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Lu R, Rong L, Ye L, Xu Y, Wu H. Effects of epidural analgesia on intrapartum maternal fever and maternal outcomes: an updated systematic review and meta-analysis. J Matern Fetal Neonatal Med 2024; 37:2357168. [PMID: 38812361 DOI: 10.1080/14767058.2024.2357168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 05/15/2024] [Indexed: 05/31/2024]
Abstract
OBJECTIVE Epidural-related maternal fever in women is a common clinical phenomenon that leads to adverse consequences for mothers and neonates. The meta-analysis aimed to quantify the risk for intrapartum maternal fever after epidural analgesia (EA) stratified according to parity. The secondary objective was to investigate the association between EA and maternal outcomes. METHODS An electronic literature search of the Medline/PubMed, Embase, Cochrane Library, Wanfang Data, and China National Knowledge Infrastructure databases was performed to identify studies reporting the occurrence of intrapartum fever in parturients. Studies were reviewed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and meta-analysis was performed using Review Manager version 5.3. RESULTS Seventeen randomized controlled trials (RCTs) (5959 parturients) were included. Odds ratios for maternal fever in the analysis were 4.17 (95% confidence interval (CI) 2.93-5.94) and 5.83 (95% CI 4.96-6.87), respectively. Results of subgroup analysis according to parity were consistent. EA significantly prolonged the length of the first stage of labor (MD 34.52 [95% CI 12.13-56.91]) and the second stage of labor (MD 9.10 [95% CI 4.51-13.68]). Parturients who received EA were more likely to undergo instrumental delivery (OR 2.03 [95% CI 1.44-2.86]) and oxytocin augmentation (OR 1.45 [95% CI 1.12-1.88]). There were no differences in cesarean delivery rates between the EA and non-EA groups. CONCLUSIONS Parturients who received EA exhibited a higher incidence of intrapartum fever. Credibility of the subgroup analyses was low because the mixed group did not effectively represent multiparas.
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Affiliation(s)
- Rui Lu
- Department of Anesthesiology, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, China
| | - Lijuan Rong
- Institute for Hospital Management, Tsinghua University, Shenzhen, China
| | - Li Ye
- Institute for Hospital Management, Tsinghua University, Shenzhen, China
| | - Ying Xu
- Institute for Hospital Management, Tsinghua University, Shenzhen, China
- Evidence-Based Medicine Center, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, China
| | - Hao Wu
- Department of Anesthesiology, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, China
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Xiao F, Yao H, Qian J, Huang J, Xia G. Dexmedetomidine improves mitophagy and pyroptosis through the ALKBH5/FUNDC1 axis during epidural-related maternal fever. Adv Med Sci 2024; 69:272-280. [PMID: 38815927 DOI: 10.1016/j.advms.2024.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 04/30/2024] [Accepted: 05/27/2024] [Indexed: 06/01/2024]
Abstract
PURPOSE Epidural analgesia has emerged as a commonly used method for relieving labor pain. However, epidural-related maternal fever (ERMF) is characterized by a high occurrence rate and can have detrimental consequences for the well-being of both the mother and the fetus. This study aimed to investigate the functional role and underlying mechanism of dexmedetomidine (DEX) in ERMF. MATERIALS AND METHODS Ropivacaine (ROP)-induced human umbilical vein endothelial cells (HUVECs) were treated with DEX and/or transfected with ALKBH5 or FUNDC1 overexpression plasmid. qPCR and Western blot were adopted for mitophagy and pyroptosis marker protein detection. Autophagosomes were observed through electron microscopy, Caspase-1/PI double-positive cells were determined using flow cytometry. Inflammation-related factors were quantified using ELISA. The N6-methyladenosine (m6A) modification of FUNDC1 mRNA was examined using methylated RNA immunoprecipitation (MeRIP) and the binding between ALKBH5 and FUNDC1 mRNA was confirmed by RNA immunoprecipitation (RIP). RESULTS In ROP-induced HUVECs, there was a significant upregulation in ALKBH5 and FUNDC1, resulting in a notable increase in inflammation, pyroptosis, and mitophagy. The administration of DEX demonstrated the ability to alleviate ROP-induced pyroptosis and promote protective mitophagy. Interestingly, DEX treatment significantly reduced the interaction between ALKBH5 and FUNDC1 mRNA, while simultaneously increasing the m6A level of FUNDC1 mRNA in ROP-treated cells. Moreover, the overexpression of FUNDC1 partially reversed the effects of ALKBH5 overexpression on mitophagy and pyroptosis in HUVECs. CONCLUSIONS DEX can promote mitophagy and inhibit pyroptosis through the ALKBH5/FUNDC1 axis in ERMF, indicating its potential as a therapeutic strategy for clinical ERMF treatment.
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Affiliation(s)
- Fei Xiao
- Department of Anesthesia, Jiaxing University Affiliated Women and Children Hospital, Jiaxing, Zhejiang Province, PR China
| | - Hanqing Yao
- Department of Anesthesia, Jiaxing University Affiliated Women and Children Hospital, Jiaxing, Zhejiang Province, PR China
| | - Jing Qian
- Department of Anesthesia, Jiaxing University Affiliated Women and Children Hospital, Jiaxing, Zhejiang Province, PR China
| | - Jiayue Huang
- Department of Anesthesia, Jiaxing University Affiliated Women and Children Hospital, Jiaxing, Zhejiang Province, PR China
| | - Guangfa Xia
- Department of Breast Surgery, Jiaxing University Affiliated Women and Children Hospital, Jiaxing, Zhejiang Province, PR China.
