Maternal Fever Associated With Continuous Spinal Versus Epidural Labor Analgesia: A Single-Center Retrospective Study

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.

Delivery, maternal and neonatal outcomes in nulliparous women with gestational diabetes undergoing epidural labour analgesia: a propensity score-matched analysis

“…Similarly, we also found the incidence of fever increased in the ELA group compared with that of patients who did not receive ELA in the present study. Although the mechanisms by which intrapartum fever develops as a result of ELA remain unclear, numerous studies suggest that maternal fever during delivery may be a consequence of non-infectious inflammatory resulting from central neuraxial blockade 26–28. Fever during labour with ELA may be associated with adverse maternal outcomes and increased risk of neonatal complications.…”

“…Although the mechanisms by which intrapartum fever develops as a result of ELA remain unclear, numerous studies suggest that maternal fever during delivery may be a consequence of non-infectious inflammatory resulting from central neuraxial blockade. [26][27][28] Fever during labour with ELA may be associated with adverse maternal outcomes and increased risk of neonatal complications. Recent studies have shown that among those receiving ELA, women who developed intrapartum fever had a significantly longer first stage of labour and a higher incidence of caesarean deliveries, assisted vaginal delivery, intrapartum haemorrhage and turbid amniotic fluid than those with no intrapartum temperature elevation.…”

Interleukin-1 Receptor Antagonist, Mode of Analgesia and Risk of Cesarean Delivery After Onset of Labor: A Mendelian Randomization Analysis

“…Moreover, duration of exposure to epidural analgesia or length of labor in unmedicated women remains a risk factor for intrapartum fever 1 . There is no evidence that the rates of fever or exposure to inflammatory cytokines are altered with traditional epidural when compared with combined spinal epidural or continuous spinal analgesia nor with patient-administered epidural boluses 3 . No specific neuraxial technique has been recommended to reduce maternal fever or fetal inflammation 1…”

“…1 There is no evidence that the rates of fever or exposure to inflammatory cytokines are altered with traditional epidural when compared with combined spinal epidural or continuous spinal analgesia nor with patient-administered epidural boluses. 3 No specific neuraxial technique has been recommended to reduce maternal fever or fetal inflammation. 1 Several studies have evaluated the effects of local anesthetic medications on inflammatory pathways.…”

Hot Off the Press! Commentary on “Maternal Fever Associated With Continuous Spinal Versus Epidural Labor Analgesia: A Single-Center Retrospective Study”

“…The article by Seiler et al 1 in this issue of Anesthesia & Analgesia examines the difference in the rate of maternal fever in patients with continuous spinal analgesia as compared to those with epidural labor analgesia. Multiple investigations have concluded that the fever associated with neuraxial analgesia is not related to maternal or fetal infection.…”