Advertisement

Severity of intrapartum fever and neonatal outcomes

      Background

      The few studies that have addressed the relationship between severity of intrapartum fever and neonatal and maternal morbidity have had mixed results. The impact of the duration between reaching maximum intrapartum temperature and delivery on neonatal outcomes remains unknown.

      Objective

      To test the association of severity of intrapartum fever and duration from reaching maximum temperature to delivery with neonatal and maternal morbidity.

      Study Design

      This was a secondary analysis of a prospective cohort of term, singleton patients admitted for induction of labor or spontaneous labor who had intrapartum fever (≥38°C). Patients were divided into 3 groups according to maximum temperature during labor: afebrile (<38°C), mild fever (38°C–39°C), and severe fever (>39°C). The primary outcome was composite neonatal morbidity (umbilical artery pH <7.1, mechanical ventilation, respiratory distress, meconium aspiration with pulmonary hypertension, hypoglycemia, neonatal intensive care unit admission, and Apgar <7 at 5 minutes). Secondary outcomes were composite neonatal neurologic morbidity (hypoxic-ischemic encephalopathy, hypothermia treatment, and seizures) and composite maternal morbidity (postpartum hemorrhage, endometritis, and maternal packed red blood cell transfusion). Outcomes were compared between the maximum temperature groups using multivariable logistic regression. Cox proportional-hazards regression modeling accounted for the duration between reaching maximum intrapartum temperature and delivery.

      Results

      Of the 8132 patients included, 278 (3.4%) had a mild fever and 74 (0.9%) had a severe fever. The incidence of composite neonatal morbidity increased with intrapartum fever severity (afebrile 5.4% vs mild 18.0% vs severe 29.7%; P<.01). After adjusting for confounders, there were increased odds of composite neonatal morbidity with severe fever compared with mild fever (adjusted odds ratio, 1.93 [95% confidence interval, 1.07–3.48]). Severe fevers remained associated with composite neonatal morbidity compared with mild fevers after accounting for the duration between reaching maximum intrapartum temperature and delivery (adjusted hazard ratio, 2.05 [95% confidence interval, 1.23–3.43]). Composite neonatal neurologic morbidity and composite maternal morbidity were not different between patients with mild and patients with severe fevers.