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Hafner C, Windpassinger M, Tretter EV, Rebernig KA, Reindl SM, Hochreiter B, Dekan S, Haider P, Kiss H, Klein KU, Wohlrab P. Role of mitochondrial DNA level in epidural-related maternal fever: a single-centre, observational, pilot study. BMC Pregnancy Childbirth 2024; 24:341. [PMID: 38702618 PMCID: PMC11067090 DOI: 10.1186/s12884-024-06551-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 04/28/2024] [Indexed: 05/06/2024] Open
Abstract
INTRODUCTION Epidural analgesia has been associated with intrapartum maternal fever development. Epidural-related maternal fever (ERMF) is believed to be based on a non-infectious inflammatory reaction. Circulating cell-free mitochondrial deoxyribonucleic acid (mtDNA) is one of the possible triggers of sterile inflammatory processes; however, a connection has not been investigated so far. Therefore, this study aimed to investigate cell-free mtDNA alterations in women in labour with ERMF in comparison with non-febrile women. MATERIAL AND METHODS A total of 60 women in labour were assessed for maternal temperature every 4 h and blood samples were obtained at the beginning and after delivery. Depending on the analgesia and the development of fever (axillary temperature ≥ 37.5 °C), the women were allocated either to the group of no epidural analgesia (n = 17), to epidural analgesia no fever (n = 34) or to ERMF (n = 9). Circulating cell-free mtDNA was analysed in the maternal plasma for the primary outcome whereas secondary outcomes include the evaluation of inflammatory cytokine release, as well as placental inflammatory signs. RESULTS Of the women with epidural analgesia, 20% (n = 9) developed ERMF and demonstrated a decrease of circulating mtDNA levels during labour (p = 0.04), but a trend towards higher free nuclear DNA. Furthermore, women with maternal pyrexia showed a 1.5 fold increased level of Interleukin-6 during labour. A correlation was found between premature rupture of membranes and ERMF. CONCLUSIONS The pilot trial revealed an evident obstetric anaesthesia phenomenon of maternal fever due to epidural analgesia in 20% of women in labour, demonstrating counterregulated free mtDNA and nDNA. Further work is urgently required to understand the connections between the ERMF occurrence and circulating cell-free mtDNA as a potential source of sterile inflammation. TRIAL REGISTRATION NCT0405223 on clinicaltrials.gov (registered on 25/07/2019).
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Affiliation(s)
- Christina Hafner
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Division of General Anaesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria
| | - Marita Windpassinger
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Division of General Anaesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria
| | - Eva Verena Tretter
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Division of General Anaesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria
| | - Katharina Anna Rebernig
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Division of General Anaesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria
| | - Sophie Marie Reindl
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Division of General Anaesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria
| | - Beatrix Hochreiter
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Division of General Anaesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria
| | - Sabine Dekan
- Department of Pathology, Medical University of Vienna, Vienna, Austria
| | - Patrick Haider
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Herbert Kiss
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Feto-Maternal Medicine, Medical University of Vienna, Vienna, Austria
| | - Klaus Ulrich Klein
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Division of General Anaesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria
| | - Peter Wohlrab
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Division of Cardiothoracic and Vascular Anaesthesia and Intensive Care Medicine, Medical University of Vienna, Spitalgasse 23, Vienna, 1090, Austria.
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Kinishi Y, Koyama Y, Yuba T, Fujino Y, Shimada S. Fever in childbirth: a mini-review of epidural-related maternal fever. Front Neurosci 2024; 18:1389132. [PMID: 38707593 PMCID: PMC11065963 DOI: 10.3389/fnins.2024.1389132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 04/05/2024] [Indexed: 05/07/2024] Open
Abstract
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.
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Affiliation(s)
- Yuki Kinishi
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, Suita, Japan
- Department of Neuroscience and Cell Biology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yoshihisa Koyama
- Department of Neuroscience and Cell Biology, Osaka University Graduate School of Medicine, Osaka, Japan
- Addiction Research Unit, Osaka Psychiatric Research Center, Osaka Psychiatric Medical Center, Osaka, Japan
- Global Center for Medical Engineering and Informatics, Osaka University, Suita, Japan
- Integrated Frontier Research for Medical Science Division, Institute for Open and Transdisciplinary Research Initiatives (OTRI), Osaka University, Suita, Japan
| | - Tomoo Yuba
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, Suita, Japan
- Department of Neuroscience and Cell Biology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yuji Fujino
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Shoichi Shimada
- Department of Neuroscience and Cell Biology, Osaka University Graduate School of Medicine, Osaka, Japan
- Addiction Research Unit, Osaka Psychiatric Research Center, Osaka Psychiatric Medical Center, Osaka, Japan
- Global Center for Medical Engineering and Informatics, Osaka University, Suita, Japan
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Jung E, Romero R, Suksai M, Gotsch F, Chaemsaithong P, Erez O, Conde-Agudelo A, Gomez-Lopez N, Berry SM, Meyyazhagan A, Yoon BH. Clinical chorioamnionitis at term: definition, pathogenesis, microbiology, diagnosis, and treatment. Am J Obstet Gynecol 2024; 230:S807-S840. [PMID: 38233317 DOI: 10.1016/j.ajog.2023.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 01/31/2023] [Accepted: 02/02/2023] [Indexed: 04/05/2023]
Abstract
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.
