Epidural-related maternal fever: incidence, pathophysiology, outcomes, and management

Predictive value of neutrophil-to-lymphocyte ratio on admission for intrapartum maternal fever in parturients undergoing epidural analgesia: A retrospective cohort study using propensity score-matched analysis

OBJECTIVE

To identify the predictive value of the neutrophil-to-lymphocyte ratio (NLR) on admission for intrapartum maternal fever in parturients undergoing epidural analgesia (EA).

METHODS

In this retrospective cohort study, propensity score matching (PSM) was applied to address covariates. Univariate and multivariate regression analyses were implemented in sequence to find out the factors influencing intrapartum fever. The receiver operating characteristics curve was applied to determine the area under the curve (AUC) of NLR for intrapartum fever.

RESULTS

NLR and duration of EA were independent risk factors for intrapartum fever. The AUC of the combined indicator (NLR + duration of EA) was higher than that of NLR (AUC = 0.583, 95% confidence interval [CI] 0.53-0.64) and duration of EA (AUC = 0.702, 95% CI 0.66-0.75), reaching 0.715 (95% CI 0.67-0.76; p < 0.001). NLR increased predictive performance for intrapartum fever when added to the duration of EA (net reclassification index 0.076, p = 0.022; integrated discrimination improvement 0.020, p = 0.002).

CONCLUSION

NLR has limited predictive power for intrapartum fever. The combination of NLR and duration of epidural analgesia may be considered a promising predictor for intrapartum maternal fever in parturients undergoing epidural analgesia.

SYNOPSIS

The neutrophil-to-lymphocyte ratio is an accessible predictor for the early identification of parturients at risk of intrapartum fever.

In Situ Array Microextraction and Metabolic Profiling of Small Extracellular Vesicles to Guide and Monitor Maternal Delivery

The advantages of small extracellular vesicles (sEV) in disease management have become increasingly prominent, with the main challenge lying in meeting the demands of large-scale extraction and high-throughput analysis, a crucial aspect in the realm of precision medicine. To overcome this challenge, an engineered on-plate aptamer array (16×24 spots) is developed for continuous scale-up microextraction of plasma sEV and their in situ metabolic analysis using mass spectrometry. With this integrated array strategy, metabolic profiles of sEV are acquired from the plasma of 274 antenatal or postpartum women, reducing analysis time by half (7.5 h) and sample volume by 95% (only 0.125 µL usage) compared to the traditional suspension method. Moreover, using machine learning algorithms on sEV metabolic profiles, a risk score system is constructed that accurately assesses the need for epidural analgesia during childbirth and the likelihood of post-administration fever. The system, based on admission samples, achieves an impressive 94% accuracy. Furthermore, post-administration fever can be identified from delivery samples, reaching an overall accuracy rate of 88%. This work offers real-time monitoring of the childbirth process that can provide timely guidance for maternal delivery, underscoring the significance of sEV detection in large-scale clinical samples for medicine innovation and advancement.

Long-term effects of neuraxial analgesia

PURPOSE OF REVIEW

This review article explores the potential longer-term implications of neuraxial analgesia in labour for both the mother and her child.

RECENT FINDINGS

Neuraxial techniques for labour analgesia are well tolerated and effective, and long-term adverse sequelae are rare. Labour epidural analgesia is not independently associated with long-term headache, backache, postnatal depression or anal sphincter injury, and evidence supports that epidurals may offer protection against severe maternal morbidity, particularly in women at a higher risk of complications. However, there is an increasing awareness that postdural puncture headache may be associated with chronic headache, back pain and postnatal depression, emphasizing the need for adequate follow-up until symptoms resolve.For the neonate, a growing body of evidence refutes any association between epidural analgesia in labour and the later development of autism spectrum disorder. The clinical significance of epidural related maternal fever remains uncertain and is a research priority.

SUMMARY

Women should continue to access the significant benefits of neuraxial analgesia in labour without undue concern about adverse sequelae for themselves or their offspring. Measures to prevent, appropriately manage and adequately follow-up women who have suffered complications of neuraxial analgesia, such as postdural puncture headache, are good practice and can mitigate the development of long-term sequelae.

