PEDIATRICS Vol. 108 No. 3 September 2001, pp. 818

Intrapartum Maternal Fever and Neonatal Outcome

To the Editor.

We read with great interest the article by Lieberman et al¹ regarding intrapartum maternal fever related to epidural analgesia and neonatal outcome. The authors' data indicate that intrapartum fever has implications for the fetus. Infants of women who were febrile during labor were more likely to have low 1-minute Apgar scores, to require bag and mask resuscitation, to have hypotonia after delivery, and to require oxygen treatment in the nursery. A finding of greater concern was the increase in the occurrence of seizures among the infants of women with high fever.

We studied 73 women who developed fever during labor and received epidural analgesia for pain relief. Before this procedure the temperature was in the normal range. Thirty (41%) women developed a fever >38°C, 36 (49%) women had a temperature >38°C, and 7 (10%) women had a maximum temperature >39°C. The protocol of the epidural analgesia was always the same: bupivacaine 0.15% mL + fentanyl 50 mg in bolus, followed with patient-controlled analgesia (PCA) until 20 mL/hour. Seventeen women were excluded because of evidence of a maternal or a neonatal infection that was proven by positive blood, urine, or placenta cultures that were taken either from the mother or the infant. Neonatal outcomes were examined in 56 infants, after the exclusion of the 17 infants in whom infection was proven. Low 1-minute Apgar scores (<7) occurred in only 2 of the infants.

None of the infants required resuscitation after delivery, and there was no need for oxygen therapy in the nursery. Hypotonia and seizures were no more likely to be diagnosed in those infants.

Our data indicate that intrapartum fever related to the use of epidural analgesia has no implication on the fetus. We do not consider epidural analgesia to be a risk factor to the fetus.

More studies are needed to evaluate whether maternal fever has implications for neurologic outcome. Maybe we have to consider the different protocols of epidural analgesia and learn if we will get different results with different protocols.

Leshem Meiron, MD^*
Albo Jak, MD
Chavkin Shoshana, MD^§
Zeitlin Maria, MD^*
Zaritzky Aron, MD^*
* Neonatal Department
 Anesthetic Department
^§ Child Developmenatal Center
Barzilai Medical Center
Ashkeon 78306 Israel

REFERENCE

1. Lieberman E, Lang JM, Richardson DK, Intrapartum maternal fever and neonatal outcome. Pediatrics. 2000; 105:8-13 [Abstract/Free Full Text]

In Reply.

We appreciate the comments of Dr Meiron and his colleagues who report no adverse events in a sample of 53 febrile patients receiving epidural. This contrasts with our cohort study of 1218 women in which we found that a number of adverse events including low 1-minute Apgar, hypotonia, bag and mask resuscitation, and the need for oxygen in the nursery were all more common in the infants of women with epidural-related fever. It is difficult to compare the 2 sets of results since Meiron et al provide no information about the population studied. Our cohort of 1218 women was composed entirely of low-risk nulliparous women with term pregnancies. The high infection rate of 23% (17/73) reported by Meiron et al suggests that their population may have been different. With regard to epidural protocols, existing data suggests that the temperature increases occur with different concentrations of epidural medication.^1,2 In addition, data from our own institutions indicate a similar rate of fever (approximately 15%) with "light" (.04% bupivacaine) compared with standard (.125% bupivacaine) epidural analgesia. We agree that additional large studies are needed to investigate these questions.

Ellice Lieberman, MD, DrPH
Linda J. Heffner, MD, PhD
Amy P. Cohen, BA
Department of Obstetrics and Gynecology
Brigham and Women's Hospital
Harvard Medical School
Boston, MA 02115

Janet M. Lang, PhD, ScD
Department of Epidemiology and Biostatistics
Boston University School of Public Health
Boston, MA

Douglas K. Richardson, MD, MBA
Joint Program for Neonatology
Harvard Medical School
Boston, MA

Fredric D. Frigoletto, MD
Department of Obstetrics and Gynecology
Massachusetts General Hospital
Harvard Medical School
Boston, MA

REFERENCES

1. Camann WR, Maternal temperature regulation during extradural analgesia for labour. Br J Anaesth. 1991; 67:565-568 [Abstract/Free Full Text]
2. Fusi L, Maternal pyrexia associated with the use of epidural analgesia in labour. Lancet. 1989; 1:1250-1252 [CrossRef][Medline]