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Affiliation(s)
- Eunjung Jung
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Department of Obstetrics and Gynecology, Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Roberto Romero
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI.
| | - Manaphat Suksai
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Francesca Gotsch
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Piya Chaemsaithong
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Department of Obstetrics and Gynecology, Mahidol University, Faculty of Medicine, Ramathibodi Hospital, Bangkok, Thailand
| | - Offer Erez
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Department of Obstetrics and Gynecology, Soroka University Medical Center, Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Agustin Conde-Agudelo
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Nardhy Gomez-Lopez
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Department of Biochemistry, Microbiology and Immunology, Wayne State University School of Medicine, Detroit, MI; Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI
| | - Stanley M Berry
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Arun Meyyazhagan
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Centre of Perinatal and Reproductive Medicine, University of Perugia, Perugia, Italy
| | - Bo Hyun Yoon
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Republic of Korea; Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
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Chen Z, Zhu C, Huang L, Qi Y, Guo X, Xie L, Li H. Serum Magnesium Level as a Biomarker to Predict the Risk of Labor Epidural Anesthesia Associated Fever. Int J Gen Med 2023; 16:5131-5138. [PMID: 37954654 PMCID: PMC10637208 DOI: 10.2147/ijgm.s431731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 10/27/2023] [Indexed: 11/14/2023] Open
Abstract
Objective Excessive pain will have adverse effects on the mother and fetus. Labor epidural analgesia greatly reduces the pain, which is widely carried out abroad. Labor epidural anesthesia-associated fever (LEAF) is the biggest problem for labor epidural anesthesia. This study aimed to evaluate the clinical value of serum magnesium levels to predict the LEAF. Methods Overall 528 singleton term-pregnant women who underwent labor epidural anesthesia in Fujian Provincial Maternity and Children's Health Hospital, affiliated hospital of Fujian Medical University from January 2019 to June 2019, were analyzed retrospectively. The serum magnesium level was detected using venous blood samples. The relationship between the serum magnesium level and LEAF was interpreted, and the optimal cut-off values of the serum magnesium level to predict LEAF were calculated. Results Overall, 65 (12.30%) participants had LEAF. And a higher rate of the bulging membrane, gestational hypertension, neonatal intensive care unit (NICU) admission, and the different mode of delivery was significantly associated with LEAF. Also, the serum magnesium level demonstrated higher significantly in presence of LEAF than absence (P<0.05). What is more, it indicated that the area under the receiver operating characteristic curve (AUC) for the serum magnesium level was 0.825, and an optimal cut-off of the serum magnesium level was 0.855 mg/dl. Furthermore, it demonstrated that the serum magnesium level had the highest OR (OR= 7.49; 95% CI (4.58-14.35)) (P<0.001). The bulging membrane is an independent risk factor presence of LEAF (OR = 1.55; 95% CI (1.01-2.43)) (P=0.038). Conclusion This study demonstrated that the baseline of serum magnesium can provide a suitable biomarker to predict LEAF. It can help to provide a useful target for LEAF treatment and enhance surveillance before fever.
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Affiliation(s)
- Zhiwei Chen
- Department of Gynecologic, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, People’s Republic of China
| | - Chuling Zhu
- Department of Women’s health Department, QuanZhou Women and Children’s Hospital, Quanzhou, People’s Republic of China
| | - Lingna Huang
- Department of Gynecologic, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, People’s Republic of China
| | - Yuanjie Qi
- Department of Gynecologic, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, People’s Republic of China
| | - Xiaoyao Guo
- Department of Gynecologic, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, People’s Republic of China
| | - Li Xie
- Department of Gynecologic, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, People’s Republic of China
| | - Hua Li
- Department of Gynecologic, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, People’s Republic of China
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7
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Sultan P, Blumenfeld Y. Elucidating the effects of labor analgesia on fetal immune function and in utero temperature: a novel approach to understanding epidural-related maternal fever. Am J Obstet Gynecol 2023; 229:476-477. [PMID: 37120048 DOI: 10.1016/j.ajog.2023.04.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 04/24/2023] [Indexed: 05/01/2023]
Affiliation(s)
- Pervez Sultan
- Department of Anesthesia, Critical Care and Pain Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305.
| | - Yair Blumenfeld
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA
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Zhang Z, Deng CM, Ma JH, Li S, Lei B, Ding T. Effects of neuraxial labor analgesia on intrapartum maternal fever in full-term pregnancy and its influence on birth outcomes. Front Med (Lausanne) 2023; 10:1208570. [PMID: 37534315 PMCID: PMC10390729 DOI: 10.3389/fmed.2023.1208570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 06/27/2023] [Indexed: 08/04/2023] Open
Abstract
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.
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Affiliation(s)
- Zhen Zhang
- Department of Anesthesiology, Peking University First Hospital, Beijing, China
| | - Chun-Mei Deng
- Department of Anesthesiology, Peking University First Hospital, Beijing, China
| | - Jia-Hui Ma
- Department of Anesthesiology, Peking University First Hospital, Beijing, China
| | - Shu Li
- Department of Anesthesiology, Beijing Obstetrics and Gynecology Hospital, Beijing, China
| | - Bo Lei
- Department of Anesthesiology, Haidian Maternal and Child Health Hospital, Beijing, China
| | - Ting Ding
- Department of Anesthesiology, Peking University First Hospital, Beijing, China
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9
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Patel S, Ciechanowicz S, Blumenfeld YJ, Sultan P. Epidural-related maternal fever: incidence, pathophysiology, outcomes, and management. Am J Obstet Gynecol 2023; 228:S1283-S1304.e1. [PMID: 36925412 DOI: 10.1016/j.ajog.2022.06.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 06/17/2022] [Accepted: 06/20/2022] [Indexed: 03/18/2023]
Abstract
Epidural-related maternal fever affects 15% to 25% of patients who receive a labor epidural. Two meta-analyses demonstrated that epidural-related maternal fever is a clinical phenomenon, which is unlikely to be caused by selection bias. All commonly used neuraxial techniques, local anesthetics with or without opioids, and maintenance regimens are associated with epidural-related maternal fever, however, the impact of each component is unknown. Two major theories surrounding epidural-related maternal fever development have been proposed. First, labor epidural analgesia may lead to the development of hyperthermia through a sterile (noninfectious) inflammatory process. This process may involve reduced activation of caspase-1 (a protease involved in cell apoptosis and activation of proinflammatory pathways) secondary to bupivacaine, which impairs the release of the antipyrogenic cytokine, interleukin-1-receptor antagonist, from circulating leucocytes. Detailed mechanistic processes of epidural-related maternal fever remain to be determined. Second, thermoregulatory mechanisms secondary to neuraxial blockade have been proposed, which may also contribute to epidural-related maternal fever development. Currently, there is no prophylactic strategy that can safely prevent epidural-related maternal fever from occurring nor can it easily be distinguished clinically from other causes of intrapartum fever, such as chorioamnionitis. Because intrapartum fever (of any etiology) is associated with adverse outcomes for both the mother and baby, it is important that all parturients who develop intrapartum fever are investigated and treated appropriately, irrespective of labor epidural utilization. Institution of treatment with appropriate antimicrobial therapy is recommended if an infectious cause of fever is suspected. There is currently insufficient evidence to warrant a change in recommendations regarding provision of labor epidural analgesia and the benefits of good quality labor analgesia must continue to be reiterated to expectant mothers.