Fever in childbirth: a mini-review of epidural-related maternal fever

Fever during childbirth, which is often observed in clinical settings, is characterized by a temperature of 38°C or higher, and can occur due to infectious and non-infectious causes. A significant proportion of non-infectious causes are associated with epidural-related maternal fever during vaginal delivery. Therapeutic interventions are required because fever has adverse effects on both mother and newborn. Effective treatment options for ERMF are lacking. As it is difficult to distinguish it from intrauterine infections such as chorioamnionitis, antibiotic administration remains the only viable option. We mentioned the importance of interleukin-1 receptor antagonist in the sterile inflammatory fever pathway and the hormonal influence on temperature regulation during childbirth, an important factor in elucidating the pathophysiology of ERMF. This review spotlighted the etiology and management of ERMF, underscoring recent advancements in our understanding of hypothalamic involvement in thermoregulation and its link to sterile inflammation. We propose to deepen the understanding of ERMF within the broader context of autonomic neuroscience, aiming to foster the development of targeted therapies.

Clinical chorioamnionitis at term: definition, pathogenesis, microbiology, diagnosis, and treatment

Clinical chorioamnionitis, the most common infection-related diagnosis in labor and delivery units, is an antecedent of puerperal infection and neonatal sepsis. The condition is suspected when intrapartum fever is associated with two other maternal and fetal signs of local or systemic inflammation (eg, maternal tachycardia, uterine tenderness, maternal leukocytosis, malodorous vaginal discharge or amniotic fluid, and fetal tachycardia). Clinical chorioamnionitis is a syndrome caused by intraamniotic infection, sterile intraamniotic inflammation (inflammation without bacteria), or systemic maternal inflammation induced by epidural analgesia. In cases of uncertainty, a definitive diagnosis can be made by analyzing amniotic fluid with methods to detect bacteria (Gram stain, culture, or microbial nucleic acid) and inflammation (white blood cell count, glucose concentration, interleukin-6, interleukin-8, matrix metalloproteinase-8). The most common microorganisms are Ureaplasma species, and polymicrobial infections occur in 70% of cases. The fetal attack rate is low, and the rate of positive neonatal blood cultures ranges between 0.2% and 4%. Intrapartum antibiotic administration is the standard treatment to reduce neonatal sepsis. Treatment with ampicillin and gentamicin have been recommended by professional societies, although other antibiotic regimens, eg, cephalosporins, have been used. Given the importance of Ureaplasma species as a cause of intraamniotic infection, consideration needs to be given to the administration of antimicrobial agents effective against these microorganisms such as azithromycin or clarithromycin. We have used the combination of ceftriaxone, clarithromycin, and metronidazole, which has been shown to eradicate intraamniotic infection with microbiologic studies. Routine testing of neonates born to affected mothers for genital mycoplasmas could improve the detection of neonatal sepsis. Clinical chorioamnionitis is associated with decreased uterine activity, failure to progress in labor, and postpartum hemorrhage; however, clinical chorioamnionitis by itself is not an indication for cesarean delivery. Oxytocin is often administered for labor augmentation, and it is prudent to have uterotonic agents at hand to manage postpartum hemorrhage. Infants born to mothers with clinical chorioamnionitis near term are at risk for early-onset neonatal sepsis and for long-term disability such as cerebral palsy. A frontier is the noninvasive assessment of amniotic fluid to diagnose intraamniotic inflammation with a transcervical amniotic fluid collector and a rapid bedside test for IL-8 for patients with ruptured membranes. This approach promises to improve diagnostic accuracy and to provide a basis for antimicrobial administration.

Antibiotic treatment of women with isolated intrapartum fever vs clinical chorioamnionitis: maternal and neonatal outcomes

BACKGROUND

Clinical chorioamnionitis refers to the presence of maternal fever (≥38°C) and at least 2 clinical signs: (1) maternal tachycardia (>100 bpm), (2) fetal tachycardia (>160 bpm), (3) maternal leukocytosis >15,000/mm2, (4) purulent vaginal discharge, and (5) uterine tenderness. Few data exist to guide the appropriate management of women with isolated intrapartum fever in the absence of other clinical signs suggesting chorioamnionitis.

OBJECTIVE

This study compared maternal and neonatal infectious outcomes and microbiological outcomes between women with isolated intrapartum fever and women with clinical chorioamnionitis.

