-83%

 Incidence of maternal fever increased from 0.6% to 11% Fusi et al 1989 Shanson 1999 Cameron et al 1991 Epidurals

 Cause unclear

 Reduced hyperventilation

 Reduced sweating

 Lack of narcotic attenuation of fever

 Acetominophen prophylaxis unhelpful,so not centrally mediated Epidurals

 Fever does not occur in the majority of women having epidurals

 Careful attention to history Epidurals

 Group I – Chorioamnionitis  Group II – LEA with chorioamnionitis  Group III – LEA without chorioamnionitis

Histology of placenta

 Can Jour Anaes.2001  Dec;48(11)1122-6 Epidurals

 Group I – Chorioamnionitis  Group II – LEA with chorioamnionitis Fever 100%  Group III – LEA without chorioamnionitis Fever 1%

Histology of placenta

 Can Jour Anaes.2001  Dec;48(11)1122-6 Epidurals

 Average 5-6 hours before Temp rise

 Average temperature rise is 0.1’C/hour Infection

UTI, URTI, Chorioamnionits Chorioamnionitis

 Incidence 1.5 – 10 % N. America Petrova et al 2001 Lieberman et al 2000 2-7% W. Europe Herbert et al 1995 Impy et al 2001 Chorioamnionitis

Maternal fever greater than 38’C

At least two features : Maternal tachycardia ( >100/min) Fetal tachycardia ( >160/min) Uterine tenderness Offensive liquor Maternal leucocytosis ( > 16,000 cells/cu.mm) Chorioamnionitis

 Polymicrobial infection Bugs

 Ascending infection

 Suggest initiating antibiotics even if epidural as cause of the fever

 Treat if suspected ,even if already on antibiotics for GBS Chorioamnionitis

 Babies born to mothers with this have a 5 fold risk of encephalopathy

 Combination of fever & acidosis have a greater incidence of encephalopathy …additive effect Chorioamnionitis

Triggers for neonatal sepsis Low birth weight Prematurity Hypothermia at birth Maternal GBS colonisation PET Maternal hypertension Chorioamnionitis

Typical antibiotic regime Ampicillin 2G IV then 1G q6h Plus Gentamycin 1.5 mg/kg IV q8h

Clindamycin 900 mgs IV if C.Section or Penicillin allergic Intrapartum fever

 Infection must be ruled out before a decision is made to withold antibiotic therapy.

Am.J.Perinatology 2000;17(3):127-3 Intrapartum fever

 Rather than treating all women with fever & epidurals for presumed chorioamnionitis target : Fetal tachycardia Meconium stained liquor Abnormal amniotic fluid characteristics Am J Perinatology 1997;14(2):83-86 Genital sepsis

 Beware of sepsis…..beware of sepsis

Confidential Enquiry into Maternal Deaths March 2011. Leading cause of Direct death in the UK Genital sepsis

 “Its course is often insidious & women with serious illness may appear deceptively well before suddenly collapsing with little or no warning”.

 “Once established,sepsis may be fulminating & irreversible”. Genital sepsis

 “Sepsis is complex, incompletely understood, often difficult to recognise and manage & presents a continuing challenge”. Genital sepsis

 Although a high WCC & pyrexia are usual, leucopenia & hypothermia can occur.

 Diarrhea common

 Severe lower abdominal pains & after pains important symptoms. Ominous signs

 Pyrexia common, but normal Temp does NOT exclude sepsis  Hypothermia is significant.  Persistent P>100  Tachypnea is sepsis until proved otherwise.  Leucopenia  Diarrhea +/_ vomiting  Persistent abdominal pain  Fetal heart rate abnormalities Antibiotic therapy

 Cefuroxime 1.5G q8h + Metronidazole 500mhq8h

 Cefotaxime 1-2G q6-12h + Metronidazole

 Penicillin allergy: Clindamycin 600-1.2G q6-8h + Gentamycin

Severe septic shock…..Cipro,Piperacillin-tazobactam etc Intrapartum fever

 History…..History…..History

 Hope for the best, but plan for the worst

 Beware of sepsis….Bewary of sepsis