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Affiliation(s)
- Selina Patel
- Department of Anesthesia, Pain and Perioperative Medicine, University of Miami, Miller School of Medicine, Miami, FL
| | - Sarah Ciechanowicz
- Department of Anaesthesia, University College London Hospital, London, United Kingdom
| | - Yair J Blumenfeld
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA
| | - Pervez Sultan
- Department of Anesthesia, Critical Care and Pain Medicine, Stanford University School of Medicine, Stanford, CA.
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Seiler FA, Scavone BM, Shahul S, Arnolds DE. Maternal Fever Associated With Continuous Spinal Versus Epidural Labor Analgesia: A Single-Center Retrospective Study. Anesth Analg 2022; 135:1153-1158. [PMID: 35051951 DOI: 10.1213/ane.0000000000005905] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Neuraxial labor analgesia is associated with elevations in maternal temperature; the mechanism responsible is unknown. Proposed mechanisms have included infection, altered thermoregulation, and inflammation, potentially triggered by local anesthetics. Studies of the association between neuraxial labor analgesia and maternal fever have focused on epidural analgesia, and there have been no comparisons of the rate of maternal fever between continuous spinal and epidural labor analgesia. METHODS We performed a retrospective study to compare the rate of maternal fever between patients who received continuous spinal versus epidural labor analgesia between June 2012 and March 2020. Each patient who received continuous spinal analgesia was matched to 2 patients who received epidural analgesia and had the same nulliparous status. The primary outcome of our study was the incidence of intrapartum maternal fever, which we defined as any temperature ≥38 °C before delivery and compared between the continuous spinal and epidural groups using Fisher exact test. RESULTS We identified 81 patients who received continuous spinal analgesia and 162 matched controls who received epidural analgesia. Demographic and obstetric characteristics of the patients were similar between groups. While the duration of analgesia did not significantly differ, there was markedly increased bupivacaine consumption in women with epidural analgesia. Eight of 81 (9.9%; 95% confidence interval [CI], 5.1-18.3) women with continuous spinal analgesia developed an intrapartum fever compared to 18 of 162 (11.1%; 95% CI, 7.1-16.9) of women with epidural analgesia ( P = .83; Fisher exact test). CONCLUSIONS There was no significant difference in the rate of maternal fever between women with continuous spinal compared to epidural labor analgesia. While the route of administration and dose of bupivacaine differs between epidural and spinal labor analgesia, they are titrated to produce similar levels of neuraxial blockade. Our results are consistent with a model in which epidural related maternal fever is due to altered thermoregulation from a central neuraxial block and argue against a direct effect of bupivacaine or fentanyl, although we cannot rule out a concentration-independent effect of bupivacaine or fentanyl or an inflammatory effect of the catheter itself. These retrospective results highlight the importance of prospective and mechanistic study of neuraxial analgesia-related maternal fever.
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Affiliation(s)
| | - Barbara M Scavone
- From the Departments of Anesthesia and Critical Care.,Obstetrics and Gynecology, University of Chicago, Chicago, Illinois
| | - Sajid Shahul
- From the Departments of Anesthesia and Critical Care
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11
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Yao Z, Zhou J, Li S, Zhou W. The effects of combined spinal-epidural analgesia and epidural anesthesia on maternal intrapartum temperature: a randomized controlled trial. BMC Anesthesiol 2022; 22:352. [PMCID: PMC9664822 DOI: 10.1186/s12871-022-01898-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 11/07/2022] [Indexed: 11/16/2022] Open
Abstract
Abstract
Background
Labor epidural analgesia has been suggested to be associated with intrapartum fever. We designed this study to investigate the effects of epidural analgesia and combined spinal-epidural analgesia on maternal intrapartum temperature.
Methods
Four hundred healthy nullipara patients were randomly assigned to receive either epidural analgesia (EA group) or combined spinal-epidural analgesia (CSEA group). Maternal temperature was measured hourly after analgesia administration. The primary outcome was the incidence of maternal fever, and the secondary outcomes were the duration of analgesia, analgesia to full cervical dilation and analgesia to delivery. Neonatal outcomes and other basic labor events were also recorded.
Results
Maternal temperature gradually increased with time in both analgesia groups during labor. However, the CSEA group had a lower incidence of maternal fever, and a lower mean maternal temperature at 5 h, 6 h, and 9 h after analgesia. In addtion, the CSEA group also had a shorter time of analgesia duration, analgesia to full cervical dilation, analgesia to delivery, and less dose of epidural local anesthetic than the EA group.
