Epidural Fever?! Have You Heard of it?

Have you seen this in your clinical practice that a patient you placed an epidural 10 hours ago developed a fever? You may not have thought into it too much. After all, there are many possibilities that laboring woman can develop fever. There are many etiologies that can cause  intrapartum fever such as maternal chorioamnionitis and other infections. On one postpartum floor in a regular size hospital earlier this year, almost a third of the women were treated with antibiotics as well as some of their babies. The antibiotics were being given prophylactically due to symptoms of pyrexia and/or tachycardia following labor and birth. Yet all the culture came back negative. And all of the women’s and babies’ symptoms self resolved. So what caused these women and babies to show symptoms of infection, but no infection could later be found? This is a mystery!!! Is it a new and insidious wonder bug that can cause spiking in temperature and pulse without any findings in the lab?

Have you heard of epidural fever on OB floor? I know if something goes wrong, everyone would want to point finger at us. I didn’t know there was such a term until recently. Maybe part of me didn’t want to admit that it could be associated with epidural placement.   download.png

Studies have shown that there is an association of maternal fever and epidural analgesia. Several randomized trials have demonstrated a higher likelihood of developing fever in epidural-exposed women. For instance, 19% women with epidural developed fever compared to 2.4% women without epidural in one clinical trial. Women who developed fevers are usually older, and have larger babies and longer labors. In addition, most epidural-related fevers develop after the woman has been numb for six hours or more. IL6 is found significantly increased with the women who received epidural. The raise in temperature can be attributed to the decrease in IL-6 levels.he increase in IL6 and fever can be suppressed when epidural dexamethasone was given after epidural analgesia. Several other clinical studies showed similar findings, indicating there is a causal relationship.

The mechanisms of epidural-induced fever is unclear. It is postulated that the etiology is likely inflammation either in the placenta or membranes. Studies have shown that epidurals in laboring women can result in 1 degree Celsius increase every 6-7 hours.

ž1 degree Celsius increase per 7 hours

Others report 0.1 degrees Celsius per hour

Why would this relevant to us? Because there are maternal Consequences associated with fever as below. In addition, maternal inflammatory fever may be associated with increased risks for neurological depression in babies.

-Increased HR, CO, O2 consumption

-Rigors, shaking

-Antibiotic exposure

-Change in obstetric plans:  Obstetricians are more likely to surgically intervene in laboring women with fever.

neonate: neonatologists are more likely to evaluate neonates of febrile women for sepsis.

Epidural analgesia-associated fever may have significant consequences for both the mother and the fetus/neonate. Hence, it is good for us to be aware of this information.

žReference:

Segal, Scott MD, MHCM. Labor Epidural Analgesia and Maternal Fever. Anesthesia & Analgesia. 2010 Dec. Vol 111.6.1467-1475

žNegishi C, Lenhardt R, Ozaki M, Ettinger K, Bastanmehr H, Bjorksten AR, Sessler DI. Opioids inhibit febrile responses in humans, whereas epidural analgesia does not: an explanation for hyperthermia during epidural analgesia. Anesthesiology 2001;94:218–22

Goetzl L, Evans T, Rivers J, Suresh MS, Lieberman E. Elevated maternal and fetal serum interleukin-6 levels are associated with epidural fever. Am J Obstet Gynecol 2002;187:834–8

Wang LZ1, Hu XX, Liu X, Qian P, Ge JM, Tang BL. Influence of epidural dexamethasone on maternal temperature and serum cytokine concentration after labor epidural analgesia. Int J Gynaecol Obstet. 2011 Apr;113(1):40-3. doi: 10.1016/j.ijgo.2010.10.026

 

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