      Conclusion

      Composite neonatal morbidity correlated with intrapartum fever severity in a potentially dose-dependent fashion. This correlation was independent of the duration from reaching maximum intrapartum temperature to delivery, suggesting that clinical management of intrapartum fever, in terms of timing or mode of delivery, should not be affected by this duration.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Obstetrics & Gynecology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Greenwell E.A.
        • Wyshak G.
        • Ringer S.A.
        • Johnson L.C.
        • Rivkin M.J.
        • Lieberman E.
        Intrapartum temperature elevation, epidural use, and adverse outcome in term infants.
        Pediatrics. 2012; 129: e447-e454
        • Towers C.V.
        • Yates A.
        • Zite N.
        • Smith C.
        • Chernicky L.
        • Howard B.
        Incidence of fever in labor and risk of neonatal sepsis.
        Am J Obstet Gynecol. 2017; 216: 596.e1-596.e5
        • Acker D.B.
        • Schulman E.B.
        • Ransil B.J.
        • Sachs B.P.
        • Friedman E.A.
        The normal parturient’s admission temperature.
        Am J Obstet Gynecol. 1987; 157: 308-311
        • Higgins R.D.
        • Saade G.
        • Polin R.A.
        • et al.
        Evaluation and management of women and newborns With a maternal diagnosis of chorioamnionitis: summary of a workshop.
        Obstet Gynecol. 2016; 127: 426-436
        • Yancey M.K.
        • Zhang J.
        • Schwarz J.
        • Dietrich C.S.
        • Klebanoff M.
        Labor epidural analgesia and intrapartum maternal hyperthermia.
        Obstet Gynecol. 2001; 98: 763-770
        • Lieberman E.
        • O’donoghue C.
        Unintended effects of epidural analgesia during labor: a systematic review.
        Am J Obstet Gynecol. 2002; 186: S31-S68
        • Riley L.E.
        • Celi A.C.
        • Onderdonk A.B.
        • et al.
        Association of epidural-related fever and noninfectious inflammation in term labor.
        Obstet Gynecol. 2011; 117: 588-595
        • Curtin W.M.
        • Katzman P.J.
        • Florescue H.
        • Metlay L.A.
        • Ural S.H.
        Intrapartum fever, epidural analgesia and histologic chorioamnionitis.
        J Perinatol. 2015; 35: 396-400
        • Goetzl L.
        • Manevich Y.
        • Roedner C.
        • Praktish A.
        • Hebbar L.
        • Townsend D.M.
        Maternal and fetal oxidative stress and intrapartum term fever.
        Am J Obstet Gynecol. 2010; 202: 363.e1-363.e5
        • Dior U.P.
        • Kogan L.
        • Eventov-Friedman S.
        • et al.
        Very high intrapartum fever in term pregnancies and adverse obstetric and neonatal outcomes.
        Neonatology. 2016; 109: 62-68
        • Petrova A.
        • Demissie K.
        • Rhoads G.G.
        • Smulian J.C.
        • Marcella S.
        • Ananth C.V.
        Association of maternal fever during labor with neonatal and infant morbidity and mortality.
        Obstet Gynecol. 2001; 98: 20-27
        • Perlman J.M.
        Hyperthermia in the delivery: potential impact on neonatal mortality and morbidity.
        Clin Perinatol. 2006; 33 (55–vi)
        • Blume H.K.
        • Li C.I.
        • Loch C.M.
        • Koepsell T.D.
        Intrapartum fever and chorioamnionitis as risks for encephalopathy in term newborns: a case-control study.
        Dev Med Child Neurol. 2008; 50: 19-24
        • Lieberman E.
        • Cohen A.
        • Lang J.
        • Frigoletto F.
        • Goetzl L.
        Maternal intrapartum temperature elevation as a risk factor for cesarean delivery and assisted vaginal delivery.
        Am J Public Health. 1999; 89: 506-510
        • Bensal A.
        • Weintraub A.Y.
        • Levy A.
        • Holcberg G.
        • Sheiner E.
        The significance of peripartum fever in women undergoing vaginal deliveries.
        Am J Perinatol. 2008; 25: 567-572
        • Ashwal E.
        • Salman L.
        • Tzur Y.
        • et al.
        Intrapartum fever and the risk for perinatal complications – the effect of fever duration and positive cultures.
        J Matern Fetal Neonatal Med. 2018; 31: 1418-1425
        • Hochler H.
        • Lipschuetz M.
        • Guedalia J.
        • et al.
        The impact of peak and duration of maternal intrapartum fever on perinatal outcomes.
        Am J Obstet Gynecol MFM. 2021; 3: 100390
        • Kim S.Y.
        • Hong S.Y.
        • Kwon D.Y.
        • et al.
        Degree of intrapartum fever and associated factors: three group analysis of no fever, borderline and overt fever.
        J Obstet Gynaecol Res. 2021; 47: 1153-1163
        • Cahill A.G.
        • Tuuli M.G.
        • Stout M.J.
        • López J.D.
        • Macones G.A.
        A prospective cohort study of fetal heart rate monitoring: deceleration area is predictive of fetal acidemia.
        Am J Obstet Gynecol. 2018; 218: 523.e1-523.e12
        • Committee Opinion No. 712
        intrapartum management of intraamniotic infection.
        Obstet Gynecol 08. 2017; 130: e95-e101
        • Srinivasakumar P.
        • Zempel J.
        • Wallendorf M.
        • Lawrence R.
        • Inder T.
        • Mathur A.
        Therapeutic hypothermia in neonatal hypoxic ischemic encephalopathy: electrographic seizures and magnetic resonance imaging evidence of injury.
        J Pediatr. 2013; 163: 465-470
        • Fajgenbaum D.C.
        • June C.H.
        Cytokine storm.
        N Engl J Med. 2020; 383: 2255-2273
        • Walter E.J.
        • Hanna-Jumma S.
        • Carraretto M.
        • Forni L.
        The pathophysiological basis and consequences of fever.
        Crit Care. 2016; 20: 200
        • Smulian J.C.
        • Bhandari V.
        • Vintzileos A.M.
        • et al.
        Intrapartum fever at term: serum and histologic markers of inflammation.
        Am J Obstet Gynecol. 2003; 188: 269-274
        • Lagodka S.
        • Petrucci S.
        • Moretti M.L.
        • Cabbad M.
        • Lakhi N.A.
        Fetal and maternal inflammatory response in the setting of maternal intrapartum fever with and without clinical and histologic chorioamnionitis.
        Am J Obstet Gynecol MFM. 2022; 4: 100539
        • Segal S.
        • Pancaro C.
        • Bonney I.
        • Marchand J.E.
        Noninfectious fever in the near-term pregnant rat induces fetal brain inflammation: a model for the consequences of epidural-associated maternal fever.
        Anesth Analg. 2017; 125: 2134-2140
        • Zackler A.
        • Flood P.
        • Dajao R.
        • Maramara L.
        • Goetzl L.
        Suspected chorioamnionitis and myometrial contractility: mechanisms for increased risk of cesarean delivery and postpartum hemorrhage.
        Reprod Sci. 2019; 26: 178-183
        • Cheng Y.W.
        • Hopkins L.M.
        • Laros R.K.
        • Caughey A.B.
        Duration of the second stage of labor in multiparous women: maternal and neonatal outcomes.
        Am J Obstet Gynecol. 2007; 196: 585.e1-585.e6
        • Allen V.M.
        • Baskett T.F.
        • O’Connell C.M.
        • McKeen D.
        • Allen A.C.
        Maternal and perinatal outcomes with increasing duration of the second stage of labor.
        Obstet Gynecol. 2009; 113: 1248-1258
        • Bleich A.T.
        • Alexander J.M.
        • McIntire D.D.
        • Leveno K.J.
        An analysis of second-stage labor beyond 3 hours in nulliparous women.
        Am J Perinatol. 2012; 29: 717-722
        • Blankenship S.A.
        • Raghuraman N.
        • Delhi A.
        • et al.
        Association of abnormal first stage of labor duration and maternal and neonatal morbidity.
        Am J Obstet Gynecol. 2020; 223: 445.e1-445.e15
        • Herbst A.
        • Wølner-Hanssen P.
        • Ingemarsson I.
        Risk factors for fever in labor.
        Obstet Gynecol. 1995; 86: 790-794
        • Maayan-Metzger A.
        • Mazkereth R.
        • Shani A.
        • Kuint J.
        Risk factors for maternal intrapartum fever and short-term neonatal outcome.
        Fetal Pediatr Pathol. 2006; 25: 169-177
        • Puopolo K.M.
        • Draper D.
        • Wi S.
        • et al.
        Estimating the probability of neonatal early-onset infection on the basis of maternal risk factors.
        Pediatrics. 2011; 128: e1155-e1163