Conclusion
Our findings suggest that combined spinal-epidural analgesia is associated with a lower risk of intrapartum fever than epidural analgesia.
Trial registration
ChiCTR1900026606. Registered on 16/10/2019.
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12
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Interventions for the prevention or treatment of epidural-related maternal fever: a systematic review and meta-analysis. Br J Anaesth 2022; 129:567-580. [PMID: 35934529 PMCID: PMC9575042 DOI: 10.1016/j.bja.2022.06.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 05/18/2022] [Accepted: 06/16/2022] [Indexed: 11/28/2022] Open
Abstract
Background Epidural-related maternal fever in women in labour has consequences for the mother and neonate. There has been no systematic review of preventive strategies. Methods RCTs evaluating methods of preventing or treating epidural-related maternal fever in women in active labour were eligible. We searched MEDLINE, EMBASE, CINAHL, Web of Science, CENTRAL, and grey literature sources were searched from inception to April 2021. Two review authors independently undertook study selection. Data extraction and quality assessment was performed by a single author and checked by a second. The Cochrane Risk of Bias 2 tool was used. Meta-analyses for the primary outcome, incidence of intrapartum fever, were performed using the DerSimonian and Laird random effects model to produce summary risk ratios (RRs) with 95% confidence intervals (95% CIs). Results Forty-two records, representing 34 studies, were included. Methods of reduced dose epidural reduced the incidence of intrapartum fever, but this was not statistically significant when six trials at high risk of bias were removed (seven trials; 857 participants; RR=0.83; 95% CI, 0.41–1.67). Alternative methods of analgesia and high-dose prophylactic systemic steroids reduced the risk of intrapartum fever compared with epidural analgesia. Prophylactic paracetamol was not effective. Conclusions There is no clear evidence to support the use of any individual preventative or therapeutic intervention for epidural-related maternal fever. Further research should focus on understanding the mechanism of fever development to enable RCTs of potential interventions to reduce the incidence of intrapartum fever development and the subsequent disease burden felt by the neonate. Clinical trial registration CRD42021246929.
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13
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Ali A, Weber V, Thompson SJ, EF Abbott T, Harmston R, David AL, Ackland GL. IL1-ra polymorphisms and risk of epidural-related maternal fever (EPIFEVER-2): study protocol for a multicentre, observational mechanistic cohort study. Int J Obstet Anesth 2022; 50:103540. [DOI: 10.1016/j.ijoa.2022.103540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 02/28/2022] [Accepted: 03/12/2022] [Indexed: 10/18/2022]
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Zhao W, Wang L, Chang X, Zhang Y, Xiao F, Xia F. Maternal serum C-reactive protein and white blood cell count at hospital admission as predictors of intrapartum maternal fever: a retrospective case-control study in women having epidural labor analgesia. Int J Obstet Anesth 2022; 50:103537. [DOI: 10.1016/j.ijoa.2022.103537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 01/10/2022] [Accepted: 03/12/2022] [Indexed: 11/24/2022]
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15
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Chen X, Zhang Y, Ni X, Liu Z. Effects of labour analgesia with different concentrations of ropivacaine on maternal body temperature and inflammatory factor: A randomized controlled study. Anaesth Crit Care Pain Med 2022; 41:101030. [PMID: 35123105 DOI: 10.1016/j.accpm.2022.101030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 12/19/2021] [Accepted: 12/27/2021] [Indexed: 11/01/2022]
Abstract
PURPOSE To investigate the effect of different concentrations of ropivacaine on maternal temperature and inflammatory factors during epidural analgesia. METHOD One hundred and forty healthy term nulliparas were randomly assigned to receive epidural analgesia with either 0.1% ropivacaine (group H) or 0.068% ropivacaine (group L). Epidural sufentanil 0.3 μg/ml was added in both groups. Maternal tympanic temperature was measured at initiation of epidural analgesia (baseline temperature) and each hour thereafter. Maternal blood samples were taken at the time of epidural placement and 4 hours after analgesia to detect IL-6 and IL-1β serum concentrations. Visual analog scale pain scores, labour events and neonatal outcomes were recorded. RESULTS Epidural analgesia using 0.1% or 0.068% ropivacaine both achieved satisfactory pain relief. Increases in maternal body temperature and in IL-6 levels were observed in both groups, but there was no significant difference between the two groups. The incidence of maternal fever was similar between the two groups. CONCLUSION Maternal body temperature and serum inflammatory factors are similarly affected by 0.1% or 0.068% ropivacaine used during epidural analgesia use for labour pain relief.
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Affiliation(s)
- Xiubin Chen
- Department of Anaesthesiology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai 201204, China
| | - Yueqi Zhang
- Department of Anaesthesiology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai 201204, China
| | - Xiu Ni
- Department of Anaesthesiology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai 201204, China
| | - Zhiqiang Liu
- Department of Anaesthesiology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai 201204, China.