STUDY DESIGN

This 10-year retrospective study included all the laboring women at our institution, at ≥34 weeks of gestation, with a singleton pregnancy and body temperature of ≥38.0°C, with or without other evidences of infection. According to our department protocol, women with isolated intrapartum fever received intravenous ampicillin, whereas women with clinical chorioamnionitis received intravenous ampicillin plus gentamicin. The primary outcome was puerperal endometritis, compared between women with isolated intrapartum fever (treated with ampicillin) and women with clinical chorioamnionitis (treated with ampicillin plus gentamicin). The secondary maternal outcomes consisted of (1) maternal clinical outcomes, such as cesarean delivery, surgical site infection, postpartum hemorrhage, and postpartum length of stay, and (2) microbiological studies, including positive chorioamniotic membrane swabs and blood culture. Among the secondary neonatal outcomes were early-onset sepsis, neonatal intensive care unit admission, and length of stay. Of note, 2 multivariate logistic regression models were created. A model aimed to predict puerperal endometritis controlled for gestational age of >41 weeks, diabetes mellitus, obesity, positive group B streptococcus status, rupture of membrane ≥18 hours, meconium staining, positive chorioamniotic membrane swabs, cesarean delivery, and empiric postdelivery antibiotic administration. A model aimed to predict neonatal early-onset sepsis controlled for gestational age of 34 to 37 weeks, positive group B streptococcus status, rupture of membrane ≥18 hours, and positive chorioamniotic membrane swabs.

RESULTS

Overall, 458 women met the inclusion criteria. Compared with women with clinical chorioamnionitis (n=231), women with isolated intrapartum fever (n=227) had higher rates of puerperal endometritis (3.9% vs 8.8%; P=.03), early-onset sepsis (0.4% vs 4.4%; P=.005), positive chorioamniotic membrane swabs (46.3% vs 63.9%; P<.001), and ampicillin-resistant Escherichia coli (35.5% vs 48.9%; P=.033). The rate of group B streptococcus-positive chorioamniotic membrane swabs was similar between the groups. In a subanalysis of women with negative or unknown group B streptococcus status, the puerperal endometritis and neonatal early-onset sepsis rates were higher among women with isolated intrapartum fever than women with suspected chorioamnionitis (8.7% vs 3.3% [P=.041] and 4.1% vs 0% [P<.001], respectively). In 2 multivariate analysis models, among women with isolated intrapartum fever treated with ampicillin compared with those with clinical chorioamnionitis treated with ampicillin and gentamicin, the odds ratio of antibiotic treatment of endometritis was 2.65 (95% confidence interval, 1.06-6.62; P=.036), and the odds ratio of neonatal early-onset sepsis was 8.33 (95% confidence interval, 1.04-60.60; P=.045).

CONCLUSION

Women with intrapartum fever, with or without other signs of infection, were at increased risk of maternal and neonatal complications. The use of ampicillin as a sole agent in isolated intrapartum fever might promote ampicillin-resistant E coli growth in the chorioamniotic membranes and consequently lead to puerperal endometritis and early-onset sepsis. In this context, a broad-range antibiotic should be considered.

Causes and consequences of fever in Amazonian pregnant women: A large retrospective study from French Guiana

OBJECTIVE

The aim of this study was to describe different causes and consequences of fever during pregnancy in Western French Guiana and along the Maroni River.

STUDY DESIGN

A retrospective single-center study including all patients with a history of documented fever ≥ 38°C during pregnancy at the West French Guiana Hospital for 9 years. Postpartum fever and nosocomial infections were excluded. We focused on medical history and on clinical and biological findings. Causes were characterized as confirmed or uncertain and then classified as preventable or non-preventable.

RESULTS

A total of 940 pregnant women who experienced at least one episode of fever were included and compared to 23,811 deliveries who occurred during the same period without documented fever. Among them, 43.7% (411/940) were in labor. About 3.7% (35/940) of febrile pregnant women had at least two episodes of fever, while 0.3% (3/940) had a coinfection at the time of diagnosis, resulting in a total of 978 febrile episodes. Among them, causes remained unknown or uncertain in 7.6% (75/978) and 0.9% (9/978) of cases, respectively. Among confirmed causes of fever throughout pregnancy (n = 483), the most common known cause was arbovirus infection (146/483, 30.2%), followed by urinary tract infection (134/483, 27.7%), chickenpox (27/483, 5.6%), and gastrointestinal (14/483, 2.9%) and pulmonary infections (10/483, 2%). Mothers with fever had a higher risk of cesarean section (19.8% vs 15.5%, aOR 1.3 [95% CI 1.14-1.6], stillbirth (5.5% versus 1.9%, aOR 2.7 [95% CI 2-3.7]), and preterm delivery < 34 weeks of gestation (7.2% vs 4.7%, aOR 1.5 [95% CI 1.2-2].