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16
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Ackland GL, Van Duijvenboden S, Abbott TE, Gutierrez del Arroyo A, Wilson MJ, David AL. Interleukin-1 receptor antagonist, mode of analgesia and risk of Caesarean delivery after onset of labour: a Mendelian randomisation analysis. Br J Anaesth 2022; 128:89-97. [PMID: 34802694 PMCID: PMC8787778 DOI: 10.1016/j.bja.2021.09.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 09/27/2021] [Accepted: 09/28/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Lower circulating levels of the anti-inflammatory cytokine interleukin-1 receptor antagonist (IL-1ra) are associated with intrapartum inflammation and epidural analgesia-related maternal fever, both of which increase the rate of obstetric interventions. We hypothesised that genetic variants determining IL-1ra levels would be associated with Caesarean delivery rates after the onset of labour. METHODS We performed Mendelian randomisation analyses in parous women ≥16 yr old who received either non-neuraxial or neuraxial analgesia for their first two labours (UK Biobank). We used an established genetic score (calculated as 0-4, determined by the presence/absence of rs6743376 and rs1542176 alleles), in which the complete absence of both alleles causes the lowest IL-1ra levels. The primary outcome was Caesarean delivery after the onset of labour (odds ratio [OR]: 95% confidence intervals). RESULTS There were 7731 women (mean [standard deviation] age at first birth: 25 [5] yr) who had complete genetic scores and delivery data. For women who received non-neuraxial analgesia, Caesarean delivery rates were different across allele scores (χ2=12.4; P=0.015): 104/596 (17.4%) women with zero allele score underwent Caesarean delivery, compared with 654/5015 (13.0%) with allele score ≥1 (OR 1.41; 1.12-1.77). For women who had neuraxial analgesia, Caesarean delivery was not different across allele scores, ranging from 18.1% to 20.8% (χ2=0.29; P=0.99). Caesarean delivery was independent of type of analgesia for 818/7731 (10.6%) women with zero allele scores (OR 0.93; 0.63-1.39), but was higher in women receiving neuraxial analgesia with allele scores ≥1 (OR 1.55; 1.35-1.79; P<0.001). CONCLUSIONS Mendelian randomisation analysis suggests that higher IL-1ra levels are associated with reduced Caesarean delivery rate. Neuraxial analgesia appears to disrupt this link. CLINICAL TRIAL REGISTRATION UK Biobank study 62745.
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Affiliation(s)
- Gareth L. Ackland
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK,Corresponding author.
| | | | - Tom E.F. Abbott
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Ana Gutierrez del Arroyo
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Matthew J. Wilson
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Anna L. David
- Elizabeth Garret Anderson Institute for Women's Health, University College London, London, UK
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17
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Zhao BS, Li B, Wang QN, Jia JX, Song XR. Time- and dose-dependent correlations between patient-controlled epidural analgesia and intrapartum maternal fever. BMC Anesthesiol 2021; 21:31. [PMID: 33514322 PMCID: PMC7845030 DOI: 10.1186/s12871-021-01249-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 01/20/2021] [Indexed: 11/10/2022] Open
Abstract
Background To investigate the relationship between intrapartum maternal fever and the duration and dosage of patient-controlled epidural analgesia (PCEA). Methods This observational study included 159 pregnant women who voluntarily accepted PCEA. During labor, patients with body temperature ≥ 38 °C were classified into the Fever group, (n = 42), and those with body temperature < 38 °C were classified into the No-fever group (n = 117). The outcome measures included the duration of PCEA, number of PCEA, and total PCEA amount. Body temperature and parturient variables, including interpartum fever status and the duration of any fever were monitored. Results The total PCEA duration and total PCEA amount in the Fever group were significantly higher than the corresponding values in the No-fever group (both, p < 0.05). The duration of fever was weakly correlated with the duration of PCEA (R2 = 0.08) and the total PCEA amount (R2 = 0.05) (both, p < 0.05). The total and effective PCEA were higher in the Fever group than in the No-fever group (both, p < 0.05). The total PCEA duration and total PCEA amount were positively correlated with the incidence of fever (both, p < 0.05). The diagnostic cutoff value for fever was 383 min, with a sensitivity of 78.6% and specificity of 57.3%. The mean temperature-time curves showed that parturients who developed fever had a steeper rise in temperature. Conclusions This study showed that there were weak time- and dose-dependent correlations between PCEA and maternal fever during delivery. A total PCEA duration exceeding 6.3 h was associated with an increase in the duration of maternal intrapartum fever.
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Affiliation(s)
- Bai-Song Zhao
- Department of Anesthesiology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jinsui Road, Tianhe District, Guangzhou, 510623, Guangdong, China
| | - Bing Li
- Department of Anesthesiology, Women and Children's Hospital, School of Medicine, Xiamen University, Xiamen, 361000, Fujian, China
| | - Qing-Ning Wang
- Department of Anesthesiology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jinsui Road, Tianhe District, Guangzhou, 510623, Guangdong, China
| | - Jun-Xiang Jia
- Department of Anesthesiology, Women and Children's Hospital, School of Medicine, Xiamen University, Xiamen, 361000, Fujian, China.
| | - Xing-Rong Song
- Department of Anesthesiology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jinsui Road, Tianhe District, Guangzhou, 510623, Guangdong, China.
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18
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Thorburn PT, Monteiro R, Chakladar A, Cochrane A, Roberts J, Mark Harper C. Maternal temperature in emergency caesarean section (MATES): an observational multicentre study. Int J Obstet Anesth 2021; 46:102963. [PMID: 33773300 DOI: 10.1016/j.ijoa.2021.102963] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 12/16/2020] [Accepted: 01/01/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Temperature regulation in women undergoing emergency caesarean section is a complex topic about which there is a paucity of evidence-based recommendations. The adverse effects of inadvertent peri-operative hypothermia are well described. Hyperthermia is also associated with adverse neonatal outcomes, an increased risk of obstetric intervention and increased treatment for suspected sepsis. We conducted a multi-centre observational cohort study to identify the prevalence of hypothermia and hyperthermia during emergency caesarean section. S: Participants undergoing emergency caesarean section were recruited across 14 sites in the UK. The primary end point was maternal temperature in the recovery room. Temperature was measured using a zero heat-flux temperature monitoring device. RESULTS Two hundred and sixty-five participants were recruited over a 12-month period. The prevalence of hypothermia (<36.0°C) was 10.7% and the prevalence of hyperthermia (>37.5°C) was 14.7% on admission to recovery. The prevalence of hypothermia, normothermia, and hyperthermia differed among type of anaesthesia: 71.4% of the hypothermic group had received a spinal anaesthetic whereas 76.9% of the hyperthermic group had received epidural top-up anaesthesia. There was a significant decrease in maternal temperature between the time of delivery and admission to the recovery room of 0.20°C (95% CI 0.15 to 0.25, P<0.001). CONCLUSIONS Both hypothermia and hyperthermia are prevalent findings in mothers who undergo emergency caesarean section. Therefore, accurate temperature measurement is essential to ensure that an appropriate intra-operative temperature management strategy is employed.
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Affiliation(s)
- P T Thorburn
- Department of Anaesthesia, Brighton & Sussex University Hospitals NHS Trust, Brighton, UK.
| | - R Monteiro
- Department of Anaesthesia, Brighton & Sussex University Hospitals NHS Trust, Brighton, UK
| | - A Chakladar
- Department of Anaesthesia, Brighton & Sussex University Hospitals NHS Trust, Brighton, UK
| | - A Cochrane
- Department of Anaesthesia, St Helens and Knowsley Teaching Hospital NHS Trust, St Helens, UK
| | - J Roberts
- Department of Anaesthesia, Brighton & Sussex University Hospitals NHS Trust, Brighton, UK
| | | | - C Mark Harper
- Department of Anaesthesia, Brighton & Sussex University Hospitals NHS Trust, Brighton, UK
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Mullington CJ, Malhotra S. Hyperthermia after epidural analgesia in obstetrics. BJA Educ 2021; 21:26-31. [PMID: 33456971 DOI: 10.1016/j.bjae.2020.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2020] [Indexed: 11/17/2022] Open
Affiliation(s)
| | - S Malhotra
- Fiona Stanley Hospital, Murdoch, Australia
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20
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Chai J, Jia L, Cao H, Zhang X, Xu Z. Association of lymphocyte count and incidence of maternal fever in epidural analgesia-involved labor. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1584. [PMID: 33437783 PMCID: PMC7791247 DOI: 10.21037/atm-20-1724] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background Evidence showed that the use of epidural analgesia increased the risk of maternal fever during labor, and the potential mechanisms involved inflammation. Lymphocyte played a role in the inflammatory responses, and lymphopenia predicted adverse outcomes for patients. The aim of this study was to investigate whether lymphocyte count was associated with the incidence of intrapartum fever in nulliparous women undergoing vaginal delivery. Methods In this retrospective cohort study, electronic medical record data at the International Peace Maternity and Child Health Hospital (IPMCH, Shanghai, China) between 2012 and 2017 were extracted. The primary outcome of this study was baseline lymphocyte count in febrile and afebrile parturients who received labor epidural analgesia. Other confounding factors associated with the development of intrapartum fever were analyzed using multivariable logistic regression. Results The final study population consisted of 36,562 parturients, of whom 18,952 (51.8%) received labor epidural analgesia. Labor epidural analgesia was associated with an increased risk of maternal fever [relative risk: 4.55; 95% confidence interval (CI): 4.16–4.98; P<0.001]. Among the parturients who received epidural analgesia, both baseline lymphocyte count and lymphocyte percentage were lower in the febrile patients than those in the afebrile patients (P<0.001; P=0.015). The lower (<1.1×109/L) baseline lymphocyte was associated with a higher risk of maternal fever (adjusted odds ratio: 1.30, 95% CI: 1.14–1.48; P<0.001). Conclusions Our results suggested that lower lymphocyte baseline indicated an increased risk of maternal fever during epidural analgesia-involved labor. Further studies are needed to confirm the findings and determine the potential mechanisms.
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Affiliation(s)
- Jing Chai
- Department of Anesthesiology, International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China
| | - Lijie Jia
- Department of Anesthesiology, International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China
| | - Huimin Cao
- Department of Anesthesiology, International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China
| | - Xiaoyu Zhang
- Department of Anesthesiology, International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China
| | - Zifeng Xu
- Department of Anesthesiology, International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China
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Epidural analgesia, intrapartum hyperthermia, and neonatal brain injury: a systematic review and meta-analysis. Br J Anaesth 2020; 126:500-515. [PMID: 33218673 DOI: 10.1016/j.bja.2020.09.046] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 09/21/2020] [Accepted: 09/23/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Epidural analgesia is associated with intrapartum hyperthermia, and chorioamnionitis is associated with neonatal brain injury. However, it is not known if epidural hyperthermia is associated with neonatal brain injury. This systematic review and meta-analysis investigated three questions: (1) does epidural analgesia cause intrapartum hyperthermia, (2) is intrapartum hyperthermia associated with neonatal brain injury, and (3) is epidural-induced hyperthermia associated with neonatal brain injury? METHODS PubMed, ISI Web of Knowledge, The Cochrane Library, and Embase were searched from inception to January 2020 using Medical Subject Headings (MeSH) terms relating to epidural analgesia, hyperthermia, labour, and neonatal brain injury. Studies were reviewed independently for inclusion and quality by two authors (Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach). Two meta-analyses were performed using the Mantel-Haenszel fixed effect method to generate odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS Forty-one studies were included for Question 1 (646 296 participants), 36 for Question 2 (11 866 021 participants), and two studies for Question 3 (297 113 participants). When the mode of analgesia was randomised, epidural analgesia was associated with intrapartum hyperthermia (OR: 4.21; 95% CI: 3.48-5.09). There was an association between intrapartum hyperthermia and neonatal brain injury (OR: 2.79; 95% CI: 2.54-2.3.06). It was not possible to quantify the association between epidural-induced hyperthermia and neonatal brain injury. CONCLUSIONS Epidural analgesia is a cause of intrapartum hyperthermia, and intrapartum hyperthermia of any cause is associated with neonatal brain injury. Further work is required to establish if epidural-induced hyperthermia is a cause of neonatal brain injury.