CONCLUSIONS

In the Amazon region, causes of fever are diverse and often associated with epidemic waves, notably arboviruses. This must be considered when exploring possible causes of fever during pregnancy in these localities, including fetal anomalies and/or fetal loss. Physicians should consider the epidemiological context and avoid generalizations. Given the impact of emergent agents such as arboviruses on pregnancy, particular attention must be paid to the epidemiological context. This study can also help clinicians when managing fever in pregnant travelers or in their partner after having visited exposed areas. In this context, fetal abnormalities and adverse obstetric outcomes should be explored accordingly.

Alliance for Innovation on Maternal Health: Consensus Bundle on Sepsis in Obstetric Care

Sepsis in obstetric care is one of the leading causes of maternal death in the United States, with Black, Asian/Pacific Islander, and American Indian/Alaska Native obstetric patients experiencing sepsis at disproportionately higher rates. State maternal mortality review committees have determined that deaths are preventable much of the time and are caused by delays in recognition, treatment, and escalation of care. The "Sepsis in Obstetric Care" patient safety bundle provides guidance for health care teams to develop coordinated, multidisciplinary care for pregnant and postpartum people by preventing infection and recognizing and treating infection early to prevent progression to sepsis. This is one of several core patient safety bundles developed by AIM (the Alliance for Innovation on Maternal Health) to provide condition- or event-specific clinical practices that should be implemented in all appropriate care settings. As with other bundles developed by AIM, the "Sepsis in Obstetric Care" patient safety bundle is organized into five domains: Readiness, Recognition and Prevention, Response, Reporting and Systems Learning, and Respectful, Equitable, and Supportive Care. The Respectful, Equitable, and Supportive Care domain provides essential best practices to support respectful, equitable, and supportive care to all patients. Further health equity considerations are integrated into the elements of each domain.

Effects of neuraxial labor analgesia on intrapartum maternal fever in full-term pregnancy and its influence on birth outcomes

Introduction

This study aimed to explore the relationship between neuraxial labor analgesia and intrapartum fever and to demonstrate the influence of maternal fever on perinatal outcomes within 6 weeks after birth.

Methods

This was a secondary analysis of a multicenter prospective cohort study that enrolled women with single- and full-term cephalic pregnancy in northern China. Intrapartum maternal fever was defined as the highest axillary temperature during labor ≥37.5°C. Data on baseline characteristics, maternal variables, and neonatal outcomes were all collected. The association between neuraxial labor analgesia and intrapartum maternal fever was analyzed with logistic regression models, and the cutoff point was identified by the receiver operating characteristic curve.

Results

Of 577 parturients, 74 (12.8%) developed intrapartum fever. Neuraxial analgesia was associated with an increased risk of maternal intrapartum fever with or without adjusting for confounding factors (adjusted OR = 2.68; 95% CI: 1.32-5.47; p = 0.007). Further analysis showed that neuraxial analgesia of <5 h did not increase the risk of intrapartum fever compared with no analgesia (OR = 1.52; 95% CI: 0.63-3.64; p = 0.35), and longer neuraxial labor analgesia time (over 5 h) significantly increased the risk of fever (OR = 3.38; 95% CI: 1.63-7.01; p = 0.001). Parturients with intrapartum fever suffered more maternal adverse outcomes compared with those without fever (p < 0.001). Neonates of women with intrapartum fever had slightly higher rates of composite adverse neonatal outcomes compared with those without fever; however, the difference was not statistically significant (p = 0.098).

Conclusion

In women with low-risk pregnancies, a longer time of neuraxial labor analgesia was associated with an increased risk of intrapartum maternal fever. Intrapartum fever was related to adverse maternal outcomes but did not significantly affect neonatal outcomes within 6 weeks after delivery.