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Sultan P, Segal S. In Response. Anesth Analg 2020; 131:e162. [DOI: 10.1213/ane.0000000000004991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Sultan P, Segal S. Epidural-Related Maternal Fever: Still a Hot Topic, But What Are the Burning Issues? Anesth Analg 2020; 130:318-320. [PMID: 31934906 DOI: 10.1213/ane.0000000000004576] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Pervez Sultan
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Scott Segal
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
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Remifentanil patient-controlled versus epidural analgesia on intrapartum maternal fever: a systematic review and meta-analysis. BMC Pregnancy Childbirth 2020; 20:151. [PMID: 32164593 PMCID: PMC7069013 DOI: 10.1186/s12884-020-2800-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 02/10/2020] [Indexed: 01/07/2023] Open
Abstract
Background Intravenous remifentanil patient-controlled analgesia (RPCA) is an alternative for epidural analgesia (EA) in labor pain relief. However, it remains unknown whether RPCA is superior to EA in decreasing the risk of intrapartum maternal fever during labor. Methods According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic review and meta-analysis was performed by searching PubMed, EMBASE and the Cochrane Central Register of Controlled Trials from inception to April 2019. All randomized controlled trials (RCTs) investigating the risk of intrapartum maternal fever with RPCA compared with EA alone or EA in combination with spinal analgesia during labor were included. Results A total of 825 studies were screened, and 6 RCTs including 3341 patients were identified. Compared with EA, RPCA was associated with a significantly lower incidence of intrapartum maternal fever (risk ratio [RR] 0.48, P = 0.02, I2 = 49%) during labor analgesia. After excluding 2 trials via the heterogeneity analysis, there was no difference in the incidence of intrapartum fever between patients receiving RPCA and those receiving EA. Satisfaction with pain relief during labor was lower in the RPCA group than that in the EA group (− 10.6 [13.87, − 7.44], P < 0.00001, I2 = 0%). The incidence of respiratory depression was significantly greater in the RPCA group than that in the EA group (risk ratio 2.86 [1.65, 4.96], P = 0.0002, I2 = 58%). The incidence of Apgar scores < 7 at 5 min in the RPCA group was equivalent to that in the EA group. Conclusion There is no solid evidence to illustrate that the incidence of intrapartum maternal fever is lower in patients receiving intravenous RPCA than in patients receiving EA.
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Wohlrab P, Boehme S, Kaun C, Wojta J, Spittler A, Saleh L, Knöfler M, Markstaller K, Klein KU, Tretter V. Ropivacaine Activates Multiple Proapoptotic and Inflammatory Signaling Pathways That Might Subsume to Trigger Epidural-Related Maternal Fever. Anesth Analg 2020; 130:321-331. [DOI: 10.1213/ane.0000000000004402] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Arce DY, Bellavia A, Cantonwine DE, Napoli OJ, Meeker JD, James-Todd T, McElrath TF, Tsen LC. Average and time-specific maternal prenatal inflammatory biomarkers and the risk of labor epidural associated fever. PLoS One 2019; 14:e0222958. [PMID: 31689293 PMCID: PMC6830771 DOI: 10.1371/journal.pone.0222958] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 09/10/2019] [Indexed: 02/03/2023] Open
Abstract
Background The use of labor epidural analgesia has been associated with intrapartum fever, known as labor epidural associated fever (LEAF). LEAF is most commonly non-infectious in origin and associated with elevated inflammatory cytokines. Methods The LIFECODES pregnancy cohort was designed to prospectively collect data to evaluate the association of maternal inflammatory biomarkers with preterm birth in women who delivered between 2007 and 2008 at Brigham and Women’s Hospital. Our secondary analysis of the data from the cohort identified 182 women for whom inflammatory biomarkers (i.e. interleukin-10, interleukin-1β, interleukin-6, tumor necrosis factor-α and C-reactive protein) collected longitudinally over four prenatal visits was available. Maternal temperature and other clinical variables were abstracted from medical records. The primary outcome, the presence of LEAF, was defined as oral temperature ≥ 38°C (≥100.4°F) after epidural analgesia initiation. Multivariable logistic regression estimated the association between inflammatory biomarker concentrations and the odds of developing an intrapartum fever after adjusting for a number of potential confounders. Results Women who developed LEAF were more likely to have a longer duration of epidural analgesia, whereas women who did not develop LEAF were more likely to have induced labor and positive or unknown Group B Streptococcus colonization status. However, no differences were seen by nulliparity, mode of delivery, white blood cell count at admission, baseline temperature, length of rupture of membranes and number of cervical exams performed during labor. Unadjusted and multivariable logistic regression models did not provide evidence for or exclude an association between individual maternal inflammatory biomarkers and the odds of developing LEAF, regardless of visit time-period. Conclusion The predictive value of maternal inflammatory biomarkers measured during early- and mid-pregnancy for the risk of developing LEAF cannot be excluded.
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Affiliation(s)
- Dominique Y. Arce
- Department of Anesthesiology, Perioperative and Pain Medicine, Division of Obstetric Anesthesia, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
| | - Andrea Bellavia
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - David E. Cantonwine
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Olivia J. Napoli
- Lake Erie College of Osteopathic Medicine, Erie, Pennsylvania, United States of America
| | - John D. Meeker
- Department of Environmental Health Sciences, University of Michigan School of Public Health, Ann Arbor, Michigan, United States of America
| | - Tamarra James-Todd
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Thomas F. McElrath
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Lawrence C. Tsen
- Department of Anesthesiology, Perioperative and Pain Medicine, Division of Obstetric Anesthesia, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
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